HEALTH  SUIbNGbti  t 


HX00030120 


^C^^Q 


COLUMBIA    UNIVERSITV 
EDWARD   G.    [ANEWAY 
M  K  \1  O  R  I  A  L   L I  B  R  A  R  Y 


Digitized  by  tine  Internet  Arciiive 

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http://www.archive.org/details/practiceofmediciOOtyso 


THE  PRACTICE   OF  MEDICINE 


TYSON 

AND 

FUSSELL 


BY  DR.  TYSON 


A  Treatise  on  Bright's  Disease  and  Diabetes. 

With  especial  reference  to  Pathology  and  Thera- 
peutics. Including  a  section  on  Ocular  Changes 
in  Bright's  Disease  and  Diabetes.  Second  Edi- 
tion Revised.  Seven  Colored  Plates  and  43  other 
Illustrations.     Octavo.     Cloth,  net,  S4.00. 

"Dr  Tyson's  special  interest  and  long  experience 
in  the  observation  and  treatment  of  Bright's  Disease 
and  Diabetes  cause  the  profession  to  welcome  with 
pleasure  this  second  edition." — Bulletin  of  Johns 
Hopkins  Hospital. 


THE 

PRACTICE 

OF 


MEDICINE 

A  TEXT-BOOK  FOR  PRACTITIONERS  AND  STUDENTS 
WITH  SPECIAL  REFERENCE  TO  DIAG- 
NOSIS AND  TREATMENT 


BY 
JAMES    TYSON,    M.  D.,  LL.  D. 

EMERITUS  PROFESSOR  OF  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA  AND  FORMERLY  PHYSICIAN  TO  THE 

HOSPITAL  OF  THE  UNIVERSITY;    FORMERLY  PHYSICIAN    TO    THE    PENNSYLVANIA  HOSPITAL; 

LATE  PRESIDENT  OF  THE  COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA;   MEMBER 

OF  THE  ASSOCIATION  OF  AMERICAN  PHYSICIANS,  ETC. 

AND 
M.    HOWARD    FUSSELL,    M.  D. 

PROFESSOR  OF  APPLIED  THERAPEUTICS  IN  THE  UNIVERSITY  OF  PENNSYLVANIA  AND  PHYSICIAN  TO  THE 

HOSPITAL  OF  THE  UNI\'ERSITY;  EPISCOPAL  HOSPITAL;  ST.  TIMOTHY'S  HOSPITAL,  CHESTNUT 

HILL     HOSPITAL;     MEMBER     OF     THE     ASSOCIATION     OF     AMERICAN     PHYSICIANS; 

MEMBER  OF  THE  COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA,   ETC.,  ETC. 


SIXTH  EDITION,  REVISED  AND  REWRITTEN 


WITH  SIX  PLATES 
AND  179  OTHER  ILLUSTRATIONS 


PHILADELPHIA 

BLAKISTON'S  SON  &   CO. 

1012  WALNUT   STREET 
1913 


Copyright,  1913,  by  P.  Blakiston's  Son  &  Co. 


THD. MAPLE-PRESS. YORK. PA 


TO  THE  MEjMORY  OF 
PROFESSOR  J.  M.  DA  COSTA,  M.D.,  LL.D. 

LATE  PROFESSOR  OF  PRACTICE  OF  MEDICINE  AND  OF  CLINICAL  MEDICINE 
IN  THE  JEFFERSON  MEDICAL  COLLEGE  OF  PHILADELPHIA 


PREFACE  TO  THE  SIXTH  EDITION. 

It  was  with  a  desire  to  do  all  possible  to  bring  my  book  thorough!}' 
up  to  date  that  I  associated  with  me  in  the  preparation  of  this  edition, 
Dr.  M.  Howard  Fussell,  Professor  of  Applied  Therapeutics  in  the  University 
of  Pennsylvania,  whose  broad  training  and  large  experience  fit  him  eminently 
for  this  service. 

As  intimated  in  the  title  page  the  book  has  been  rewritten  to  a  consid- 
erable extent.  This  may  be  said  particularly  of  the  sections  on  Pellagra, 
Acute  Anterior  Poliomyelitis,  and  Caisson  Disease.  To  other  sections  much 
has  been  added.  This  is  true  of  Typhoid  and  Typhus  Fevers,  of  Tuberculosis 
and  Diseases  of  the  Heart  and  Kidneys.  Qmte  a  number  of  new  subjects 
have  been  introduced  and  while  some  are  of  minor  importance,  it  is  thought 
that  all  demand  a  place  in  a  book  which  aims  to  cover  more  or  less  the 
whole  field  of  internal  medicine.  Among  these  are  Diseases  of  the  Pituitary 
Gland,  Trypanosomiasis,  Rocky  Mountain  Spotted  Fever,  Diverticuhtis, 
Bacteriuria,  Melaniuia,  Oxaltiria,  Phosphaturia,  Indicanuria,  Cystinuria, 
Erythremia,  Diseasesof  the  Thymus  Gland,  Hypothyroidism  and  Hyperthy- 
roidism, Hypertrophic  Pulmonary  Arthropathy,  Osteitis  Deformans,  Leon- 
tiasis  Ossea,  Osteogenesis  Imperfecta,  Osteopsathyrosis,  and  Oxycephaly. 

The  section  on  Pellagra  has  been  written  by  Dr.  Edward  Jenner  Wood  of 
of  Wilmington,  North  Carolina,  the  accomplished  author  of  the  new  Treatise 
on  Pellagra,  1913,  and  that  on  the  Phenosulphonephthalein  Test  by  Dr. 
Alexander  Randall,  whose  experience  with  it  has  been  very  large.  Dr. 
Spiller  has  continued  his  supervision  of  the  section  on  Nervous  Diseases. 
For  these  services  I  am  greatly  indebted. 

The  paragraphs  heretofore  devoted  to  the  historj^  of.  the  development 
of  our  knowledge  as  far  as  obtainable  of  the  various  diseases  considered 
have  been  omitted,  because  more  space  had  to  be  secured  for  new  matter 
without  increasing  the  size  of  the  book.  Readers  will  have  to  consult 
previous  editions  for  these  interesting  histories.  For  the  same  reason  the 
valuable  chapter  on  Parasites  by  Dr.  Allen  J.  Smith  had  to  be  curtailed. 

JAMES  TYSON. 
1506  Spruce  St.,  Philadelphia. 


PREFACE  TO  THE  FIRST  EDITION. 

I  HAVE  no  apology  to  make  for  preparing  this  book.  I  have  long  con- 
templated it,  and  have  finished  it  after  several  years'  labor.  It  has  taken 
some  time,  because  it  represents  almost  purely  personal  work,  which  has 
been  frequently  interrupted.  It  does  not  pretend  to  be  based  on  my  per- 
sonal practice  only.  In  these  days  of  specialized  work  this  would  be  im- 
possible, though  with  most  of  even  the  rare  forms  of  disease  in  even.' 
section  I  have  had  some  experience.  To  fill  in  the  gaps  of  my  own  knowl- 
edge, I  have  used  that  of  others,  but  have  always  sought  to  make  suitable 
acknowledgment  to  the  proper  source,  and  if  this  has  not  been  done  in  any 
case,  it  has  been  a  matter  of  oversight. 

I  had  not,  at  the  outset,  expected  to  illustrate  the  work,  but,  as  it  pro- 
gressed, a  certain  number  of  illustrations  seemed  necessar\",  not  only  to 
explain  the  text,  but  also,  in  a  few  instances,  to  render  clearer  the  treatment 
described.  Thus  the  number  of  charts  and  other  dra-nangs  has  grown  to 
nearly  a  hundred,  aU  of  which,  it  is  hoped,  will  be  found  useful.  In  expec- 
tation of  the  ultimate  adoption  of  the  metric  system  for  the  measuring  of 
doses,  these  have  been  indicated  throughout  the  book  in  the  metric  and 
English  measures. 

Acknowledgment  is  due  to  Dr.  Joseph  P.  Walsh  and  Mr.  M.  A.  Morin 
for  suggestions  after  reading  the  text,  to  Dr.  WilUam  Schleif  for  material 
assistance  in  Section  XV,  and  to  my  son.  Dr.  T.  Mellor  Tyson,  for  assistance 
throughout  the  work  and  especially  in  preparing  the  index. 
1506  Spruce  St.,  Philadelphia. 


CONTENTS 


SECTION  I. 


INFECTIOUS  DISEASES. 


Typhoid  Fever,      I 

Paratyphoid  Fever, 34 

Rocky  Mountain  Spotted  Fever,     .     .  34 

Typhus  Fever, 36 

Relapsing  Fever, 40 

Malta  Fever, 45 

The  Malarial  Fevers, 47 

Yellow  Fever 67 

Dengue, 74 

Cholera, 76 

Dysentery, 85 

The  Plague, 92 

Measles, 97 

Rubella,       loi 

Scarlet  Fever, 103 

Diphtheria, 112 

Follicular  Tonsillitis, 123 

Vincent's  Angina, 124 

Smallpox, 124 

Vaccine  Disease, 131 

Chicken-pox, 135 

Whooping-cough, 137 

Mumps, 140 

Influenza, 142 

Cerebrospinal  Fever, 146 


Erysipelas, 156 

Septicemia  and  Pyemia, 161 

Hydrophobia, 164 

Tetanus, 169 

Anthrax,      1 74 

Glanders  and  Farcy,          176 

Actinomycosis, 178 

Foot  and  Mouth  Disease, 180 

Milk  Sickness, 181 

Syphilis, 182 

Diseases  Due  to  Animal  Parasites,.    .  190 

The  Gonococcus  Infection, 244 

Gonococcus  Arthritis, 244 

Rheumatic  Fever,      246 

Croupous  Pneumonia, 253 

Bronchopneumonia, 268 

Tuberculosis, 272 

Leprosy, 312 

Infectious      Diseases      of      Doubtful 

Nature, 315 

Acute  Febrile  Jaundice, 315 

Miliary  Fever, 316 

Glandular  Fever, 317 

Leishmaniasis, 318 

Acute  Poliomyelitis, 319 


SECTION  II. 
DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Diseases  of  the  Mouth, 322 

Diseases  of  the  Salivary  Glands,     .    .331 
Diseases  of  the  Tonsils  and  Pharynx, .   333 

Diseases  of  the  Esophagus, 341 

Diseases  of  the  Stomach  and  Intes- 
tines,      349 

Diseases  of  the  Intestines,    .    .    .    .    .391 
Diseases  of  the  Liver, 433 


Diseases    of    the    Bile    Passages    and 

Gall-bladder, 434 

Diseases  of  the  Blood-vessels  of  the 

Liver 450 

The  Cirrhoses  of  the  Liver,      ....   457 
Acute  Yellow  Atrophy  of  the  Liver,  .   466 

Diseases  of  the  Pancreas, 478 

Diseases  of  the  Peritoneum,     ....   482 


SECTION  III. 
DISEASES  OF  THE  RESPIRATORY  SYSTEM 


Diseases  of  the  Nose, 494 

Hay-fever, 496 

Diseases  of  the  Larynx, 499 

Diseases  of  the  Trachea  and  Bronchial 


Tubes,      506 

Diseases  of  the  Lungs, 528 

Diseases  of  the  Pleura, 535 

Mediastinal  Disease, 548 


xii  CONTENTS 

SECTION  IV. 
DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS. 

PAGE  PAGE 

General  Symptomatology  o£  Cardiac  Diseases  of  the  Myocardium 6oo 

Disease, 555  Irregular  Action  of  the  Heart,     .    .    .  6io 

Diseases  of  the  Pericardium,   ....   557  Angina  Pectoris,  or  Stenocardia,     .  616 

Diseafes  of  the  Endocardium,.         .    .    565  Diseases  of  the  Blood-vessels,  .    .    .  618 

SECTION  V. 
DISEASES  OF  THE  BLOOD  AND  BLOOD-MAKING  ORGANS. 

P.VGIi  PACE 

The  Anemias,.    .    .' 634       The  Primary  or  Essential  Anemias,   .   636 

Secondary    or    Symptomatic    Ane- 
mia— Simple  Anemia, 634 

SECTION  VI. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 

PAGE  PACE 

Diseases  of  the  Thyroid  Gland,  .    .    .  668  Neoplasms  of  the  Thyroid, 680 

Myxedema, 675  Diseases  of  the  Suprarenal  Capsules,  681 

Diseases  of  the  Parathyroid  Glands,  .  678  Diseases  of  the  Spleen, 684 

Tetany 678  Disease  of  the  Pituitary  Body,    .    .    .  686 

SECTION  VH. 
DISEASES  OF  THE  URINARY  ORGANS. 

PAGE  PACE 

General  SymptOmology, 693      Diseases  of  the  Bladder, 768 

Diseases  of  the  Kidney, 707 

SECTION  VIII. 
DISEASES  OF  DERANGED  METABOLISM  (.Constitutional  Diseases). 

PAGE  PACE 

Myalgia,      779  Diabetes  Mellitus, 797 

Arthritis  Deformans, 782  Diabetes  Insipidus, 816 

Osteitis  Deformans 786  Obesity, 820 

Osteogenesis  imperfecta, 787  Rickets, 824 

Osteopsothyrosis, 787  Achondroplasia, 830 

Leontiasis  Ossea, 788  Osteomalacia, 831 

Oxycephaly, 788  Multiple  Myeloma, 833 

Gout 788 


SECTION  IX. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 

PAGE  PACE 

General  Introduction, 835               IV.  Mental  Phenomena,     .    .    .      859 

Histology  of  the  Nervous  System,     835               V.  Alterations   in    Vision    and 

General  Symptomatology   (Inves-  Hearing, 860 

tigation  of  a  Case  of  Ner-                        VI.  Alterations     in     Breathing 

vous  Disease, 838  and  Pulse,      860 

I.   Phenomena  of  Motion,    .    .      838             VII.  Focal    Disease    and    Focal 

II.  Sensory  Phenomena,    .    .    .      854  Symptoms, 861 

III.  Va.somotor     and     Trophic 

Phenomena 858 


CONTENTS 


PAGE 

Affections  of  the  Peripheral  Nerves,.  86i 

Neuritis, 86 1 

Adiposis  Dolorosa, 871 

Neuralgia, 872 

Tumors  of  Nerves, 878 

Affections  of  the  Spinal  Cord,    .    .    .  880 
Localization   of   the   Functions  of 

the  Segments  of  the  Spinal  Cord,  881 
Affections  of  the  Membranes  of  the 

Cord 886 

Spinal  Pachymeningitis, 887 

Spinal  Leptomeningitis, 889 

Hemorrhage  into  the  Spinal  Mem- 
branes,     890 

Affections  of  the  Substance  of  the 

Cord,      891 

Secondary     Systemic      Degenera- 
tions of  the  Spinal  Cord,    .    .    .  892 
Acute  Affections  of  the  Spinal  Cord,  895 
Disturbances  of  the  Circulation  of 

the  Spinal  Cord, 895 

Hemorrhage  into  the  Substance  of 

the  Cord 895 

Diffuse      Myelitis      (Acute      and 

Chronic), 897 

Acute  Ascending  Spinal  Paralysis,  903 
■    Chronic  Affections  of  the  Spinal 

Cord,      905 

Spastic  Spinal  Paralysis,     ....  905 

Tabes  DorsaUs, 907 

Hereditary  Ataxia, 918 

Ataxic     Spastic      Paraplegia,      or 

Combined  Sclerosis, 920 

Syringomyelia,      922 

Morvan's  Disease, 924 

Compression  of  the  Spinal    Cord,  924 
Tumors  of  the  Spinal    Cord    and 

Membranes,      927 

Lesions  of  the  Cauda  Equina  and 

Conus  Medullaris, 931 

Spina  Bifida, 932 

Progressive  Bulbar  Palsy,  ....  932 

Acute  Bulbar  Palsy, 935 

Myasthenia  Gravis, 936 

Amytrophic  Lateral  Sclerosis,    .    .  937 
Progressive       Spinal       Muscular 

Atrophy 939 

Diseases  of  the  Brain, 944 

Localization  of  Cerebral  Disease,    .  944 
I.  The    Motor    Areas    of    the 

Cortex, 945 

II.  Sensory  Areas  of  the  Cortex 

and  Sensory  Paths,      .    .    .  950 

Cortical  Areas  Covering  Speech,  954 
The    Various    Forms    of    Aphasia 

and  their  Anatomical  Lesions,  954 
The  Physical  Basis  of  Thought— 

Apraxia 956 


Aphasia,  or  Loss  of  the  Faculty 

of  Speech,      958 

Derangements  of  Speech  of  Irri- 
tative Origin,    k 962 

Cortical  Areas  Whose  Function  is 

Unknown  or  Uncertain,      .    .     964 

Tracts  Within  the  Brain — Cen- 
trum Ovale,  Internal  Capsule, 
Central  Ganglia,  Corpora 
Quadrigemina,      965 

Cerebellar  Disease, 967 

Diseases  of  the  Cranial  Nerves,     .    .     970 

Olfactory  Nerve,      970 

Optic  Nerve  and  Tract,      ....      971 

1.  Affections  of  the  Retina,    .    .      971 

2.  Affections  of  the  Optic  Nerve,     972 

3.  Lesions   of   the   Chiasm   and 

Tract, 975 

4.  Lesions    of    the    Tract    and 

Cortical  Centers 976 

Lesions  of  the  Motor   Nerves  of 

the  Eyeball,       981 

Third  Nerve, 981 

Fourth  Nerve, 984 

Sixth  Nerve, 984 

Phenomena  in  General  of  Par- 
alysis   of    Motor    Nerves    of 

the  Eye, 985 

Ophthalmoplegia, 986 

Lesions    of   the    Trifacial,    or   Fifth 

Nerve    (Trigeminus), 988 

Lesions    of    the    Facial    Nerve    or 

Seventh  Pair, 989 

Lesions  of  the  Auditory  or    Eighth 

Nerve, 997 

1.  Loss    of    Function;    Nervous 

Deafness,      998 

2.  Auditory  Hyperesthesia,    .    .    1000 

3.  Irritation    of    the    Auditory 

Nerve — Tinnitus    Aurium,   1000 

4.  Disturbance   of   Equilibrium 

Associated  with  Defect  of 
Hearing  Labyrinthine  Ver- 
tigo, Meniere's  Disease,    .    looi 
Lesions  of  the  Ninth  or  Glossophar- 
yngeal Nerve, 1003 

Lesions    of    the    Pneumogastric    or 

Vagus  Nerve,  the  Tenth  Pair,   1003 
Lesions  Involving  the   Nucleus 
and   Trunk   of   the   Pneumo- 
gastric and  Branches,      .    .    .    1004 
Lesions     of     the     Pharyngeal 

Branches, 1004 

Lesions       of       the      Laryngeal 

Branches, 1005 

Spasm  of  the  Larynx,      ....    1008 
Lesions  of  the  Cardiac  Branches,   1008 


CONTENTS 


Lesions  of  Gastric  and  Esoph- 
ageal Branches, 1009 

Lesions  of  Pulmonary  Branches,   1009 
Lesions    of    the    Eleventh    Pair    or 

Spinal  Accessory  Nerve, .    .    .    loii 

Paralysis  of  the  External 
Branch  of  the  Spinal  Acces- 
sory  10 1 1 

Accessory  Spasm, 10 12 

1.  Congenital     Torticollis,     or 

Fixed  Wry-neck 1012 

2.  Spasmodic  Wry-neck,     .    .    .    1013 
Lesions  of  the  Twelfth  Pair  or  Hypo- 
glossal Nerve, 1015 

Diseases  of  the  Spinal  Ner\'es  and 

Branches, 1016 

Cervical  Plexus, 1016 

Lesions  of  the  Brachial  Plexus, .    .    1017 
Of  the  Combined  Plexus,    .    .    .    1017 

Nerves  of  the  Arm, 1018 

Lumbar  and  Sacral  Plexuses,     .    .    1021 
Effect    of    Sections    of    Sensory 
Nerves.     Sensory  Mechanism 
of  Peripheral  Nerves,  ....    1023 
Diseases  of  the  Membranes  of  the 

Brain 1025 

Affections    of   the    Blood-vessels   of 

the  Brain,      1032 

Hyperemia, 1032 

Anemia 1033 

Edema, 1034 

Apoplexy 1035 

L  Cerebral  Hemorrhage,      .    .    1035 
n.  Embolism   and  Thrombosis 
of  the  Cerebral  Vessels,  .    .    .    1044 
Thrombosis  of  the  Cerebral  Sin- 
uses and  Veins, 1048 

Intracranial  Aneurysms, 1049 

The  Cerebral  Palsies  for  Children,  1050 
Spastic  Infantile  Hemiplegia,     .    1050 
Bilateral  Infantile  Spastic  Hemi- 
plegia  1053 

Infantile  Spastic  Paraplegia,      .    1054 

Herpes  Zoster,      1056 

Multiple  Sclerosis  of  the  Brain 
and  Spinal  Cord,      1057 


Paretic  Dementia, 1059 

Paralysis  Agitans, 1062 

Other  Forms  of  Tremor,     ....    1065 

Tumors  of  the  Brain 1065 

Suppurative  Encephalitis,  ....    1072 
Encephalitis  without  Abscess,  .    1075 

Chronic  Hydrocephalus 1075 

Neuroses, 1078 

Acute  Chorea, 1078 

Choreiform  Affectiuns, 1084 

I.  Simple  Tic 1084 

Dubini's  Disease, 1085 

II.    Tic   with   Explosive    Utter- 
ances, Coprolalia,  Echolalia, 

etc., 1086 

III.  Complex  Co-ordinated  Tic,   .    1086 
IV.  Spasms  of    the    Muscles    of 

Respiration  and  Deglutition,   1087 
V.  Chronic  Progressive  Chorea,   1087 

VI.  Chorea  Major, 1088 

VII.  Postparalytic    Chorea,    and 
Postchoreal  Paralysis,    .    .    .    1089 

Epilepsy 1090 

Reflex  Convulsions  of  Children,   .    1099 

Migraine, iioo 

Occupation  Neuroses, 1103 

Writers' Cramp, 1103 

Hysteria, 1 107 

Neurasthenia, 11 18 

Traumatic  Neuroses 1 1 2 1 

Other  Forms  of  Functional   Par- 
alysis,    1 122 

Abasia-atasia, 1122 

Amaurotic  Family  Idiocy,      ,    .    .    1 1 24 
Family  Periodical  Paralysis,  .    .    1123 
Vasomotor  and  Trophic  Derange- 
ments,     1 125 

Acute  Angioneurotic  Edema,     .    1125 
Intermittent  Hydrarthrosis,  .    .    1126 

Raynaud's  Disease 1 126 

Progressive       Facial       Hemia- 
trophy,   1128 

Scleroderma, 11 29 

Morphea 1130 

Ainhum, 1 1 3 1 


CONTENTS 

SECTION  X. 

DISEASES  OF  THE  MUSCULAR  SYSTEM. 


Myositis, 1132 

Progressive    Muscular    Dystrophies. 
Primary    Myopathic    Forms 
of  Muscular  Atrophy,     .    .    .    1133 
I.  Pseudohypertrophic         Mus- 
cular Paralysis, 1 133 

II.  Erb's  Juvenile  Form  of  Pro- 
gressive Muscular  Dys- 
trophy,       1 1 34 


III.  The      Facio-scapulo-humeral 

Type 1 135 

IV.  The  Peroneal  Type  of  Pro- 
gressive Muscular  Atrophy,  .    1 135 

Myotonia   Congenita    (Thomsen's 

Disease) 1136 

Amyotonia  Congenita, 1136 


SECTION  XI. 
THE  INTOXICATIONS. 


Alcoholism, 1138 

Acute  Alcoholism, 1 138 

Chronic  Alcoholism, 1139 

Delirium    Tremens,    or    Mania    a 

Potu, 1 141 

The  Morphin  Habit — Morphinism,  .  1144 

Chloralism, 11 46 

Cocainism, 1147 


Lead  Poisoning, 1147 

Arsenical  Poisoning, 1 1 53 

Bisulphide  of  Carbon  Poisoning,  .    .  1 1 54 

Ptomain  and  Leukomain  Poisoning,  .  1 1 55 

Grain  Poisoning, 1158 

1.  Ergotism, 1 1 58 

2.  Pellagra, 1161 

3.  Beri-Beri, 1159 


SECTION  XII. 

EFFECTS  OF  EXPOSURE  TO  HIGH  THOUGH  BEARABLE 
ATMOSPHERIC  TEMPERATURE  OR  PRESSURE. 

PAGE  PAGE 

Heat  Exhaustion, 1166      Caisson  Disease, 1171 

Thermic  Fever 1 167 


SECTION  XIII. 

Summary  of  Symptoms  Following  Overdoses  of  Poisons. 
(Alphabetically  Arranged.) 


Aconite 1 1 73 

Alcohol, II 73 

Ammonia,      H74 

Antimony, 1 1 74 

Arsenic, 1 1 74 

Atropin, 11 75 

Belladonna, 11 75 

Bromin, 11 75 

Bromism, 1 175 

Carbonic  Acid  Gas, 1 1 75 

Carbonic  Oxid, 1 1 76 

Caustic  Potash  or  Soda, 11 76 

Cheese  Poisoning, II 76 


Chloral,      1176 

Chloroform, 11 76 

Cocain, 11 77 

Conium, ii77 

Copper,      1 1 77 

Digitalis, 1 178 

Ergot, ■.    .    .  1178 

Fish  Poisoning, 11 78 

Hydrochloric  Acid, 1181,  1179 

Hydrocyanic  Acid, 1I79 

lodin, 1 1 79 

Iodoform II79 


CONTENTS 


Lead,     1180 

Meat 1 1 80 

Mercury, 1180 

Nitric  Acid, 1 181 

Sulphuric   Acid, 1181 

Mushroom  Poisoning 1181 

Nicotin 1182 

Nitro  Benzol, 11 82 

Opium 1 1 82 


Oxalic  Acid, 1183 

Plienol  and  Creosote, 1 1 83 

Phosphorus, 11 83 

Potassium  Nitrate, 1 1 84 

Ptomain  Poisoning, 1 1 84 

Silver  Nitrate, 11 84 

Strychnin, 1 185 

Sulphuretted  Hydrogen, 1 1 85 

Zinc, 1 1 86 


APPENDIX. 


Tables  for  the  Conversion  of  the  English  into  Metric   System,  and  the 

Reverse 11 87 

Index 1191 


PRACTICE  OF  MEDICINE. 


SECTION  I. 

INFECTIOUS  DISEASES. 

TYPHOID  FEVER. 

Synonyms. — Typhus  abdominalis ;  Enteric  Fever;  Pythogenic  Fever;  Gastro- 
enteric Fever;  Nervous  Fever. 

Definition. — Tj^phoid  fever  is  an  acute  infectious  disease  due  to  the 
typhoid  bacillus — the  bacillus  of  Eberth.  It  is  especially  characterized 
pathologically  by  hyperplastic  and  ulcerative  lesions  of  the  lymph  follicles 
of  the  intestine,  of  the  mesenteric  glands,  and  b\'  enlargement  of  the  spleen. 

Etiology. — The  bacillus  typhosus,  which  is  the  cause  of  typhoid  fever, 
was  discovered  by  Eberth  in  1880  in  the  intestine.  The  bacillus  is  found 
in  the  lymphatic  system,  including  the  mesenteric  glands  and  spleen,  in  the 
liver  and  the  kidneys,  the  blood  and  bone-marrow,  and  in  bile  and  urine, 
as  well  as  in  the  rose-colored  spots. 

The  bacillus  is  activelj^  motile,  is  short,  rod-like,  its  length  is  one  to 
three  micromillimeters,  breadth  .5  to  .8  of  a  micromillimeter.  ^  Its  size  and 
shape  vary  somewhat  with  the  culture-medium  and  the  age  of  the  bacillus. 
It  is  actively  motile  due  to  the  posession  of  from  two  to  twelve  flageUas 
attached  to  ends  and  sides.  Its  ends  are  rounded,  and  sometimes  there 
can  be  seen  toward  them,  glistening,  clear  spaces;  it  does  not  produce 
spores.^  They  closelj^  resemble  the  bacUli  coli  from  which  they  can  be 
differentiated  by  special  cultural  methods,  or  agglutinating  action  of  spe- 
cific immune  sera. 

The  bacillus  stains  readily  in  a  saturated  watery  solution  of  methyl-blue, 
but  not  by  Gram's  method.  Cultures  may  be  made  from  the  fecal  dis- 
charges on  the  tenth  day  of  the  disease  or  later,  but  with  difficulty,  and  are 
often  negative.     Cultures  are  now  readily  made  from  the  blood. 

The  resisting  powers  of  the  typhoid  bacillus  are  very  great.  It  thrives 
at  room-temperature.  The  thermal  death-point  is  given  by  Sternberg  at 
156°  F.  (69°  C).  According  to  Klemperer  and  Levy,  the  bacilli  remain  vital 
for  three  months  in  distilled  water,  though  in  ordinary  water  the  com- 
moner and  more  vigorous  saprophytes  consume  them.  When  biuied  in  the 
upper  layers  of  the  soil,  they  retain  their  vitality  for  nearly  six  months. 
Cold  has  no  effect  upon  them,  for  repeated  freezing  and  thawing  fail  to  kill 
them.     They  have  lived  upon  linen  for  from  60  to  72  days,  and  on  buck- 

*  A  micron  or  micromillimeter  is  i/iooo  of  a  millimeter  =1/2500  inch. 
2  Sternberg,  "Jour,  of  Am.  Med.  Assoc.,"  August  22,  1891,  p,  390. 

1 


2  IM-ECTIOUS  DISEASES 

skin  from  80  to  85  days.  One-tenth  to  0.2  of  one  per  cent,  carbolic  acid 
added  to  a  culture-medium  is  without  effect  upon  the  growth  of  the  bacillus; 
0.5  of  one  per  cent,  strength  of  carbolic  acid  and  0.05  of  one  per  cent,  cor- 
rosive sublimate  solutions  are,  however,  fatal  to  it.  Of  all  agents  except 
high  heat,  sunlight  seems  to  be  among  the  most  powerful  to  destroy  it. 
The  experiments  of  Billings  and  Peckham,'  go  to  show  that  insolation  for 
two  hours  destroys  98  per  cent,  of  the  germs,  and  in  three  to  six  hours 
kills  all. 

These  bacilli  yield  an  endotoxin,  and  not  a  soluble  toxin  as  was  at  first 
supposed. 

The  bacillus  itself  most  frequently  enters  the  blood  through  the  stomach 
in  drinking-water  or  milk,  in  both  of  which  it  has  been  found  during  epi- 
demics. There  is  reason  to  believe  also  that  it  may  be  inhaled.  It  has 
been  found  in  water-filters  by  Harold  C.  Ernest  and  T.  M.  Pruddcn.  It  is 
quite  well  settled  that  the  baciUi  find  their  way  into  food  and  drink  through 
the  careless  disposition  of  alvine  discharges  from  typhoid  fever  patients, 
and  that  food  may  be  contaminated  by  contagion  conveyed  from  these 
discharges  by  the  common  house-fl}'.  An  oyster  bed  maj-  be  infected  by 
sewage;  green  vegetables,  by  polluted  water  sprinkled  upon  them.  Direct 
contagion  from  the  patient  to  a  second  person  may  occur  by  means  of  fecal 
matter  or  urine  soiling  the  hands  of  an  attendant  and  being  thus  conveyed 
to  the  mouth  and  swallowed.  The  hands  of  a  nurse  ma\'  be  contaminated 
by  the  water  in  which  the  patients  are  tubbed. 

Whether  the  bacilli  multiply  outside  the  body  in  the  water  of  wells  or 
rivers  to  which  they  have  obtained  access  is  not  well  settled.  A  most 
noteworthy  instance  of  an  epidemic  caused  by  contamination  of  drinking- 
water  occurred  in  1885  at  Plymouth,  Penna.,  U.  S.  A.,  where  120&  persons 
were  attacked  and  130  died,  all  the  cases  starting  from  a  single  subject, 
whose  discharges  contaminated  the  water-supply.  The  epidemic  (1897) 
at  Maidstone,  England,  furnishes  another  illustration  of  the  effect  of  con- 
taminated water-supply.  Within  two  weeks  after  the  outbreak,  about  the 
middle  of  September,  509  cases  were  reported;  by  October  27,  1748  cases; 
November  17,  1S48  cases;  in  all,  about  1900  in  a  population  of  35,000.  The 
bacilli  develop  rapidly  in  milk  and  in  the  soil.  Many  epidemics  have  been 
directly  traced  to  contaminated  milk  supply,  the  milk  having  been 
infected  either  by  the  patient,  a  typhoid  carrier,  contaminated  water  or  flies. 
Persons  who  have  been  ill  with  typhoid  fever  and  who  have  entirely  re- 
covered have  been  found  to  transmit  the  disease  long  after  apparent  cure. 
The  source  of  contagion  in  these  "tj^phoid  carriers"  is  the  stool  which 
is  found  to  contain  myriads  of  virulent  typhoid  bacilli.  The  relatively 
infrequent  communication  of  typhoid  fever  to  ph\'sicians,  nurses,  and  others 
in  close  communication  with  the  disease  is  explained  by  the  fact  that  the 
contagion  escapes  from  the  patient  in  the  stools  and  urine,  and  as  these  are 
commonly  promptly  disposed  of,  the  chances  for  the  dissemination  of  the 
poison  from  these  sources  arc  correspondingly  few.  Carelessness  in  the 
disposition  of  these  discharges,  as  the  result  of  which  they  are  allowed  to 
dry  on  linen,  whence  the  bacilli  pass  into  the  air  of  the  room,  does  some- 

'  "Influences   of   Certain   Agents  in    Destroying  the  Vitality  of  the  Typhoid  and  Colon  Bacillus." 
"Seiene,"    February  is,  1895. 


TYFU9IB  FEVER  3 

times  occasion  the  infection  of  nurses  and  physicians  and  others  attending 
on  typhoid  cases.     BacilH  are  said  to  have  been  found  in  sputum.' 

Predisposing  Causes. — Experience  fails  to  establish  definite  predis- 
posing causes  of  typhoid  fever,  but  new-comers  to  an  infected  area  are  more 
likely  to  be  attacked  than  old  residents,  as  early  shown  by  the  French 
physicians  in  Paris.  It  certainly  often  attacks  the  strong  and  healthy  as 
fiercely  as  the  feeble  and  delicate,  while  allowance  must  be  made  for  the 
more  frequent  exposure  of  the  healthy.  Typhoid  fever  is  unlimited  in  its 
distribution  by  climate  or  civilization,  but  it  may  be  complicated  by  disease 
peculiar  to  certain  localities,  pre-eminently  malaria. 

Typhoid  fever  is  a  disease  of  adolescents  and  adults  under  30,  although 
it  may  occur  at  any  age.  Less  common  in  children,  the  disease  has  been 
found  in  a  child  five  days  old,  while  not  a  few  cases  have  been  reported 
in  sucklings.  Infection  in  utero  is  claimed  as  possible  because  of  successful 
cultures  of  bacilli  from  the  fetus.  In  the  young  the  duration  of  the  disease 
is  short  and  the  prognosis  singularly  favorable.  It  has  occurred  at  the  age 
of  75,  86,  and  even  90.  More  men  than  women  have  typhoid  fever  (71 
per  cent,  of  444  cases  collected  by  Reginald  H.  Fitz),  probably  because  of 
their  more  frequent  exposure.  The  assertion  that  the  pregnant  state 
seems  to  protect  against  typhoid  fever  is  not  substantiated  by  experience 
in  Philadelphia,  in  evidence  of  which  may  be  stated  that  within  two  months 
there  were  received  in  the  wards  at  the  Hospital  of  the  University  of  Penn- 
sylvania three  pregnant  women  with  typhoid  fever. 

Typhoid  fever  is  more  common  in  the  late  summer  and  autumn  months 
than  at  any  other  time  of  the  year,  whence  one  of  the  names,  "autumnal 
fever."  It  has  been  observed  that  hot  and  dry  summers  are  followed  by 
more  cases  than  hot  and  moist  summers.  Liebemieister  explains  the  relation 
of  typhoid  to  the  hot  and  dry  season  by  the  fact  that  at  this  season  the 
quantity  of  solid  matter  in  springs  is  relatively  larger;  that  the  poison,  in 
other  words,  is  more  concentrated,  and  therefore  more  virulent.  Special 
epidemics  may  occur  at  any  season.  Thus  the  epidemic  of  typhoid  fever 
at  Plymouth,  Penna.,  alluded  to,  began  April  10,  and  raged  with  greatest 
fury  during  May  and  June.     Other  epidemics  iUustrate  the  same  truth. 

Morbid  Anatomy. — The  characteristic  lesions  of  typhoid  fever  include 
the  changes  in  the  lymphoid  structures  of  the  intestine,  the  solitary  glands 
and  Payer's  patches,  though  properly  speaking  the  disease  afEects  the  body  as 
a  wh®le.  Histologically  according  to  Adami  there  is  proliferation  of  the 
lymphoid  elements  and  perifollicular  infiltration  of  leukocj^tes  and  intense 
congestion  of  all  the  vessels.  The  Peyer's  patches  are  prominent,  plaque- 
like, and  intensely  red,  while  the  solitary  glands  are  red,  enlarged  and  some- 
times polypoid.  In  the  second  week  the  central  portions  of  the  intestinal 
glands  undergo  coagulation  necrosis,  slough  away  and  leave  a  ragged  ulcer. 
In  a  few  days  well-defined  ulcers  are  caused  by  more  sloughing.  The  ulcers 
have  a  smooth  base  and  indurated  edges.  This,  when  it  represents  a  single 
follicle,  is  small  and  circular,  not  more  than  from  three  to  six  millimeters 
(1/8  to  1/4  inch)  in  diameter;  large  and  elliptical  when  an  entire  Peyer's 
patch  is  involved.     Such  a  patch  is  usually  opposite  the  mesenteric  attach- 


'  "Jehle.  Wien.  klin.  Wochenschrift,"  1902.     "Glaser,   Deutsch.  med.  Wochenschr.,"  1902,  No.   43, 
pages  772  and  793. 


4  IM'IiCTlOLS  DLSEASKS 

mcnt,  having  its  longest  diameter  parallel  with  the  length  of  the  bowel  and 
its  shorter  transverse,  thus  reversing  the  relations  of  the  tubercular  ulcer. 
Much  larger  ulcers  are  sometimes  formed  by  the  union  of  others,  especially 
toward  the  lower  end  of  the  bowel.  The  floor  of  the  ulcer  is  usually  the 
submucosa,  or  the  muscular  coat  of  the  bowel,  but  it  may  be  the  peritoneum, 
and  even  this  is  sometimes  sphacelated,  appearing  as  an  opaque  white 
membrane  that  sooner  or  later  breaks  and  the  bowel  is  perforated.  More 
commonly,  the  ulcer  heals,  and  the  patient  recovers,  but  the  normal  glandu- 
lar strticture  of  the  gut  at  the  seat  of  the  idcer  is  not  restored.  Necropsy 
frequently  discovers  iilcers  in  different  stages  of  healing.  The  large  intes- 
tine is  also  invaded  in  probably  one-third  of  the  cases,  and  the  process  may 
terminate  here  also  in  perforation.  Ulceration  may  extend  to  the  appendix, 
where,  too,  perforation  sometimes  takes  place. 

Similar  infiltration  of  the  lymph  nodules  and  lymph  cords  of  the  mesen- 
teric glands  and  of  the  spleen  may  occiu",  contributing  to  the  enlargement 
of  these  organs.  In  the  spleen  it  is  associated  with  an  active  hyperemia 
that  contributes  to  further  enlargement,  generally  recognizable  during  life. 
The  organ  may  reach  twice  or  three  times  its  normal  size — i.  e.,  435  to  650 
gm.  (14  to  20  ounces).  There  has  even  been  rupture  of  this  organ;  see  a  case 
recently  reported  by  Conner  of  N.  Y.  Hemorrhagic  infarcts  have  been 
found  in  the  spleen  in  from  fotir  to  seven  per  cent,  of  cases  coming  to 
autopsy.     Abscess  of  the  spleen  has  been  found. 

Perforation  has  been  noted  at  necropsy  in  5.7  per  cent,  of  cases — that 
is,  114  out  of  2000  autopsies  in  Munich;  by  Osier,  in  2.48  per  cent,  of  685 
cases;  and  J.  Alison  Scott,  in  3.6  per  cent,  of  9713  cases.  It  occurred  in 
only  one  of  105  soldiers  treated  at  the  University  Hospital  in  the  fall 
of  1898. 

As  to  the  location  of  perforation,  Hawkins  found  it  in  61  of  72  cases  in 
the  ileum,  three  in  the  cecum,  three  in  the  appendix,  and  five  in  the  colon, 
most  of  the  latter  being  in  the  sigmoid  flexure.  In  167  cases  collected  bj' 
Fitz  the  ileum  was  perforated  in  136,  the  large  intestine  in  20,  the  appendix 
in  five,  Meckel's  diverticulimi  in  four,  the  jejunum  in  two.  The  number  of 
perforations  maj'  vary  from  one  to  several.  The  accident  is  most  frequent 
in  the  third  week,  or  close  to  the  third  week.     It  is  more  frequent  in  men. 

The  liver,  among  organs  more  rarely  affected,  shows  cloudy  swelling, 
granular  and  fatty  degeneration  of  its  cells,  lymphatic  nodular  areas,  and 
even  liver  abscess  with  pylephlebitis,  and  acute  yellow  atrophy.  Abscess  of 
the  liver  was  found  12  times  in  the  Munich  necropsies,  and  acute  j-ellow 
atrophy  three  times.  P_\'lephlebitis  has  followed  abscess  of  the  mesentery 
and  perforation  of  the  appendix.  Typhoid  bacilli  are  often  found  in  the 
gall-bladder  in  fatal  cases;  in  Cliiari's  reports'  19  out  of  22;  in  Simon  Flex- 
ner's,  seven  out  of  14.  Perforation  of  the  gall-bladder  is  sometimes  met, 
and  Keen  has  collected  30  cases  in  his  book  on  the  "Surgical  Complications 
and  Sequels  of  Typhoid  Fever,"  189S. 

In  the  kidneys  there  may  be  cloudy  swelling  and  granular  degeneration 
of  renal  cells,  more  rarely  acute  nephritis,  which  may  even  be  hemorrhagic; 
also  miliary  abscesses  in  which  typhoid  bacilli  have  been  found.     Diphther- 

'  "Pragcr  medicinische  Wochcnschrift,"  1893,  No.  22. 


TYPHOID  FEVER  5 

itic  and  catarrhal  inflammation  of  the  pelvis  of  the  kidney  and  catarrhal 
inflammation  of  the  bladder  are  occasionally  present. 

Changes  in  the  respiratory  organs  axe  often  found.  Among  the  rarer 
of  these  are  edema  of  the  glottis,  ulceration  of  the  larynx,  and  even  necrosis 
of  the  laryngeal  cartilages.  This  occurs  frequently.  Keen  has  collected 
221  cases,  many  of  which  gave  rise  to  serious  symptoms.  Hypostatic  con- 
gestion of  the  lungs  is  quite  common;  pneumonia  is  more  infrequent.  The 
pneumonia  may  be  of  pneumococcic  origin  or  it  may  be  the  result  of  im- 
plantation of  the  typhoid  bacillus  in  the  lung,  a  true  typhoid  pneumonia. 
Even  gangrene  of  the  lungs  was  found  in  40  of  the  Munich  cases;  abscess, 
in  14;  and  hemorrhagic  infarction,  in  129.  Pleurisy  and  empyema  are  rare 
events. 

In  the  circulatory  system  there  may  be  thrombosis  of  veins,  especially  of 
the  femoral,  causing  the  not  very  rare  symptom  of  milk-leg;  more  rarely 
there  is  thrombosis  of  the  femoral  arterjs  which  may  be  preceded  by  embo- 
lism. Thrombosis  of  the  cerebral  veins  may  give  rise  to  hemiplegia.  En- 
docarditis, pericarditis  and  myocarditis  may  be  present.  The  latter  con- 
dition is  attested  by  a  yellow,  soft,  and  flabby  muscle  seen  after  death. 

As  to  the  nervous  system,  notwithstanding  the  intensity  of  the  nervous 
symptoms  at  times,  meningitis  is  a  rare  event,  though  both  serous  and 
purulent  forms  have  been  met,  typhoid  bacilli  being  found  in  loco  as  the 
apparent  cause;  also  thrombosis  of  cortical  veins  and  parenchj^matous 
changes  in  nerve-trunks,  even  when  there  have  been  no  symptoms  of  neuri- 
tis. Abscess  of  the  brain  has  also  been  found  with  the  bacillus  typhosus 
in  loco. 

In  the  muscular  system  granular  and  hyaline  transformation  of  volun- 
tary muscle  may  occur,  as  in  other  fever  processes. 

Osseous  System. — Periostitis  or  ostitis  in  various  bones  of  the  body  is  not 
rare.  Warfield  T.  Longcope^  has  studied  the  marrow  of  hone  in  typhoid 
fever.  He  found  congestion,  edema,  focal  necrosis  and  many  large  phago- 
cytic cells  which  last  he  regards  as  typical.  A  striking  feature  was  a 
mild  general  hyperplasia  of  all  the  blood-forming  cells,  with  also  some 
and  often  a  very  decided  increase  of  the  non-granular  cells  and  swell- 
ing of  the  lymphoid  follicles.  There  was  a  marked  scarcity  of  eosinophiles. 
Polymorphonuclear  leukocytes  were  numerous  in  the  uncomplicated  cases ; 
in  cases  complicated  by  acute  infections  they  were  less  numerous,  practi- 
cally absent.  The  lesions  were  more  marked  the  more  prolonged  the 
disease  before  death. 

Abscesses  in  the  parotid  gZawd  are  a  familiar  lesion ;  more  rarely,  abscesses 
in  the  intermuscular  tissue. 

General  invasion  of  all  organs  and  of  the  blood  (bacillsmia)  by  the 
typhoid  bacillus  are  now  not  infrequently  found. 

Typhoid  fever  without  enteric  lesions  has  been  reported  by  Sidney 
Philips,  J.  W.  Moore,  Simon  Flexner,  and  others,  without  these  lesions. 
In  doubtful  cases  the  Widal  reaction  and  the  presence  of  bacilli  as  deter- 
mined by  cultures  must  be  appealed  to. 

Symptoms  and  Course. — A  certain  period  of  incubation  is  necessary  after 

^  Longcope,  "Bulletin  of  the  Ayer  Clinical  Laboratory  of  the  Pennsylvania  Hospital,"  No,  2,  January, 
190S. 


6  INFECTIOUS  DISEASES 

the  successful  implantation  of  the  bacillus  before  typhoid  fever  arises. 
This  varies  from  a  week  to  two  weeks  and  even  longer.  The  period  of  in- 
cubation is  usually  without  symptoms,  but  there  may  be  a  sense  of  weariness 
and  indisposition  to  exertion,  the  latter  often  overcome  by  force  of  will; 
also  a  want  of  appetite  and  a  slight  coating  of  the  tongue,  These  symptoms, 
more  strictly  speaking,  belong  to  the  prodrome,  and  are  in  turn  not  sharply 
separated  from  those  of  the  disease  itself,  which  usually  sets  in  very  grad- 
ually and  is  often  quite  advanced  before  suspected,  indeed,  sometimes  well 
advanced,  constituting  the  "walking"  or  "ambulatory"  typhoid.  In 
children  the  onset  is  less  gradual,  frequently  abrupt.  There  may  be  headache, 
anorexia,  a  furred  tongue,  nausea,  chilliness,  but  only  rarely  a  decided  rigor. 
The  disease  may  be  ushered  in  by  muscular  pain  in  the  back  or  legs.  Nose- 
bleed has  always  been  considered  characteristic,  and  yet  it  is  less  fre- 
quent than  might  be  expected  from  the  text-book  statements.  More 
common  is  looseness  of  the  bowels.  Or  if  not  looseness  an  aperient  acts 
more  severely  than  it  does  in  a  healthy  person.  All  this  time  there  is  slight 
fever,  and  the  patient  feels  wretched,  the  fever  and  the  discomfort 
increase,  and  finally  he  goes  to  bed.  The  tendency  to  looseness  of  the 
bowels  and  epistaxis,  more  than  any  other  symptom  of  this  group,  justify 
strong  suspicion  of  the  existence  of  typhoid  fever.  Yet  one  or  both  are 
quite  often  absent.  Certain  epidemics  are  more  apt  to  be  attended  by 
diarrhea  than  others.  The  abdomen  soon  becomes  slightly  distended  and 
tympanitic,  and  pressure  in  the  right  iliac  fossa  will  usually  elicit  tender- 
ness with  gurgling.  At  times  there  is  colicky  pain  of  varj^ing 'severity  in- 
dependent of  pressure;  at  others  the  gastric  symptoms  are  marked  and 
nausea  and  vomiting  are  present. 

Usually  about  the  eighth  day,  rarely  later  and  sometimes  a  little  earlier, 
rose-colored  spots  make  their  appearance  on  the  skin  of  the  abdomen  and 
chest,  more  rarely  elsewhere  on  the  body.  These  call  for  further  descrip- 
tion. They  are  usually  bright  red  in  color,  and  are  well  compared  to 
a  fleabite.  They  are  very  slightly  raised  above  the  surface  and  disappear 
on  pressure,  to  return  instantly  after  its  removal.  Their  number  varies 
greatly.  Sometimes  they  are  very  numerous,  covering  the  entire  trunk; 
oftener  there  are  fotu"  or  five  to  ten,  again  one  or  two,  most  rarely  none. 
When  numerous,  they  occur  in  successive  crops,  each  crop  lasting  from  two 
to  four  days.  Histologically,  they  are  circumscribed,  actively  hyperemic 
areas,  the  hyperemia  being  excited  by  some  irritant,  which  may  be  the 
typhoid  bacillus  itself,  since  it  has  been  found  in  the  spots.  Only  in  the 
most  malignant  cases  is  there  any  blood  found  outside  of  the  vessels,  and 
when  this  occurs,  the  spots  can  be  made  to  disappear  but  partially  on  pres- 
sure. The  association  of  roseolar  spots  is  so  intimate  with  the  disease  that 
they  have  been  regarded  as  pathognomonic.  Rose-colored  spots  are  much 
more  uncommon  in  children. 

In  addition  to  rose-colored  spots,  sudamina  are  often  present  in  large 
nimibcrs  on  the  skin,  especially  when  the  disease  is  associated  with  much 
sweating,  but  their  occurrence  is  by  no  means  constant,  and  their  association 
with  other  diseases  in  which  there  is  perspiration  is  well  known.  More 
rarely,  petechia  and  vibices  are  noted  in  adynamic  forms  of  the  disease.  An 
erythema  is  quite  often  found  on  the  skin  of  the  chest  and  abdomen.     Peli- 


TYPHOID  FEVER  7 

omatous  patches — the  tdche  bleudire — sometimes  are  found  on  the  skin  of 
the  thorax,  abdomen,  and  thighs;  also  the  tdche  cerebrale — a  red  line,  pro- 
duced on  drawing  the  finger-nail  over  the  skin — but  neither  have  any 
symptomatic  significance.  Herpes  is  rare  but  occurs  according  to  McCrae 
and  to  Phillips  in  about  one  per  cent,  of  the  cases.  Jaundice  is  occasion- 
ally seen,  and  may  be  the  result  of  an  obstructive  cholangitis  excited  by 
the  bacillus. 

Enlargement  of  the  spleen  is  an  almost  constant  clinical  feature  of  typhoid 
fever.  If  the  vertical  dulness  exceeds  the  depth  of  two  ribs  and  an  inter- 
space, enlargement  is  present.  Not  only  may  this  be  recognized  by  per- 
cussion, but  by  palpation  as  well.  Clinicians  generally  lay  great  stress 
on  palpation,  and  enlargement  may  sometimes  be  detected  by  it  when 
the  organ  eludes  percussion  by  reason  of  tympany.  At  times  the  outline 
is  indistinct,  at  others  both  the  tip  and  anterior  edge  of  the  organ  can  be 
distinctly  located.  Lay  the  patient  on  his  back.  Palpate  the  abdomen 
below  the  margin  of  the  ribs  on  the  left  side  with  the  left  hand,  forcing  the 
tips  of  the  fingers  very  gently  under  the  ribs.  Have  the  patient  take 
a  deep  inspiration,  at  the  same  time  pushing  the  spleen  forward  with  the 
right  hand  placed  posteriorly  over  the  eleventh  and  twelfth  ribs.  En- 
largement can  generally  be  detected  at  the  end  of  the  first  week  or  in  the 
first  half  of  the  second  week,  when  the  organ  may  reach  twice  or  three 
times  its  normal  size.  By  the  end  of  the  third  week  in  uncomplicated  cases  it 
begins  to  diminish  in  size.  The  enlarged  spleen  may  also  be  tender.  En- 
largement is  less  frequent  in  cases  occurring  late  in  life.  Recently,  desiring 
to  know  in  what  proportion  of  cases  of  typhoid  fever  the  spleen  is  palpable, 
the  record  of  looo  cases  at  the  Pennsylvania  Hospital  was  examined  and  it 
was  found  that  in  32.8  per  cent,  the  organ  was  palpable  on  admission.  This 
can  only  be  approximate,  as  considerable  variation  was  found  in  the  obser- 
vations by  different  resident  physicians. 

Early,  too,  in  the  disease  the  patient  may  have  a  slight  cough,  unasso- 
ciated  with  physical  signs,  or  at  most  those  of  a  mild  bronchial  catarrh. 

The  fever  is  at  once  the  most  important  and  characteristic  symptom, 
and  from  the  temperature  alone  a  diagnosis  can  be  suspected.  During  the 
increment  of  the  disease  it  exhibits  a  peculiar,  tide-like  evening  rise  and 
morning  fall,  while  the  temperature  of  each  morning  and  evening  is  from 
one  and  a  half  to  three  degrees  higher  than  that  of  the  previous  morning 
and  evening.  The  patient  is  rarely  seen  at  the  very  beginning  of  this  first 
stage;  it  lasts  commonly  a  week.  Frequently  it  is  succeeded  at  the -end  of 
four  or  five  days  by  the  acme  or  fasti gium,  in  which  are  continued  the 
evening  rise  and  the  morning  fall,  but  the  evening  and  morning  difference 
is  less  marked,  the  tidal  character  is  no  longer  present,  and  the  temperature 
is  high  throughout.  The  average  duration  of  the  fastigium  is  five  to  eight 
and  ten  days,  being  longer  in  severe  cases  and  shorter  in  milder  ones.  In 
protracted  cases  the  period  of  febrile  elevation  may  be  still  longer.  It  is 
during  it  that  we  meet  the  maximum  temperature,  quite  often  105°  F. 
(40.5°  C.)  or  a  little  above,  more  rarely  106°  F.  (41.1°  C).  A  temperature 
of  106°  F.  is  not  infrequently  followed  by  recovery,  but  while  107°  F. 
(41.6°  C.)  and  108°  F.  (42.2°  C.)  and  even  109°  F.  (42.7°  C.)  are  met,  such 
cases  have  invariably,  in  our  experience,  terminated  fatally. 


8  INFECTIOUS  DISEASES 

The  fastigium  is  succeeded  by  the  third  stage,  or  period  oj  decrement  or 
decline,  in  which  the  reverse  of  the  initial  stage  is  shown  by  an  evening 
temperature  lower  than  that  of  the  previous  evening,  and  the  morning 
temperature  lower  than  that  of  the  previous  morning,  but  with  the  evening 
temperature  still  higher  than  that  of  the  morning  of  the  same  day.  This 
decline  continues  until  the  normal  is  reached,  and  from  one  to  two  weeks  are 
consumed  before  that  is  attained.  The  whole  is  much  better  shown  and 
more  easily  understood  from  a  chart  than  from  a  description  in  words. 
Such  a  chart  of  the  temperature  uninfluenced  by  treatment  is  seen  in  figure 
I,  although  the  rise  and  fall  are  not  always  as  regular  as  indicated.     In  a 


EUP 

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typical  case  one  might  safely  place  the  first  stage  at  four  days  to  a  week ; 
the  second,  or  fastigium,  as  seven  to  ten;  and  the  third,  about  as  long  as  the 
second,  the  shorter  period  corresponding  to  a  mild  case  and  the  longer  to  a 
severe  one.  The  fever  does  not  always  reach  the  higher  temperature  shown 
in  the  chart,  and  sometimes  the  maximum  never  reaches  102°  F.  (38.9°  C). 
On  the  other  hand,  there  is  sometimes  a  difference  of  three  or  four  degrees 
in  the  morning  and  evening  temperature,  and  the  latter  may  drop  to 
normal.  In  ordinary  cases  the  evening  temperature  falls  to  the  normal  in 
the  course  of  the  fourth  week,  but  in  severe  cases  the  temperature  keeps  up 
during  the  fifth  and  even  sixth  week,  these  cases  having  almost  invariably 
extensive  ulceration  wnth  great  tenderness  of  the  abdomen  and  meteorism. 


TYPHOID  FEVER  9 

Many  of  them  terminate  unfavorably  by  hemorrhage  or  perforation.  In 
some  cases  the  temperature  is  quite  irregular  throughout  the  entire  course 
of  the  disease.  Frequently  after  the  morning  temperature  has  reached 
normal,  the  fever  rises  abruptly  in  the  evening,  to  fall  again  in  the  morning, 
a  true  remittent  or  intermittent  type  of  fever,  lasting  several  days.  One 
case  on  record  at  the  Episcopal  Hospital  had  this  type  for  fifteen  days  with 
nothing  discoverable  to  account  for  it. 

When  the  disease  begins  with  a  chill — a  rare  event — the  temperature 
rises  more  rapidly  in  the  beginning.  Sudden  falls  of  a  decided  character 
may  occur  in  consequence  of  hemorrhage  from  the  bowels,  or  the  nose  or 
from  collapse  after  perforation  of  the  bowels.  Sudden  rises  are  produced  by 
indiscretion  in  diet  and  overexertion  or  the  supervention  of  some  acute 
inflammatory  affection,  as  pneumonia,  or  phlebitis.  In  a  few  cases  the  tem- 
perature is  not  at  all  characteristic.  Rarely  there  is  a  reversal  of  tempera- 
ture the  higher  being  found  in  the  morning. 

Copious  sweating  characterizes  some  cases  of  typhoid  fever,  though  the 
skin  is  more  commonly  dry.  Sometimes,  during  the  reaction  after  a  cold 
bath,  there  is  perspiration.  The  profuse  sweats  first  alluded  to  are  not 
attended  by  a  reduction  of  temperature,  being  sometimes  present  when  the 
temperature  is  highest.  Cases  of  recurring  parox5rsms  of  chiU,  fever,  and 
sweat  are  reported,  which  simulate  intermittent  fever,  and  may  reasonably- 
be  mistaken  for  it. 

The  pulse  is  only  moderately  frequent,  go  to  120  being  the  usual  range, 
while  a  proximity  to  100  is  quite  frequently  maintained.  In  grave  cases  it 
becomes  more  frequent,  140  or  more;  when,  if  maintained,  it  is  a  rather 
unfavorable  symptom,  due  to  high  temperature  or  complications.  Tem- 
perature and  pulse  do  not  always  increase  pari  passu.  Dicrotisni  may  occur 
with  frequent  pulse,  but  dicrotism  also  occurs  in  the  early  stage,  when  it  is 
regarded  by  some  as  diagnostic.  According  to  Curschmann,  dicrotism  is 
more  common  in  typhoid  fever  than  all  the  other  infectious  diseases  taken 
together.  During  convalescence  the  pulse  gradually  resumes  its  normal 
character,  and  sometimes  becomes  abnormally  slow,  falling  to  30  or  less, 
we  have  had  a  case  in  which  the  pulse  fell  as  low  as  18,  and  continued  for 
one  day  between  20  and  36.  Typhoid  fever  is  characterized  by  low  blood 
pressure  the  fall  beginning  toward  the  end  of  the  first  week.  The  pressure 
remains  low  until  convalescence  is  established. 

The  breathing  rate  commonly  advances  with  the  rate  of  the  pulse, 
but  is  sometimes  increased  in  frequency  by  temporary  causes  and 
rarely  is  disproportionately  slow.  In  a  very  striking  case  at  the 
University  Hospital  the  rate  fell  to  twelve  in  a  minute,  and  continued 
thus  for  an  hour. 

The  heart-sounds,  at  first  natural,  grow  less  loud  as  adynamia  pro- 
gresses, and  the  first  sound  may  even  disappear  in  grave  cases.  Sometimes 
a  soft  systolic  murmur  develops  at  the  apex,  usually  at  the  end  of  the  second 
week.  Sometimes  it  acquires  greater  intensity.  It  has  been  especially 
studied  by  M.  G.  Hayem,'  who  ascribes  it  not  to  an  endocarditis,  but  to  a 
relaxation  of  the  muscle  which  results  in  imperfect  apposition  of  the  valves 


*  M.    G.    Hayem.    "Des  manifestations  cardiaques  de  la  fievre  typhoid,"  "Le  Progres  Medical,"  17 
Juillet  ,187s.  p.  401  et  seq. 


10  IXFECTIOUS  DISEASES 

and  a  consequent  regurgitation.  This  murmur  disappears  as  recovery  takes 
place,  and  the  heart-muscle  grows  strong. 

In  the  beginning  the  typical  tongue  is  covered  with  white  fur  in  the 
back  and  center,  is  rather  dry,  is  somewhat  pointed,  and  the  tip  and  edges 
are  bright  red.  As  the  disease  advances,  the  tongue,  previously  furred, 
tends  to  become  dry  and  brown,  clearing,  however,  at  the  edges  and  tip  as 
the  case  improves.  In  severe  cases,  especially  if  the  mouth  is  not  kept 
clean,  stomatitis  with  fissures  and  bleeding  may  occur,  and  sordes  maj'  collect 
on  the  teeth,  while  the  lips  become  covered  with  black  crusts,  constituting 
the  "fuliginous  coating."  These  phenomena  are  almost  unknown  vnih  the 
bath  treatment.  Mild  grades  of  pharyngitis  producing  painful  swallowing, 
sometimes  usher  in  the  attack,  more  particularly  in  certain  epidemics. 

The  diarrhea  of  typhoid  fever  has  been  alluded  to.  It  is  said  to  be 
present  in  20  to  30  per  cent,  of  cases.  Usually  corresponding  in  severity 
with  the  extent  of  the  local  lesion,  it  is  seldom  troublesome  or  difficult  to 
control,  and  is  sometimes  absent  throughout.  The  stools  have  no  charac- 
teristic qualities.  They  may  be  grayish-yellow  and  are  usually  fetid. 
Persistent  severe  diarrhea  points  to  extensive  ulceration. 

Meteorism  in  moderate  degree  is  an  almost  constant  symptom.  The 
distention  by  gas  is  commonly  ascribed  to  atony  of  the  bowels.  Its  presence 
in  high  degrees  adds  to  the  seriousness  of  the  case,  since  it  corresponds 
usually  with  the  extent  of  bowel  lesion,  and  soon  succeeds  perforation. 

Hemorrhage  from  the  bowels,  also  a  consequence  of  intestinal  ulceration 
and  the  separation  of  sloughs,  is  a  serious  symptom,  but  by  no  means  al- 
ways fatal,  though  large  quantities  of  blood  are  sometimes  discharged  per 
anum.  The  occurrence  of  such  hemorrhage  is  followed  by  a  rapid  reduction 
of  the  temperature,  as  shown  in  chart  Fig.  2,  and  a  pallor  and  faintness 
such  as  are  common  to  large  hemorrhages  elsewhere.  As  stated,  very 
profuse  hemorrhages  may  be  followed  by  recovery,  and  it  is  barely  possible 
that  a  favorable  influence  may  sometimes  be  exerted  by  them.  Very 
rarely  a  patient  will  bleed  to  death.  Hemorrhage  was  a  cause  in  u  out 
of  56  deaths  in  Osier's  685  cases.  It  occurred  99  times  in  2000  cases  in 
Munich,  and  eight  times  in  105  soldiers  under  our  care  after  the  Spanish- 
American  war.  Severe  and  occasionally  fatal  hemorrhage  may  occur  from 
the  nose. 

Deliriiim  is  less  constantly  present  in  typhoid  fever  than  in  typhus, 
and  may  be  absent  throughout.  It  may,  however,  be  very  active,  requiring 
the  patient  to  be  carefully  watched  to  prevent  him  from  leaving  his  bed  and 
seriously  endangering  his  life.  More  than  one  victim  has  leaped  from  a 
window  with  fatal  results  under  such  circumstances.  In  certain  cases, 
especially  when  the  initial  headache  is  very  intense,  this  symptom  continues 
and  to  it  are  added  fever  and  delirium  so  extreme  that  meningitis  is  simu- 
lated, though  the  true  form  of  this  disease  rarely  occurs.  Such  cases 
illustrate  the  nervous  "form"  of  the  disease.  A  tendency  to  drowsiness, 
and  even  to  stupor,  .suggested  the  common  name  "typhoid,"  but  it  is  less 
characteristic  than  in  typhus.  Rarely  convulsion  occurs  in  the  course  of 
the  disease,  in  Murchison's  experience  in  six  out  of  2690  cases.' 

Muscular  tremor  is  a  symptom  in  severe  cases,  when  it  would  seem  to 

'  Sec  a  paper  by  Thomas  Claytor  in  "  Philadelphia  Medical  Journal,"  March  3,  1900. 


TYPHOID  FEVER 


11 


indicate  a  muscular  weakness  or  exhaustion,  which  may  be  an  effect  of  high 
temperature  or  of  the  specific  poison  of  the  disease.  Carphologia,  or 
"picking  at  the  bedclothes,"  is  a  symptom  of  which  the  unfavorable  im- 
port has  been  somewhat  exaggerated,  probably  because  of  the  popular  fa- 


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miliarity  with  Dame  Quickly's  interpretation  in  Falstaff's  illness.  Con- 
currently with  these  "  typhoid ' '  symptoms,  the  tongue  reaches  its  maximum 
dryness,  and  may  be  dark  and  leathery  in  appearance,  while  sordes  may 
collect  on  the  teeth. 


12  I.XFECT/OUS  DISEASES 

Hiccough  is  an  infrequent,  but  sometimes  obstinate  symptom. 
Apart  from  an  initial  bronchial  catarrh,  which  sometimes  ushers  in  the 
disease,  the  typhoid  patient  sooner  or  later  acquires  a  slight  cough,  due  to 
hypostatic  congestion  of  the  lungs,  but  it  is  easily  kept  within  bounds  by 
frequent  changes  in  the  position  of  the  patient.  Occasionally,  the  cough  is 
quite  severe,  but  seldom  requires  more  active  treatment  than  this.  The 
initial  bronchial  catarrh,  too,  sometimes  assumes  severity,  while  more  rarely 
the  symptoms  and  signs  of  pneumonia  usiier  in  the  disease. 

Changes  in  the  Urine. — The  urine  is  always  dark-hued  and  concentrated, 
with  a  correspondingly  high  specific  gravity.  Often  when  the  fever  is  high 
the  urine  contains  a  small  amount  of  albumin.  When  complicated  with 
nephritis,  there  is  more  albumin,  and  tube-casts  are  present.  Recent  French 
statistics  place  albuminuria,  regardless  of  its  cause,  at  over  20  per  cent. 
While  such  albuminurias  are  found  in  grave  cases,  they  do  not  appear 
to  add  greatly  to  the  seriousness  of  the  case,  and  recovery  is  the  usual 
termination.  More  rarely,  nephritis  in  a  mild  form  may  develop  during 
convalescence.  Most  rarely,  still,  it  may  be  an  initial  symptom  of  the 
disease,  constituting  a  nephro-typhoid  analogous  to  the  pneumo-typhoid, 
when  it  may  even  mask  the  true  disease  by  its  severity.  It  is  well  named 
by  the  French — fievre  typhoide  d  forme  renale.  Only  the  Widal  test,  the 
intestinal  symptoms,  and  the  spots  clear  up  the  diagnosis.  Such  nephritis 
may  rarely  be  hemorrhagic.  The  toxic  properties  of  urine  are  said  to  be 
increased  during  typhoid  fever,  especially  while  the  cold  baths  are  being 
used. 

The  urine  may  contain  bacilli  of  typhoid  fever,  generally  associated 
with  albumin.  The  following  summary  from  Norman  B.  GwA^n's  paper 
in  the  "Johns  Hopkins  Bulletin,"  June,  1899,  condenses  our  present 
knowledge : 

"i.  In  quite  a  high  percentage,  perhaps  from  20  to  30  per  cent.,  of  all 
cases  of  typhoid  fever  typhoid  bacilli  may  be  present  in  the  mine. 

"2.  When  present,  they  are  usually  in  pure  culture,  often  so  numerous 
as  to  make  the  freshly  voided  urine  turbid,  and  may  then  be  detected  by  a 
cover-slip  examination. 

"3.  Appearing  generally  in  the  second  and  third  week  of  illness,  the 
organisms  may  persist  for  months  or  years,  probably  multiplying  in  the 
bladder,  the  urine  being  apparently  a  suitable  medium  for  their  growth. 

"4.  Though  often  showing  evidences  of  cj'stitis  and  marked  renal  in- 
volvement, the  urine  containing  bacilli  has  usually  only  the  characteristics 
of  an  ordinary  febrile  urine ;  the  presence  of  bacilli  has  no  prognostic  impor- 
tance, and  their  disappearance  or  persistence,  without  having  induced 
local  change,  is  the  rule. 

"5.  Lastly,  as  shown  by  Richardson,  irrigation  of  the  bladder  with 
bichlorid  of  mercury  and  the  internal  administration  of  hexamethylenamine 
— a  compound  of  ammonia  and  formaldehyde — seem  to  be  safe  methods  of 
removing  the  bacilli;  30  to  60  grains  of  the  latter  quickly  removing  all 
bacilli  in  six  cases." 

More  recent  studies,  especially  by  Hiss  {loc.  citato),  go  to  show  that  the 
mine,  in  consequence  of  the  more  prolonged  presence  of  the  bacilli,  may  be  a 
more  frequent  source  of  infection  to  the  community  at  large  than  the  feces. 


TYPHOID  FEVER  13 

The  so-called  diazo  reaction  of  urine,  to  which  attention  was  first  called 
by  Ehrlich  in  1882,  is  so  constant  in  this  disease  as  to  be  deservedly  regarded 
as  a  symptom.  It  was  found  by  John  Hewetson  in  136  out  of  196  cases, 
and  by  Arthur  R.  Edwards  in  128  out  of  130  cases,  and  by  Simon  in  22  out  of 
26  cases.  I  have  never  found  it  absent  when  the  test  was  made  sufficiently 
early. 

For  making  the  test  three  solutions  are  necessary: 

1.  A  five  per  cent,  solution  of  hydrochloric  acid  saturated  with  sul- 
phanilic  acid.     This  solution  should  be  fresh.  . 

2.  A  half  of  one  per  cent,  solution  of  sodium  nitrite. 

3.  Ammonium  hydrate. 

When  it  is  desired  to  make  the  test,  40  c.c.  of  (i)  and  i  c.c.  of  (2)  are 
mixed.  The  hydrochloric  acid,  acting  on  the  sodium  nitrite,  liberates 
nitrous  acid,  which  in  its  nascent  state  combines  with  the  sulphanilic  acid, 
producing  diazo-benzine-sulphonic  acid.  Equal  parts  of  this  mixed  solu- 
tion and  urine  are  thoroughly  shaken ;  enough  of  the  ammonia  is  then  allowed 
to  flow  carefully  down  the  side  of  the  tube  to  form  a  colorless  zone  above  the 
tirine  mixture.  At  the  junction  of  the  two  fluids  a  dark-garnet  or  cherry- 
red  ring  will  form  if  the  reaction  takes  place,  and  if  the  tube  is  well  shaken, 
a  uniform  red  color  is  imparted  to  the  entire  fluid,  which,  when  allowed  to 
stand  for  some  hours,  shows  a  characteristic  olive-green  precipitate,  the 
upper  layer  of  which,  as  a  rule,  has  a  still  darker  green  color.  The  reaction 
occurs  about  the  time  of  the  appearance  of  the  rash  and  usually  continues 
until  the  22nd  day,  but  it  may  disappear  before  the  end  of  the  second  week. 
It  is,  as  stated,  symptomatic  and  not  pathognomonic,  as  it  occurs  in  many 
diseases  with  high  fever,  among  which  measles  and  miliary  tuberculosis  are 
conspicuous.  It  may,  however,  be  regarded  as  negatively  pathognomonic 
— that  is,  its  absence  is  strongly  presumptive  against  the  presence  of  typhoid 
fever. 

Polyuria  is  a  rare  symptom.  A  remarkable  case  was  reported  by  one 
of  us.^  In  this  case  as  much  as  6750  c.c.  of  urine  were  passed  in  24  hours 
dtuing  high  fever.     The  cause  of  such  excessive  polyuria  to  problematical. 

Indicanuria  is  claimed  by  Judson  Daland^  to  be  quite  frequent  in 
typhoid  fever  and  is  said  to  especially  demand  thorough  cleansing  of  the 
oral  and  nasal  cavities  whence  putrefactive  substances  may  be  carried  to 
the  stomach,  as  well  as  absorbed  ex  loco. 

Changes  in  the  Blood. — The  state  of  the  blood  in  typhoid  fever  early 
claimed  attention  and  even  the  earliest  observers,  begininng  with  Le  Canu 
in  1837,  noted  a  diminution  of  red  blood-corpuscles.  This  observation  has 
been  essentially  confirmed  by  the  most  recent  studies  with  modern  accurate 
methods,  among  which  those  by  Ouskow,^  by  Khetagurow,*  and  by  W.  S. 
Thayer^  are  conspicuous. 

At  the  beginning  of  the  fever  the  number  of  red  blood-corpuscles  is 
normal  and  even  at  the  upper  limit  of  normal,  because  the  patients  are  apt 
to  be  young  and  strong,  while  in  some  instances  the  initial  diarrhea  or  pro- 

1  Fussell,  Carmany  and  Hudson,  "Transactions  Association  of  Amer.  Physicians,"  1904. 

2  Daland,  "American  Medicine."  vol.  viii.,  1904,  p.  764. 
'  "The  Blood  as  a  Tissue,"  St.  Petersburg,  1890. 

*  "Pathological  Changes  in  the  Blood  in  Typhoid  Fever,"  Inaug.  diss.,  St.  Petersburg,  1891. 
'■'  "Two  Cases  of  Post-typhoid  Anemia,  with  Remarks  on  the  Value  of  Examination  of  the  Blood,"  vol. 
v.,  "Johns  Hopkins  Hospital  Reports,"  1895. 


14 


IXFECTIOUS  DISEASES 


nounced  sweating  may  cause  slight  concentration  of  the  blood.  During 
the  first  two  weeks  the  number  of  red  corpuscles  gradually  falls,  though  but 
slightly.  With  defervescence  they  fall  off  more  rapidly,  reaching  a  mini- 
mum usually  about  the  first  week  of  convalescence,  after  which  there  is  a 
gradual  rise  to  the  normal,  followed  again  by  a  possible  slight  fall  when  the 
patient  gets  up.  The  fall  in  the  number  of  red  corpuscles,  while  relatively 
slight,  usually  bears  a  direct  relation  to  the  severity  of  the  case. 

The  hemoglobin  is  always  reduced  and  the  reduction  is  relatively  greater 
than  the  corpuscular  loss,  with  an  even  slower  return  to  the  normal.     Ex- 


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Black — Red  Corpuscles.     Red — Hemoglobin.     Blue — Colorless  Corpuscles. 
Fig.  3. — Chart  showing  Anemia  of  Typhoid  Fever. — {From  Thayer's  "Monograph.") 


tremc  anemia,  with  a  blood  count  as  low  as  1,300,000  corpuscles  in  a  cubic 
millimeter  and  hemoglobin  as  low  as  20  per  cent.,  has  been  met. 

The  number  of  leukocytes  in  a  cubic  millimeter,  normal  at  the  begin- 
ning, tends  to  diminish  slightly  throughout  the  disease,  reaching  a  mini- 
mum toward  the  end  of  defervescence,  increasing  again  mth  the  beginning 
of  convalescence,  and  reaching  the  normal  after  several  weeks.  More 
definitely  the  change  consists  in  a  diminution  in  the  percentage  of  multinu- 
clear  or  overripe  elements,  with  a  relative  increase  in  the  large  mononuclear 
or  ripe  elements.  The  absence  of  leukocytosis  is  regarded  of  real  diagnos-  . 
tic  value,  being  in  marked  contrast  with  the  distinct  increase  in  the  number 
of  colorless  corpuscles  characteristic  of  most  other  infectious  processes.  , 


■  TYPHOID  FEVER  15 

Very  rarely  the  leukocytes  may  be  increased  with  no  signs  except  those  of 
ordinary  typhoid.  In  certain  complications  such  as  otitis,  phlebitis,  pneu- 
monia, and  perforation,  there  is  a  leukocytosis,  one  case  at  the  Episcopal 
Hospital  having  21,000  leukocytes  within  five  hours  of  a  local  peritonitis. 
Typhus  fever  is  unattended  by  blood  changes.  Pneumonia  is  usually  ac- 
companied by  leukocytosis,  while  in  a  few  cases  of  malignant  pneumococ- 
cus  infection  there  may  be  no  leukocytosis.  The  leukocyte  count  in  malarial 
fever  is  practically  the  same  as  in  typhoid  fever,  but  the  presence  of  the 
malarial  parasite  in  the  former  is  distinctive.  In  pure  miliary  tuberculosis 
unassociated  with  local  inflammatory  processes  there  is  also  an  absence  of 
leukocytosis.  It  is  important  to  remember  that  cold  baths  have  the  effect 
of  producing  a  decided  temporary  increase  in  the  proportion  of  leukocytes, 
probably  rather  in  consequence  of  an  accumulation  of  white  cells  in  the  ves- 
sels of  the  surface  than  as  the  result  of  a  true  leukocytosis. 

Unusual  Modes  of  Onset.  Atypical  Forms. — It  has  been  mentioned 
that  while  slight  chilliness  is  often  an  initial  symptom,  severe  rigor  at  the 
same  stage  rarely  occurs.  It  does,  however,  happen,  as  in  13  out  of  79  of 
Osier's  cases.  More  frequently,  chills  have  been  obser^^ed  in  the  course  of 
the  disease  from  some  one  of  the  following  causes : 

1.  At  the  onset  of  a  relapse,  or  even  during  convalescence  without 
apparent  cause. 

2 .  As  a  result  of  treatment,  especially  by  antipjnretics  internally,  guaia- 
col  externally,  or  of  a  hypodermic  injection  of  a  sterilized  culture  of  typhoid 
bacilli. 

3.  At  the  onset  of  complications,  such  as  pneumonia,  pleurisy  or 
thrombosis. 

4.  From  sepsis  during  convalescence  in  severe  and  protracted  cases. 
Under  these  circumstances  chills  may  be  frequent,  severe,  and  of  grave 
import. 

5.  From  concurrent  malaria. 

6.  From  constipation,  according  to  Herringham. 

In  epileptics  who  acquire  typhoid  fever  the  latter  disease  is  very  apt  to 
be  ushered  in  by  an  unusual  number  of  epileptic  convulsions,  which  con- 
tinue frequent  until  the  fever  becomes  established,  then  diminish,  and 
finally  cease,  often  not  recurring  until  some  time  after  recovery,  causing  the 
victim  and  his  friends  to  believe  that  the  chronic  malady  has  disappeared. 
It  returns,  however,  sooner  or  later.  The  same  is  true  of  choreic  attacks. 
Rarely,  the  disease  is  ushered  in  with  convulsions  in  children.  Convulsions 
are  rare  but  acknowledged  symptoms  in  the  course  of  the  disease  as  well  as 
at  the  onset.  Murchison  recorded  6  cases  in  2960  of  typhoid,  of  which  two 
died.  In  one  diseased  kidneys  were  discovered.  Osler^  reported  eight  cases 
of  convulsions  in  from  1500  to  1600  of  the  disease.  In  two  at  the  onset; 
in  three  during  the  course  of  the  disease,  supposed  manifestations  of  toxe- 
mia, of  which  one  died  of  perforation;  two  cases  occured  in  severe  cerebral 
complications  as  thrombosis,  meningitis  and  encephalitis  both  fatal.  One 
occurred  of  unknown  cause  during  convalescence.  The  prognosis  is  not 
considered  grave.  Aphasia  was  noted  by  S.  F.  Blakely,  of  Ora,  S.  C,  in 
the  case  of  a  girl  of  15.     The  condition  continued  for  four  weeks. 

1  Osier,  Wm.,  "Practitioner"  (London),  1906,  Ixvxxi.,  p.  i. 


16  INFECTIOUS  DISEASES 

In  diabetes  the  sugar  may  disappear  during  the  fever. 

Among  the  more  vmusual  modes  of  onset  should  be  mentioned  cases  be- 
ginning with  severe  bronchitis;  those  with  the  initial  symptoms  of  pneu- 
monia, including  chill;  those  with  initial  symptoms  of  nephritis  or  with  in- 
tense nervous  symptoms,  suggesting  cerebrospinal  meningitis.  Among  the 
latter  are  intense  headache  and  photophobia,  combinations  rapidly  passing 
over  into  active  delirium,  with  muscular  twitching  and  retraction  of  the 
head,  constituting  the  nervous  or  meningeal  form.  In  accordance  with 
recent  views  these  varieties  may  be  considered  as  representing  forms  in 
which  the  organs  especially  involved  are  the  primary  and  chief  seats  of  at- 
tack by  the  bacillus  as  contrasted  with  the  more  usual  intestinal  form.  In 
certain  long  and  severe  cases  septic  infection  occurs,  manifested  by  fever, 
sweats,  and  local  abscesses  in  various  parts  of  the  body,  including  the 
perirectal  and  perinephric  regions. 

Among  irregular  forms  is  the  so-called  abortive  form.  This  doubtful 
form  is  said  to  be  more  sudden  in  its  onset,  beginning  with  shivering  and 
fever  of  103°  F.  (39.4°  C.)  or  higher.  The  rose-colored  spots  appear  at 
from  the  second  to  the  fifth  day.  The  fever  falls  at  the  end  of  the  first  week 
or  beginning  of  the  second,  commonly  by  crisis  with  a  sweat,  after  which 
follows  convalescence.  The  hemorrhagic  is  a  grave  variety  characterized 
especially  by  cutaneous  and  mucous  hemorrhages,  and  is  fortunately  rare. 
Five  cases  of  this  variety  have  been  reported  by  Samohrd'  and  one  by  T.  H. 
Evans^  of  Philadelphia.  One  of  Samohrd's  cases  was  fatal.  Possibly  the 
hemorrhagic  sites  are  foci  of  invasion  by  bacilli,  which  weaken  the  integ- 
rity of  the  vessel  walls. 

The  mild  form  is  sometimes  so  mild  as  scarcely  to  be  recognized  as 
typhoid  fever  and  is  often  called  gastric  fever  or  simple  febricula.  There  is, 
however,  no  more  important  lesson  for  the  inexperienced  practitioner  to 
learn  than  that  some  cases  beginning  as  mere  febricula  may  pass  over  into 
forms  of  great  severity,  and  may  even  terminate  fatally.  A  vary  rare  form 
is  the  tonsillar  typhoid,  in  which  whitish  elevations  appear  on  the  tonsils, 
subsequently  becoming  ulcers. 

Complications  and  Sequelae. — The  Spanish-American  war  con- 
firmed the  possibility  of  the  coexistence  of  typhoid  fever  and  malarial 
fever,  since  a  number  of  cases  from  among  the  soldiers  have  been  reported 
in  which  not  only  all  the  necessary  clinical  features  of  typhoid  fever  were 
present,  but  also  the  Widal  reaction,  in  which,  too,  the  malarial  organism 
was  found  in  the  blood.  Such  coexistence  occurred  in  cases  in  the  Hospital 
of  the  University  of  Pennsylvania  and  Saint  Mary's  Hospital,  Philadelphia. 
It  is,  however,  an  infrequent  event.  On  the  other  hand,  a  mongrel  disease 
that  is  the  product  of  the  two  causes,  as  was  once  supposed  to  be  the  case, 
and  known  as  typhomalarial  fencer,  does  not  exist.  The  term  should  be 
dropped,  as  it  is  confusing  and  gives  rise  to  erroneous  impressions. 

Persons  with  tuberculosis,  heart  disease,  diabetes,  epilepsy  and  other 
forms  of  chronic  ner\^ous  disease  are  as  liable  to  typhoid  fever  as  others,  while 
scarlet  fever,  diphtheria,  measles,  chicken-pox,  rheumatism,  and  especially 
erysipelas,  may  befall  a  tyj^hoid  case.     Typhoid  fever  in  diabetic  cases  is 

>  Samohrd,  "Sbornik  KHnicky,"  Tomo  V,  fasc.  i,  1903,  and  abstracted  in  "II  PoHclinico,"  Rome,  No. 
3 1,' 1904. 

'  "  Medical  News,"  Sept.  3,  1904. 


TYPHOID  FEVER  17 

especially  apt  to  be  attended  with  low  temperature.  Typhoid  fever  itself 
may  be  followed  by  tuberculosis  but  in  most  instances  the  condition  was 
tuberculosis  from  the  beginning,  such  cases  arc  in  our  records. 

Perforation  occurs  most  commonly  in  the  third  or  foiu^th  week  of  the 
disease.  Though  it  may  occur  as  early  as  the  eighth  day,  and  as  late  as 
the  sixth  week.  The  premonitory  symptoms  are  sudden,  severe,  localized 
pain  with  local  tenderness  and  muscular  resistance,  most  commonly  in  the 
lower  right  quadrant  of  the  abdomen,  with  rapidly  rising  leukocytosis. 
When  the  perforation  is  complete,  sudden  or  large,  there  is  generalized 
abdominal  pain,  loss  of  peristalsis,  distention  of  the  abdomen,  disappearance 
of  liver  dulness  and  collapse.  Occasionally  the  pain  is  so  high  up  that  the 
condition  may  be  mistaken  for  pleurisy,  or  on  the  other  hand  a  pleurisy 
may  be  mistaken  for  perforation. 

Thrombosis  of  the  femoral  vein,  more  frequently  the  left,  restdting  in 
phlegmasia  alba  dolens,  or  milk-leg,  is  a  complication  that  often  greatl}' 
delays  convalescence.  It  occurs,  according  to  Murchison,  in  one  per  cent,  of 
all  cases.  It  sometimes  invades  both  legs  in  succession,  and  may  extend 
into  the  iliac  veins  and  vena  cava,  thence  even  into  the  right  auricle,  caus- 
ing death  from  syncope.  Unless  the  latter  event  occurs,  however  tedious  the 
recovery,  it  takes  place  ultimately  almost  without  exception.  Very  rarely 
there  may  be  suppuration.  Bacilli  have  been  found  in  the  thrombus. 
More  or  less  phlebitis  is  always  present.  The  question  as  to  the  primary' 
event,  whether  thrombosis  or  phlebitis,  is  seemingly  settled  by  this  finding 
of  bacilli,  in  favor  of  the  former.  Arterial  as  well  as  venous  thrombosis  may 
occur,  and  the  former  may  start  with  embolism;  femoral  arterial  obstruc- 
tion is  most  common,  resulting  in  gangrene  of  the  leg  and  foot.  Embolic 
abscess  may  occur  in  the  kidney  and  lung. 

Arterial  sclerosis  sometimes  succeeds  as  a  consequence  of  the  irritative 
eflect  of  the  toxins. 

A  gangrenous  condition  of  the  skin  and  underlying  tissues,  may  occur 
over  any  point  subjected  to  pressure,  most  commonly  over  the  prominence 
of  the  sacrum,  or  over  the  heels.  This  complication  for  want  of  examina- 
tion is  often  overlooked,  until  the  continued  fever,  often  of  remittent  type, 
forces  a  careful  examination.  Bedsores,  formerly  frequent  complications 
in  protracted  cases,  are  much  less  frequent  with  modern  nursing. 

Noma,  or  gangrenous  stomatitis,  has  appeared  as  a  complication  or 
sequel  in  children.  W.  W.  Keen  records  nine  cases,  of  which  five  proved 
fatal.  Gangrene  in  other  situations  occurs  more  rarely,  as  in  the  vulva  in 
females  and  in  the  perineum  and  about  the  anus  in  both  sexes.  This  may 
be  due  to  arterial  thrombosis.     Perineal  fistulas  may  follow  in  these  cases. 

It  has  been  mentioned  that  pneumonia  may  usher  in  the  disease,  and 
a  few  words  may  be  said  here  of  the  relation  of  the  two  conditions,  pneu- 
monia and  typhoid  fever.  The  term  typhoid  pneumonia  is  one  in  common 
use  by  many  who  have  no  definite  notion  of  its  meaning,  and,  like  the  term 
typhomalarial,  has  occasioned  confusion.  In  the  first  place,  the  case  may 
begin  as  a  lobar  pneumonia,  the  intestinal  symptoms  appearing  at  the  end  of 
the  first  week  or  later,  at  which  time  also  the  spots  may  appear,  establishing 
the  diagnosis,  while  the  usual  crisis  of  pneumonia  fails  to  make  its  appear- 
ance.    Again,  a  pneumonia  may  supervene  in  the  second  or  third  week  of  a 


18  I.XFECTIOUS  DISEASES 

typhoid  fever  as  a  complication  in  which  the  true  relation  is  less  difficult  to 
determine.  .  Finally,  there  may  be  a  true  pneumonia,  to  which  stupor,  a  dry 
tongue,  and  general  adynamia  may  be  added,  without  the  distinctive  lesions 
of  typhoid  fever.  This  is  true  typhoid  pneumonia,  which  it  may  not  always 
be  easy  to  separate  from  the  typhoid  fever  beginning  with  pneumonia.  The 
typhoid  bacillus  and  the  pneumococcus  maj'  be  present.  Hypostatic  con- 
gestion has  been  referred  to.  Many  cases  formerly  thus  named  are  really  in- 
stances of  catarrhal  or  lobular  pneumonia  belonging  to  the  class  of  inhalation 
pneumonias.  Such  may  terminate  in  abscess  and  gangrene.  When  pleurisy 
occurs,  it  has  the  same  relations  to  the  disease  as  pneumonia.  It  is,  how- 
ever, more  rare,  but  may  also  be  piunlent.  An  initial  nephritis  has  been 
mentioned  on  page  1 2 . 

Certain  suppurative  processes  sometimes  included  as  symptoms  should 
be  regarded  rather  as  complications  than  symptoms.  Of  these  those  in 
the  parotid  gland  and  ear  are  the  most  serious.  They  are,  however,  less 
frequent  in  typhoid  than  in  typhus  fever.  They  are  most  common  in  the 
parotid  gland,  where,  however,  the  inflammatory  process  does  not  always 
terminate  in  suppuration,  occasionally  resolving  itself  with  or  without 
local  treatment.  The  duct  of  Steno  is  probably  the  route  of  infection  in 
these  cases  by  the  pus  organisms  that  find  conditions  favorable  to  their 
work.  The  middle  ear  ma\^  be  invaded,  producing  otitis  media.  Here  the 
Eustachian  tube  becomes  the  route  of  infection.  Sometimes  there  are 
multiple  abscesses  due  either  to  staphylococcus  or  to  the  typhoid  bacillus 
convalescence  often  being  delaj-ed  by  these  collections  of  pus. 

The  bladder  may  be  a  seat  of  suppuration,  and  pyuria  is  not  infrequently 
present.  George  Blumer  found  it  in  ten  out  of  60  cases,  or  nearly  1 7  per 
cent.,  of  a  series  admitted  to  the  Johns  Hopkins  Hospital.  It  was  present 
in  a  pronounced  form  in  a  series  of  41  of  our  cases.  It  is  probably  caused 
by  the  typhoid  bacillus.  The  inflammation  may  extend  to  the  pelvis  of  the 
kidney  or  begin  there.  Orchitis  and  epididymitis  are  also  occasional  symp- 
toms during  convalescence.  Thompson  S.  Westcott  collected  32  cases  for 
Keen's  book.^ 

Cardiac  complications ,  including  pericarditis,  endocarditis,  and  myocar- 
ditis, are  sometimes  present.     The  latter  may  be  a  cause  of  sudden  death. 

Neuritis  is  an  occasional  complication  in  both  the  local  and  multiple 
forms.  Osier  found  it,  however,  in  but  four  of  389  cases.  The  pain  may  be 
severe  and  associated  with  the  usual  tenderness  of  the  ner\^e  trunks.  The 
tender  toes  first  described  by  Handford.  are  not  verj^  rare.  The  tenderness 
is  often  so  great  that  the  bed-clothing  must  be  kept  raised  by  a  cradle. 
Even  cases  of  optic  neuritis  with  atrophy  of  the  optic  nerve  have  been  re- 
ported, but  it  is  probable  that  these  are  sequelae  of  meningitis  mistaken  for 
typhoid  fever.     Tetany  sometimes  succeeds  typhoid  fever. 

Two  sequela;  of  typhoid  fever,  neither  of  frequent  occurrence,  are  con- 
spicuous by  their  symptoms.  They  are  insanity  and  tuberculosis  of  the  lungs. 
The  former  is  often  typical  acute  mania,  requiring  the  utmost  vigilance  to 
prevent  the  patient  from  injuring  himself  and  others,  or  from  escaping  from 
the  house  or  jiunping  from  a  window.  Although  this  form  of  insanity  is 
often  prolonged  for  many  weeks,  the  prognosis  is  singularly  fa\-orable,  and 

*  "Surgical  Complications  and  Sequels  of  Typhoid  Fever,"  189S. 


TYPHOID  FEVER  19 

recovery,  sooner  or  later,  takes  place.  Tuberculosis,  when  it  occurs,  has  its 
predisposing  cause  in  the  lower  tone  of  cell  life,  favoring  the  successful  implan- 
tation of  the  specific  bacillus,  and  is  followed  by  its  usual  consequences. 

Post-t)^phoid  bone  lesions  are  surprisingly  common.  vSir  James  Paget, 
Murchison,  W.  W.  Keen,  Haywood,  Harold  C.  Parsons,  and  others  have 
collected  many  cases.  They  include  osteitis,  necrosis,  and  periostitis. 
The  tibia  is  the  favorite  seat — gr  times  out  of  216  of  Keen's  collection — 
next  the  ribs  40  times,  the  femur  22  times,  the  vdna  15,  and  the  humerus  11. 
Ebermaier,  in  1887,  obtained  from  two  cases  of  suppurative  post-typhoid 
periostitis  the  bacillus  of  Eberth  in  pure  culture,  and  since  then  quite  a 
number  of  cases  have  been  reported;  whence  pyogenic  properties  of  this 
bacillus  may  be  inferred.  Other  bacilli — viz.,  the  staphjdococcus,  strep- 
tococcus, and  pneumococcus — are,  however,  at  times  associated.  Golgi 
also  produced  suppuration  by  injecting  pure  typhoid  bacilli  subcutaneously 
at  a  distance  from  the  fractured  ends  of  a  long  bone  in  a  lower  animal. 
The  pus  showed  in  culture  only  typhoid  bacilli. 

Perichondritis  appears  to  be  a  frequent  complication  in  German}',  as 
shown  by  the  collections  of  Keen,  Liining,  and  Westcott — 169,  13,  and  14, 
respectively.  Keen's  and  Ltining's  lists  include  the  same  cases.  The 
disease  is  certainly  less  common  in  England  and  America.  Necrosis  of  the 
cartilages,  as  well  as  ulcers,  are  frequent  results.  Arthritis  is  an  occasional 
complication.  All  of  these  surgical  complications  are  easily  explained 
since  the  discovery  of  the  bacillus. 

The  typhoid  spine,  to  which  attention  was  called  by  Gibney,  of  New 
York,  in  1889,  is  a  sequel  of  undetermined  nature.  There  is  severe  pain  in 
the  back,  commonly  aggravated  by  motion.  The  pain  may  be  throughout 
the  whole  spinal  region  or  limited  to  the  cervical,  dorsal,  or  liunbar  portions. 
From  the  latter  it  may  extend  toward  the  hips.  It  may  be  a  spondyhlis, 
but  is  probably  a  pure  neurosis.  Allied  to  this  condition  is  perhaps  an 
obstinate  periostitis  of  the  sternum  or  the  crest  of  the  ilium  or  front  of  the 
spinal  column  after  typhoid  fever,  alluded  to  by  William  Pepper  in  the 
"Text-book  by  American  Teachers."  These  conditions  are  rare  and  some- 
times, at  least,  may  be  coincidences. 

Cholelithiasis  is  now  a  well-recognized  sequel,  Dufourt  having  first  re- 
ported it  in  19  patients  who  had  their  first  attack  after  typhoid  fever. 
Further  interest  attaches  because  there  is  every  reason  to  believe  that  the 
bacilli  in  the  gaU-bladder  va&y  be  the  initial  cause  of  the  process  which  re- 
sults in  stone.  Bernheim  first  called  attention  to  this  possibility  in  1889, 
and  is  sustained  by  Dufoiu-t,  Milan,  Hanot,  Maurice  H.  Richardson,  Mason, 
W.  H.  Welch,  and  W.  W.  Keen. 

Relapses. — These  occur  readily.  As  long  ago  as  187 1,  Hamernjk,  quoted 
by  Miu-chison  and  Maclagan,^  suggested  that  the  relapse  is  really  a  rein- 
fection of  the  large  intestine  from  the  small  by  the  passage  of  sloughs  over 
healthy  lymphoid  follicles.  Hugh  Stewart-  reiterated  this  suggestion  in 
1894,  but  Murchison  had  early  noted  that  the  fresh  lesions  are  sometimes 
higher  up  in  the  ileum  than  those  of  the  first  attack.  Liebermeister  believed 
that  a  part  of  the  typhoid  poison  remained  latent  somewhere  in  the  body, 


20  INFECTIOUS  DISEASES 

awaiting  some  exciting  cause  to  bring  it  into  activity.  G.  Futterer'  claims 
to  have  been  the  first  to  discover  the  typhoid  bacillus  in  the  gall-bladder  in 
1888;-  also  that  he  was  the  first  to  express  the  opinion  that  relapses  are 
caused  by  typhoid  bacilli  entering  the  intestines  with  the  bile.  Dupre' 
and  Chiari''  were  among  the  first  to  find  typhoid  bacilli  almost  constantly 
present  in  the  gall-bladder  of  those  ill  with  typhoid  fever,  and  also  suggested 
the  possible  responsibility  of  these  bacilli  for  relapses.  They  may  be  dis- 
charged into  the  small  intestine  without  harming  it  after  immunity  is 
secured.  Prior  to  this,  however,  the  patient  may  suffer  a  relapse.  Thus 
may  be  explained  the  occurrence  of  relapses  after  indiscretions  in  diet, 
which  stimulate  the  discharge  of  bile  and  bacilli  into  the  bowel,  thus  increas- 
ing the  chances  of  infection.  Chiari's  experience  adds  further  confirma- 
tion, since  in  three  cases  of  relapse  the  number  of  bacilli  in  the  gall-bladder 
was  very  large.  B.  Curshmann,  in  his  paper  on  typhoid  fever  in  Noth- 
nagel's  "Encyclopedia  of  Practical  Medicine,"  says  of  relapses:  "Undoubt- 
edly their  development  is  to  be  attributed  to  the  re-entrance  into  the  cir- 
culation of  living  typhoid  bacilli  which,  after  the  primary  attack,  were  left 
behind  in  various  organs;  and  associated  with  this,  more  or  less  complete 
development  of  the  local  and  general  typhoid  lesions  occurs."* 

The  signs  necessary  to  the  diagnosis  of  relapse  are  the  presence  of  those 
symptoms,  essential  to  the  primary  diagnosis — viz.,  the  characteristic 
spots,  a  return  of  the  tidal  or  step-like  temperature,  and,  scarcely  less 
so,  the  enlarged  spleen,  and  all  of  these  after  complete  defervescence.  The 
attack  is  usually  less  severe,  the  duration  shorter,  and  recovery  the  rule.  Re- 
lapses are  to  be  distinguished  from  recrudescence,  which  is  a  simple  return  of 
fever,  often  induced  by  numerous  causes,  including  lapses  in  diet,  too  much 
excitement,  and  the  like.  Relapses  may  be  multiple.  Transverse  mark- 
ings on  the  finger-nails  incident  to  multiple  relapses  are  sometimes  noted. 
The  nmnber  of  cases  in  which  relapses  occur  varies  greatly  in  the  ex- 
perience of  different  observers — from  one  to  18  per  cent.  Of  112  cases 
admitted  to  the  Hospital  of  the  University  of  Pennsylvania  from  the  various 
military  camps  of  the  country,  in  the  fall  of  1S98,  there  was  a  percentage 
of  10.7. 

Relapses  are  more  frequent  in  young  persons  than  in  older  ones.  A 
little  girl  of  14  in  the  Pennsylvania  Hospital  had  six  relapses  with  febrile 
periods  of  two  or  more  weeks  and  a  total  duration  of  the  illness  of  almost 
a  year. 

Diagnosis. — Typhoid  fever  is  usually  easily  recognized,  but  sometimes 
the  diagnosis  may  have  to  be  delayed  until  the  distinctive  signs  appears 
The  peculiar  range  of  temperature  is  the  most  distinctive  symptom,  and 
from  it  alone  the  diagnosis  may  be  tentatively  made.  The  rose-colored 
spots,  occurring  about  the  eighth  day,  are  conclusive  if  present,  but  they 
are  occasionally  absent.     Diarrhea  is  less  constant,  and  nosebleed  still 

'  "  Medicine,"  November,  i8p8. 

3  "Munchener  med.  Wochenschrift,"  No.  19.  1888. 

'  "Les  infections  biliaires."  "Those  de  Paris."  1891. 

*  "  Prager  medicinische  Wochenschrift,"  1893.  No.  22.  See  also  Brannan,  "  Twentieth  Century  Practice 
of  Med.,"  vol.  xvi.,  pp.  678  and  679. 

^  The  terra  recrudescence  is  not  always  similarly  used.  Thus  Curschmann,  in  the  paper  alluded  to, 
regards  relapse  and  recrudescence  as  due  to  the  same  cause  and  calls  it  relapse  if  it  succeeds  upon  a  perfectly 
afebrile  period,  and  recrudescence  if  the  rise  in  temperature  occurs  during  the  period  of  involution  before 
the  declining  temperature  has  completely  returned  to  the  normal.  I  prefer  to  retain  the  distinction  giver 
in  the  text,  which  is  also  that  adopted  by  Osler.J 


TYPHOID  FEVER  21 

less  so,  but  more  characteristic.  Both,  however,  require  to  be  weighed  in 
association  with  other  symptoms.     No  one  symptom  is  pathognomonic. 

The  resemblance  of  typhoid  fever  to  certain  cases  of  acute  tuberculosis 
has  long  been  recognized.  Certain  cases  of  malarial  fever,  especially  the 
autumnal  type,  also  very  closely  resemble  typhoid,  but  here,  too,  the  tem- 
perature diagram  is  not  identical,  while  the  usually  easy  recognition  of  the 
malarial  organism  completes  the  solution.  Where  the  two  diseases  are  con- 
current, as  is  sometimes  the  case,  the  difficulties  are  increased. 

Mention  has  been  made  of  the  close  resemblance  of  the  so-called  nervous 
variety  of  typhoid  fever  to  meningitis,  and  it  is  sometimes  so  misinter- 
preted. In  every  doubtful  case  a  spinal  puncture  should  be  made.  This 
will  decide  the  question.  As  the  disease  progresses,  the  distinctive  signs 
develop  and  the  correct  diagnosis  is  gradually  made.  The  popular  term, 
"brain  fever,"  now  passing  into  disuse,  doubtless  included  many  of  the 
cases  of  nervous  typhoid. 

More  misleading,  even  though  less  frequent,  are  the  cases  beginning 
with  decided  pulmonary  symptoms  suggesting  pneumonia  rather  than 
typhoid  fever,  and  unless  the  physician  is  awake  to  the  possibilities  of  such 
a  beginning  and  watches  further  developments  the  case  may  be  regarded  as 
one  of  pneumonia  with  typhoid  symptoms.  Doubtless  some  cases  that  are 
still  regarded  as  lobar  pneumonia  are  typhoid  fever.  Such  a  mistake 
might  have  been  made  in  the  case  reported  by  Osier  in  the  third  edition  of 
his  "Text-book,"  when  only  the  symptoms  and  morbid  anatomy  of  pneu- 
monia were  found,  but  in  which  piare  cultrues  of  the  typhoid  bacUlus  were 
isolated  from  the  lungs,  liver,  kidneys,  and  spleen.  No  lesion  of  the 
intestine  and  no  other  organisms  were  present. 

Certain  cases  of  concealed  suppuration  resemble  typhoid  fever  in  the 
symptoms  produced,  and  may  for  a  time  mislead.  But  again  the  tempera- 
ture chart,  after  a  few  days'  observation,  will  help  to  solve  the  question. 
It  is  in  such  cases  that  a  study  of  the  blood  is  of  value — the  presence  of 
leiikocytosis  pointing  to  suppuration,  and  its  absence,  to  typhoid.  Brill's 
disease,  which  Anderson  and  Goldberg  have  proven  identical  with  mild 
typhus  fever,  is  characterized  by  mild  fever,  but  the  rash  is  different,  and 
it  may  certainly  be  distinguished  from  typhoid  by  the  absence  of  Widal 
reaction  and  the  sterility  of  blood  cultures. 

Of  specific  aids  to  diagnosis  the  isolation  of  the  bacillus  is  now  done  with 
ease  in  any  good  laboratory.  Some  recent  studies  by  Warren  Coleman  and 
B.  H.  Buxton  go  to  show  that  in  75  per  cent,  of  604  cases  bacilli  have  been 
isolated  from  the  blood  at  some  stage  of  the  disease.^  The  serum  diagnosis, 
or  the  Widal-Gruber  reaction,  which  depends  upon  the  fact  that  the  diluted 
serum  of  a  patient  suffering  from  typhoid  fever  will  cause  actively  motile 
typhoid  bacilli  to  lose  their  motility  and  to  become  aggregated  into  clumps, 
is  the  best  aid  at  hand.  The  active  principle  underlying  this  reaction  is  the 
presence  in  the  blood  of  a  substance  termed  agglutinin.  In  many  diseases 
this  substance  is  present,  and  it  is  found  to  be  specific  in  its  reaction  to  the 
causal  bacterium.  However,  in  some  normal  sera  a  non-specific  agglutinin  is 
found,  which  will  produce  the  agglutination  of  several  varieties  of  bacteria. 

'  "Bacteriology  of  the  Blood  in  Typhoid  Fever."  Proceedings  of  the  New  York  Pathological  Society, 
1904,  N.  S.  iv. 


22  I XF  EC  nous  DISEASES 

The  test  may  be  said  to  be  pathognomonic,  but,  because  of  conditions  to  be 
spoken  of  later,  not  always  applicable  as  an  aid  to  the  immediate  diagnosis 
of  a  doubtful  case.  Kneass  and  Stengel'  report  that  in  2383  cases  of  typhoid 
fever  the  reaction  was  present  in  95.5  per  cent,  of  the  cases,  and  that  in 
1365  non-typhoid  cases  it  was  absent  in  98.4  per  cent,  of  the  cases.  Taking 
these  statistics,  the  absence  of  the  reaction  in  4.5  per  cent,  of  the  typhoid 
cases  may  be  due  first,  to  faulty  clinical  diagnosis,  for  at  the  present  time 
there  is  reason  to  believe  that  there  are  infections  caused  by  bacilli  of  the 
typhoid-coli  group,  the  sera  of  which  will  only  agglutinate  these  modified 
types,  which  have  been  termed  paracolon  and  paratyphoid  infections. 
Second,  it  may  be  due  to  the  fact  that  in  these  cases  the  test  was  not  applied 
continuously  during  the  supposed  attack  of  typhoid  fever,  since  from  statis- 
tics collected  by  Hermann  Biggs,  of  the  Health  Department  of  New  York 
City,  the  serum  of  typhoid  patients  gave  the  reaction  during  the  first 
week  in  about  70  per  cent.;  during  the  second  week  in  about  80  per  cent.; 
and  during  the  third  and  fourth  weeks  in  about  90  per  cent,  of  the  cases. 
Thus  in  cases  clinically  typhoid  the  test  should  be  made  every  two  or  three 
days  during  the  disease  before  it  can  be  said  that  the  reaction  is  absent. 
This  late  reaction,  of  course,  is  of  little  practical  value,  since  the  diagnosis 
will  have  been  made  much  earlier  by  the  more  usual  methods.  The  reaction 
has  appeared  for  the  first  time  as  late  as  the  42nd  day,  and  in  a  few  isolated 
cases  has  remained  absent  throughout  the  course  of  the  disease.  The  re- 
action has  been  found  as  long  as  eight  years  after  recovery.^ 

The  presence  of  the  reaction  in  1.6  per  cent,  of  non- typhoid  cases  is 
due  either  to  faulty  technique,  i.  e.,  the  dilutions  were  not  high  enough  since 
the  agglutinin  found  in  some  normal  sera  will  agglutinate  the  typhoid  bacilli 
in  insufficient  dilution;  or  to  the  fact  that  the  patient  may  have  passed 
through  a  typhoid  infection  some  months  previous,  because  the  reaction  has 
been  found  in  some  cases  to  be  present  many  months  after  the  recovery 
from  the  disease.  It  may  occur  as  early  as  the  third  day,  but  is  usually 
observ^ed  about  the  seventh  day.  It  gradually  becomes  more  marked  as 
the  disease  progresses,  and  is  commonly  present  in  the  blood  of  conva- 
lescents, and  for  months  after  recovery,  though  in  some  cases  it  disappears 
before  the  end  of  the  disease.  It  is  also  true  that  the  severer  the  infection, 
the  more  marked  the  reaction,  and  vice  versa.  Pleural  and  pericardial 
effusions,  the  bile,  the  milk,  and  to  some  extent,  the  urine  of  typhoid  fever 
cases,  as  well  as  the  blood  serum,  possess  this  agglutinative  property  for 
typhoid  bacilli.  Widal  reaction  is  present  after  vaccination  by  typhoid 
cultures. 

Diagnosis  of  Perforation. — In  view  of  recent  increased  success  of  opera- 
tion for  perforation,  an  early  recognition  of  this  accident  becomes  imperative, 
to  which  end  a  daily  examination  of  the  abdomen  should  be  made.  A  case 
of  typhoid  at  any  stage  of  the  disease  presenting  the  signs  of  local  pain, 
tenderness  and  rigiditj-  in  the  abdomen,  should  at  once  be  suspected  of  per- 
foration. If  these  local  signs  are  proven  not  to  be  caused  by  pneumonia  or 
pleurisy  and  especially  if  they  are  accompanied  by  levikocytosis,  not  the 
result  of  some  other  complication  they  are  signs  of  a  preforative  perito- 

'  Gould's  "Year  book,"  1898. 

*  "Clinical  and  Scientific  Contributions  upon  the  Value  of  the  Widal  Reaction,  based  upon  the  Study  of 
Two  Hundred  and  Thirty  Cases."  Philadelphia  Med.  Jour.,  vol.  iii.,  p.  778. 


TYPHOID  FEVER  23 

nitis,  and  a  surgeon  shotdd  be  consulted.  To  wait  for  tympany,  decrease  of 
liver  dullness,  drop  of  temperature  and  rapid  pulse  is  to  wait  for  general 
peritonitis  and  the  probable  death  of  the  patient.  It  may  occur  in  the  mild- 
est cases,  and  after  the  temperature  has  been  normal  for  ten  days,  and  in 
such  especially,  the  appearance  of  localized  pain  and  tenderness  may  also  be 
regarded  as  a  warning.  Hemorrhage  from  the  bowel  is  occasionally  fol- 
lowed by  perforation.     Every  case  should  be  carefully  watched. 

In  a  second  class  of  severe  cases  where  there  is  delirium  or  stupor, 
abdominal  distention  may  be  the  only  symptom.  In  a  few  instances  there 
are  no  evident  signs  and  the  perforation  may  be  first  found  at  autopsy. 
This  occurs  commonly  in  cases  of  unusual  gravity  where  the  event  is  masked 
by  the  severity  of  the  symptoms. 

Prognosis. — The  mortality  of  typhoid  fever  varies  so  much  in  different 
epidemics  and  under  different  circumstances  that  statistics  are  of  doubtful 
value  in  measuring  fatality.  Extremes  of  mortality  claimed  are  as  low  as 
one  per  cent.,  and  even  less  by  the  Brand  bath  method  as  carried  out  on  the 
continent  of  Europe,  and  as  high  as  55  in  army  practice  during  campaigns 
and  among  negroes.  The  average  of  all  may  be  put  down  approximately 
at  from  ten  to  30  per  cent,  before  the  Brand  cold  tub  treatment  was  insti- 
tuted. Prior  to  this,  hospital  treatment  appeared  less  successful  than  that 
of  private  practice.  Since  its  introduction,  because  of  the  greater  ease  with 
which  that  treatment  can  be  applied  in  hospitals,  this  can  hardly  be  said  to 
be  the  case. 

In  private  practice  a  decided  majority  get  well,  fully  80  per  cent.,  vnfh 
rest,  liquid  diet,  and  family  nursing.  With  skilled  nursing,  judicious  feed- 
ing, and  symptomatic  treatment,  a  larger  proportion  of  recoveries  takes 
place,  say  90  per  cent.  In  hospitals  where  the  Brand  method  is  correctly 
carried  out  there  is  an  easy  reduction  of  mortality  to  seven  per  cent,  and  less. 
In  this  country  the  results  have  not  been  quite  so  satisfactory  as  claimed  on 
the  continent  of  Europe.  The  mortality  of  William  Osier's  cases  at  the 
Johns  Hopkins  Hospital,  Baltimore,  has  been  7.3  per  cent.  Tyson,  at  the 
Hospital  of  the  University  of  Pennsylvania  and  at  the  Philadelphia  Hospital 
has  been  7.3 ;  that  of  James  C.  Wilson  and  others  at  the  German  Hospital,  up 
to  January  i,  1896,  7.25  per  cent. — astonishingly  uniform  results.  Brand's 
own  mortality  has  been  but  one  per  cent.  Of  Tyson's  cases  treated  by  the 
Brand  method  almost  all  who  died  perished  through  perforation  or  hemor- 
rhage of  the  bowels,  the  remainder  from  exhaustion,  or  toxemia.  Among 
the  soldiers  at  the  University  Hospital  in  1898-99  treated  by  the  Brand 
method  the  mortality  was  4.5  per  cent.  Of  1948  cases  at  the  Pennsyl- 
vania^ Hospital  in  the  years  1901  to  1903,  inclusive,  the  mortality  was  7.8 
per  cent.  The  Brand  bath  treatment  is  less  rigidly  carried  out  at  this 
hospital  than  at  the  University  Hospital  or  the  German  Hospital  in  Phila- 
delphia. Among  causes  which  have  contributed  to  reduce  percentage 
of  deaths  is  the  including  of  mild  cases  as  determined  by  more  accurate 
diagnosis. 

Unfavorable  symptoms  are  persistent  high  temperature,  above  105°  F. 
(40.5°  C.),  low  muttering  delirium,  extreme  tympany,  hemorrhage  from  the 
bowels,  and  the  signs  of  perforation.  Walking  typhoid  is  frequently  fatal, 
exhaustion  being  apparently  caused  by  the  continued  muscular  effort  during 


24  INFECTIOUS  DISEASES 

fever.  Complications  such  as  hemorrhage  and  perforation  are  likely  to 
occur. 

Sudden  death  by  sj-ncope  occasionally  occurs,  sometimes  when  least 
expected,  during  convalescence,  or  it  may  happen  during  the  acme  of  the 
fever.  In  either  event  the  immediate  cause  is  not  always  discoverable, 
evident  lesions  being  wanting  in  most  cases.  Pulmonar>'  thrombosis  and 
myocarditis  have  been  found  at  autopsy  in  these  obscure  cases.  Sudden 
death  is  much  more  frequent  in  men  than  women — 114  to  26,  according  to 
Dewevre's  statistics — a  surprising  and  almost  incredible  difference. 

The  prognosis  in  children  under  15  is  especially  favorable.  Recover}' 
takes  place  in  them  with  few  exceptions,  while  the  number  of  fatal  cases  in 
young  people  from  18  to  22  is  remarkable.  Then  follows  a  period  favorable 
to  recovery,  but  after  40  the  mortality  again  increases.  The  dangers  at  this 
older  age  appear  to  be  from  complications,  especially  pneumonia,  as  the 
symptoms  peculiar  to  the  disease  are  not  increased  in  severity. 

The  prognosis  in  pregnant  women  is  grave.  In  the  first  place,  the  preg- 
nant woman  usually  aborts  in  the  second  week.  According  to  L.  Brieger, 
the  mortality  was  20  per  cent,  of  cases  treated  by  other  than  the  bath 
method.  The  results  of  the  bath  treatment  seem  to  be  better.  Recently 
Tyson  had  under  his  care  two  pregnant  women  at  the  end  of  the  fifth  and 
sixth  months,  respectively,  now  recovered,  who  were  treated  throughout  by 
cold  tub-baths  without  accident.  Under  any  circiunstances  more  women 
die  of  typhoid  than  men — this,  too,  though  the  disease  is  more  frequent 
in  men  than  in  women.  Fat  persons  bear  the  disease  badly.  Hemorrhage 
and  perforation  seem  to  be  in  no  degree  diminished  bj-  the  Brand  bath  treat- 
ment. On  the  other  hand,  careful  investigation  shows  that  these  accidents 
are  not  more  frequent,  as  has  been  alleged. 

Death  in  typhoid  fever  may  be  the  result  of  any  of  the  following  causes: 
exhaustion  incident  to  prolonged  illness,  hemorrhage,  peritonitis,  shock  due 
to  perforation,  intoxication  by  the  toxin  of  the  disease,  thrombosis  or  com- 
plications such  as  pneumonia  or  nephritis.  As  already  intimated,  sudden 
death  sometimes  occurs  inexplicably. 

Treatment. — Rest  and  Diet. — The  primarj'  conditions  of  a  successful 
treatment  of  typhoid  fever  are  rest  in  bed  and  a  selected  diet,  of  which 
milk  forms  an  important  part.  No  one  questions  the  necessity  of  putting 
the  typhoid  fever  patient  absolutely  at  rest  in  bed  and  not  permitting  him 
to  rise  for  any  purpose  until  convalescence  is  thoroughly  established. 
Coleman  has  shown  that  star^'ation  leads  to  complications.  The  diet 
should  be  selected  and  contain  a  sufficient  nimiber  of  calories  2500  to  3000 
for  an  adult  to  fully  sustain  the  patient's  strength,  bearing  in  mind  the  fact 
that  the  vast  majority  of  patients  with  typhoid  fever  have  a  local  ulceration 
in  the  intestine  that  must  not  be  unduly  irritated.  Each  individual  must 
be  treated  and  given  the  diet  best  suited  to  his  particular  case.  In  the  semi- 
conscious patients,  or  in  those  very  delirious,  a  liquid  diet  made  up  largely  of 
milk,  is  best  suited.  One  quart  of  mill-:  contains  700  calories.  The  calorie 
value  can  be  greatly  increased  by  the  addition  of  cream  and  milk  sugar,  i 
ounce  of  cream  being  equivalent  to  60  calories,  and  one  ounce  of  milk  sugar 
is  equivalent  to  36  calories.  One  and  one-half  quarts  of  milk,  8  ounces  of 
cream,  and  6  ounces  of  lactose  will  furnish  1700  calories.     This  has  been 


TYPHOID  FEVER  25 

carefully  worked  out  by  Coleman,  his  patients  all  doing  well  upon  the  diet. 
Patients  who  are  quite  rational,  and  who  are  able  to  eat,  can  be  given  a 
carefully  selected  diet  in  addition  to  the  above,  the  one  selected  by  Shattuck 
in  1897  seems  perfectly  satisfactory.  This  diet  consists  of  the  following 
articles : 

1.  Milk,  hot  or  cold  with  or  without  salt,  diluted  with  lime  water,  soda 
water,  ApoUinaris,  or  Vichy.  Peptonized  milk;  cream  and  water  {i.  e.,  less 
albumen)  mUk  with  white  of  egg,  buttermilk,  kumiss,  matzoon,  milk  whey, 
milk  with  tea,  coffee,  cocoa. 

2.  Soups:  beef,  veal,  chicken,  tomato,  potato,  oyster,  mutton,  pea,  bean, 
squash,  carefully  strained  and  thickened  with  rice,  powdered  arrowroot, 
flour,  milk  or  cream,  egg,  barley. 

3.  Horlick's  food,  Mellin's  food,  malted  milk,  somatose. 

4.  Beef  juice. 

5.  Gruels:  Strained  cornmeal,  crackers,  flour,  barley-water,  toast  water, 
albumen-water  with  lemon  juice. 

6.  Ice  cream. 

7.  Eggs,  soft  boiled  or  raw,  egg-nogg. 

8.  Finely  minced  lean  meat;  scraped  beef;  the  soft  part  of  raw  oysters; 
soft  crackers  with  milk  or  broth ;  soft  puddings,  without  raisins ;  soft  toast, 
without  crust;  blanc  mange,  wine  jelly,  apple  sauce,  and  macaroni. 

Ice  cream  may  be  given  in  any  quantity  which  does  not  cause  nausea  or 
diarrhea. 

The  Brand  Bath  Treatment. — In  addition  to  rest  and  selected  diet,  the 
treatment  that  experience  places  easily  at  the  head,  in  every  case  when  it 
can  be  carried  out,  is  the  cold  tub-bath  treatment,  commonly  known  as  the 
Brand  treatment.  ■  Our  method  is  as  follows ; 

Before  the  bath  the  patient  is  first  encouraged  to  empty  the  bladder, 
and  if  sweating,  he  is  wiped  dry.  He  is  then  covered  loosely  with  a  sheet 
and  gently  lifted  into  the  bath  sufficiently  filled  with  water  at  70°  F.  (2 1°  C), 
provision  being  made  to  rest  the  head  upon  an  air-cushion  or  platform. 
During  the  bath  he  is  vigorously  rubbed  by  the  nurse,  and  encouraged  also 
to  rub  himself.  A  compress  wrung  out  of  ice-water  or  an  ice-cap  is  kept 
upon  his  head,  or  water  at  the  same  temperature  is  poured  at  intervals  upon 
it,  say,  three  times  in  the  course  of  the  bath,  or  the  head  is  sponged  with 
cold  water  from  time  to  time.  This  is  important  in  severe  cases  with  decided 
nervous  symptoms.  At  the  end  of  15  minutes  he  is  lifted  on  the  bed,  which 
has  been  previously  protected  with  a  mackintosh  and  blanket.  The  wet 
sheet  is  replaced  by  a  dry  blanket,  and  the  patient  is  rubbed  dry.  When 
this  is  accomplished,  the  under  blanket  and  mackintosh  are  withdrawn  and 
he  is  comfortably  covered. 

As  soon  as  the  patient  ceases  to  shiver  after  his  removal  from  the  bath, 
which  is  usually  in  20  minutes,  the  temperature  is  taken  with  a  view  to 
determine  the  effect  of  the  bath.  If  delayed  longer  he  may  be  in  a  restful 
sleep,  and  to  wake  him  for  the  purpose  of  taking  his  temperature  is  need- 
lessly disturbing.  After  this  the  temperature  is  not  again  taken  until  three 
hours  after  the  bath.  If  then  it  exceeds  102°  F.  (39°  C),  the  bath  is 
repeated.  If  the  temperature  is  between  101°  F.  (38.. 2°  C.)  and  102°  F. 
(39"  C),  it  is  taken  again  in  an  hour;  if  between  100°  F.  (37.8°  C.)  and  101° 


26 


INFECTIOUS  DISEASES 


F.  (38.3°  C),  in  two  hours;  if  below  100°  F.  (37.8°  C),  not  until  three  hours, 
but  whenever  the  temperature  exceeds  102°  F.  (39°  C.)  the  bath  is  given, 
provided  three  hours  at  least  have  elapsed  since  the  previous  bath.  This 
makes  more  than  eight  baths  in  the  24  hours  impossible. 

The  effect  of  the  bath  upon  the  temperature  varies  with  the  stage  of  the 
disease;  the  reduction  during  the  first  week  being  often  less  than  one  degree, 
while  toward  the  end  of  the  second  week  and  in  the  third  week  a  fall  of  two 
or  more  degrees  is  quite  usual.     Fig.  4  shows  these  effects  very  nicely.     In 


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Disease. 


addition  to  the  lower  temperatiu-e  the  immediate  effect  of  the  bath  is  to  add 
strength  to  the  heart  and  volume  to  the  pulse.  The  shivering,  which  be- 
gins from  five  to  ten  minutes  after  the  immersion,  is  not  allowed  to  interfere 
with  the  continuance  of  the  bath,  and  it  very  rarely  happens — indeed, 
scarcely  ever — that  anything  occurs  to  interrupt  the  bath.  It  would  be 
wrong,  however,  to  say  that  there  are  no  conditions  under  which  it  should  be 
discontinued  and  the  patient  at  once  returned  to  bed.  Such  conditions 
are  an  almost  absolute  pulselessness  with  a  blue,  cyanosed  appearance 


TYPHOID  FEVER  27 

of  the  skin.  Should  this  occur,  hot-water  bags  should  be  applied  to  the 
feet  and  legs  after  the  patient  is  put  to  bed. 

The  more  remote  effect  of  the  bath  may  be  said,  in  a  word,  to  be  ameliora- 
tion of  the  symptoms  in  every  particular.  Delirium  and  stupor  are 
lessened.  The  dry  tongue  is  very  much  more  infrequent,  and  diarrhea  rarely 
demands  other  treatment.  The  majority  of  cases  require  no  medicine  but 
symptoms  should  be  treated  that  demand  it  by  appropriate  treatment. 
Sometimes  whisky  and  water  during  the  bath  are  necessary. 

None  of  the  complications  except  hemorrhage  from  the  bowels  ard  signs 
of  perforation  is  allowed  to  interfere  with  the  carrying  out  of  this  treatment,  nor 
is  menstruation  or  even  pregnancy.  The  baths  are  discontinued  during 
hemorrhage,  lest  the  necessary  movements  of  the  body  should  re-excite  it. 
It  is  not  claimed  that  the  baths  shorten  the  illness,  they  simply  ameliorate 
it.  While  it  is  probably  true  of  typhoid  fever,  as  of  pneumonia,  that  it 
may  abort  spontaneously,  we  cannot  cause  it  to  abort  by  any  means  we 
possess. 

In  private  practice  the  difficulties  of  the  Brand  treatment  are  greatly 
increased — unfortunately,  sometimes  are  insuperable.  They  consist  chiefly 
in  the  difficulty  in  arranging  the  bath  and  the  strain  on  the  attendants.  By 
means  of  a  portable  tub  devised  by  A.  H.  Bmr,'  of  Chicago,  a  very  large 
part,  if  not  the  whole,  of  these  difficulties  is  removed.  A  large  rubber 
blanket  spread  upon  the  bed  and  lifted  at  each  corner  allows  the  giving  of 
what  is  practially  a  tub  bath.  The  blanket  is  large  enough  to  extend  far 
over  the  edges,  the  foot  and  head  of  the  mattress,  the  corners  are  looped  up 
and  securely  tied.  The  patient  is  stripped,  then  water  of  the  desired  tempera- 
ture is  dripped  in  a  stream  from  a  sponge  held  over  the  patient.  The  surplus 
water  is  caught  by  the  blanket,.  This  bathing  is  continued  15  to  20  minutes. 
The  water  is  removed  by  sponging  or  a  hose.  The  patient  is  dried  and 
covered. 

Other  Methods  of  Reducing  Temperature. — As  contrasted  with  the 
Brand  bath,  other  methods  of  securing  the  good  effects  of  hydrotherapy 
seem  trifling;  yet,  as  it  may  be  impossible  to  carry  out  this  treatment,  such 
methods  must  be  considered.  Sponging  is  one  of  the  most  usual,  and  if 
rightly  carried  out  may  be  quite  efficient.  It  should  be  resorted  to,  as  is  the 
bath,  when  the  temperature  exceeds  102°.  F.  (39°  C),  and  continued  for 
15  minutes,  or  until  the  temperature  falls.  An  important  condition  of 
successful  sponging  is  often  overlooked.  A  thin  film  of  water  should  be 
left  on  the  surface  sponged,  as  it  is  the  evaporation  of  this,  rather  than  the 
temperature  of  the  water,  which  is  effectual  in  cooling  the  body.  Tem- 
peratures that  cannot  be  thus  controlled  can  often  be  kept  down  by  a  partial 
wet-pack,  which  is  often  very  efficient:  The  patient's  trunk  is  enveloped 
from  the  axilla  to  the  thighs  in  a  folded  sheet,  which  is  kept  constantly 
wet,  or  as  much  so  as  is  required  to  control  the  temperature,  by  the 
continual  addition  of  cold  water. 

Antipyretics,    including    antipyrin,    antifebrin  (acetanUid) ,  phenacetin, 


1  The  Burr  bath-tub  is  sold  by  E.  H.  Sargent  &  Co.,  io6  Wabash  Avenue,  Chicago,  111.  Another  tub, 
as  convenient  and  as  easily  managed,  has  been  devised  by  S.  Clifford  Boston,  West  Grove,  Pa.,  who  dis- 
penses with  the  framework,  substituting  strong  iron  supports,  made  by  Jones,  Leopold  '&  Co.,  Southwest 
corner  Ridge  Avenue  and  Fairmount  Avenue,  Philadelphia. 

A  convenient  tub  which  may  be  used  on  the  bed,  known  as  the  "  Coile  Bath  Tub  "  is  made  by  the  Roco 
Bath  Co.,  Knoxville.  Tenn.     The  price  advertised  is  Sioo. 


28  INFECTIOUS  DISEASES 

and  others  of  the  same  class  are  mentioned  to  be  condemned.  They  should 
never  be  used. 

The  Expectant-symptomatic  Treatment. — Where  the  difficulties  in  the 
way  of  the  Brand  method  are  insuperable,  we  prefer  to  place  the  patient  in 
bed  on  the  diet  described,  combat  the  temperature  by  sponging  or  wet- 
packs,  and  for  the  rest  adopt  what  may  be  termed  the  expectant- 
symptomatic  method,  meeting  the  symptoms  as  they  arise  in  accordance 
with  the  following: 

Alcohol  is  not  a  heart  stimulant  as  formerly  supposed.  That  a  certain 
amount  may  be  utilized  as  food  is  certain.  That  alcoholics  afflicted  with 
typhoid  fever  need  some  form  of  alcohol  seems  certain,  therefore  alcohol  is 
used  in  good  doses  30  to  60  c.c.  every  two  or  three  hours  in  alcoholics  in  the 
early  stages  but  is  gradually  reduced  in  amount.  It  is  sometimes  used  in 
small  amounts  as  a  food  when  this  seems  necessary. 

It  is  never  used  in  large  doses  as  a  stimulant  for  it  does  not  have  this 
effect.  However  when  the  heart  muscle  begins  to  flag,  the  pulse  becomes 
rapid,  and  the  patient  extremely  weak,  doses  of  15  to  30  c.c.  may  be  given 
every  two  or  three  hours  with  good  effect.  It  may  thus  act  as  a  fuel  and  in- 
directly stimulate  the  heart.  A  low,  muttering  delirium,  feeble,  dicrotic 
pulse,  and  dry  tongue  are  among  the  indications  which  imperatively  de- 
mand small  amounts  of  alcohol;  a  high  teraperatru-e  does  not  contraindicate 
it,  as  an  antipyretic  effect  also  follows  its  use  and  delirium  is  sometimes 
calmed  by  it.  Other  diffusible  stimulants  which  may  be  used  in  conjunc- 
tion or  alternation  with  alcohol  are  the  aromatic  spirit  of  ammonia  and  the 
carbonate  of  ammonium,  while  digitalis  and  strychnin  may  tide  a  feeble 
heart  over  a  period  of  weakness.  From  5  to  10  minims  (0.333  to  0.666  gm.) 
of  the  tincture  of  the  former,  and  1/30  to  1/20  of  a  grain  (0.002 16  to  0.00324 
gm.)  of  the  latter  may  be  given  as  demanded,  while  their  hypodermic  use 
may  be  availed  of.  We  have  found  hypodermic  injections  of  camphorated 
oil  I  grain  (0.066  gm.)  to  15  minims  of  the  oil  (i  gm.)  verj'  useful  in  tiding 
over  extreme  adynamia.  The  injections  may  be  repeated  once  in  four  hours 
or  oftencr.  Caffein,  2  grains  (12);  may  be  taken  by  the  mouth.  It  is  an 
excellent  stimulant. 

Transfusion  or,  what  is  more  practicable  and  as  efficient,  hypoder- 
moclysis  of  normal  salt  solution  (0.8  per  cent,  sodium  chlorid)  may  be  availed 
of  in  the  extreme  adynamia  which  sometimes  attends  protracted  typhoid 
fever.  Vaccine  treatment  by  killed  bacilli  is  not  of  value.  No  serum  has 
been  found  of  value. 

(6)  Treatment  of  Special  Symptoms. — Methods  more  directly  adapted 
to  control  delirium  are  an  ice-cap  to  the  head,  the  bromids,  spirit  of  chloro- 
form, chloral,  and  Hoffmann's  anodyne.  With  the  cold-bath  treatment 
they  are  rarely  necessary-. 

Little  difficulty  is  commonly  experienced  in  controlling  the  diarrhea 
of  typhoid  fever.  As  stated,  with  the  cold  bath  treatment  very  little  special 
treatment  is  necessary.  Often  omission  of  all  food  is  necessary.  Simple 
preparations  of  opium,  either  alone  or  in  combination  with  bismuth  or  ni- 
trate of  silver  or  acetate  of  lead,  or  salol,  are  usually  sufficient.  One-quarter 
grain  of  nitrate  of  silver  and  1/4  grain  of  extract  of  opium  is  an  excellent 
remedy  for  diarrhoea.     The  impression  made  by  the  teachings  of  the  late 


TYPHOID  FEVER  29 

George  B.  Wood  on  the  profession  of  the  United  States  as  to  the  effect  of  oil 
of  turpentine  has  not  yet  been  effaced.  He  held  that  the  dry,  leathery 
tongue  so  often  presented  in  this  disease  is  the  indication  for  its  use. 
Whether  such  view  was  correct  or  not,  few  who  have  used  the  oil  of  tur- 
pentine have  failed  to  see  the  coated  tongue  clear  up  under  its  use.  Tur- 
pentine is  also  useful  as  a  stimulant.  It  should  be  administered  in  doses 
of  lo  minims  (0.66  gm.)  in  mucilage  of  acacia  every  six  or  eight  hours. 

Constipation,  especially  during  convalescence,  is  not  infrequent,  and 
should  not  be  too  hastily  interfered  with.  If  it  is  necessary  to  interfere,  it 
should  be  simple  enema  only.  Aperients  by  the  mouth  in  this  stage  are 
dangerous,  they  may  be  succeeded  by  perforation,  peritonitis,  and  death. 
On  the  other  hand,  indifference  to  the  condition  of  the  bowels  sometimes 
leads  to  fecal  impaction,  which  can  only  be  relieved  by  the  finger.  Such 
a  state  of  affairs  should  be  averted  by  watchful  care. 

Hemorrhage  from  the  bowels  should  be  treated  by  absolute  quiet  with 
cold  to  the  abdomen.  Food  should  be  interdicted.  The  administration  of 
food  may  be  suspended  for  some  hours  without  risk.  In  severe  cases  the 
foot  of  the  bed  should  be  raised,  and  a  hypodermic  injection  of  1/8  to  1/4  of 
a  grain  (0.008  to  0.016  gm.)  of  morphin  given  at  once  and  the  extremities 
bandaged.  In  cases  where  prompt  and  decisive  action  is  necessary,  hypo- 
dermoclysis,  or  intravenous  injection  of  normal  salt  solution,  may  be  neces- 
sary, to  which  10  minims  of  a  i-iooo  adrenalin  chloride  solution  may  be 
added.  This  is  rarely  necessary.  The  lowered  blood  pressure  is  one  of 
nature's  ways  of  controlling  the  bleeding.  Therefore  do  not  give  stimula- 
tion to  every  severe  case  of  hemorrhage.  In  mild  cases,  astringents  such  as 
tannic  acid  or  gallic  acid  and  the  acetate  of  lead,  may  be  given  by  the  mouth, 
the  former  in  doses  of  10  to  15  grains  (0.666  to  i  gm.)  hourly  until  some  hoiirs 
have  elapsed  without  a  hemorrhage.  The  acetate  of  lead  should  be  given 
in  I  to  3  grain  (0.066  to  0.194  gm.)  doses  every  three  hours,  combined  with 
extract  of  opium,  1/4  of  a  grain  (0.016  gm.).  Turpentine  is  of  value  in  the 
treatment  of  hemorrhage  from  the  bowels.  In  cases  of  extreme  bleeding 
from  the  bowel  apparently  due  to  hemorrhagic  diathesis,  injection  of 
normal  blood  serum  may  be  used  with  good  effect. 

Tympanitic  distention  of  the  abdomen  is  often  a  distressing  symptom. 
It  is  usual  to  treat  it  with  turpentine  in  10  minim  (0.666  gm.)  doses  every 
four  to  six  hours.  The  rectal  tube  should  be  cautiously  used  if  the  meteor- 
ism  is  great,  and  large  quantities  of  gas  are  sometimes  thus  disengaged  from 
the  large  intestine.  The  quantity  of  food  should  also  be  reduced  to  a  mini- 
mum, as  its  fermentation  and  decomposition  contribute  to  the  gas. 

Pain  induced  by  meteorism  or  otherwise  may  be  allayed  by  turpentine 
stupes  over  the  abdomen,  though  sometimes  it  may  be  necessary  to  rein- 
force the  stupes  by  small  doses  of  opium,  or  a  light,  warm  poultice  may  be 
substituted.  Sudden,  sharp  pain,  similar  to  that  produced  by  tympanitic 
distention  of  the  bowel,  is  also  caused  by  peritonitis,  of  which  tympany  is 
likewise  a  symptom,  and  the  two  often  occasion  many  anxiovis  moments  to 
the  physician  necessarily  in  doubt  as  to  whether  this  serious  complication 
may  occasion  them.  Here  the  surgeon  must  at  once  be  called.  A  local 
peritonitis  is  a  call  for  a  laparotomy. 

Perforation  is  the  most  serious  accident  which  can  happen  to  the  typhoid 


30 


INFECTIOUS  DISEASES 


fever  patient,  though  it  is  claimed  that  recovery  has  taken  place  where 
peritonitis  has  been  thus  caused.  Indeed,  according  to  Murchison,  lo  per 
cent,  of  all  cases  recover,  five  per  cent,  if  general  peritonitis  supervene. 
Even  this  seems  a  large  proportion,  for  in  our  experience  no  case  of  un- 
doubted perforation  has  recovered  mthout  operation.  On  the  other  hand, 
recent  results  after  operation  have  been  so  favorable  as  to  make  it  impera- 
tive that  every  case  should  be  operated  upon.  It  is  important  to  remember 
that  early  operations  are  those  attended  with  largest  success.  In  an  exhaus- 
tive paper  ("Jour.  Am.  Med.  Assoc,"  January  20,  1900)  on  the  "Surgical 
Treatment  of  Perforation  of  the  Bowel  in  Typhoid  Fever,"  W.  W.  Keen 
collected  158  cases  and  summarizes  as  follows: 

OUT  OF  158  CASES  OF  OPERATION  FOR  PERFORATION. 


When  Done 


Total 


Within  4  hours 

In  4  to  8  hours, 12 

In  8  to  12  hours, 16 

In  12  to  18  hours, |  25 

In  18  to  24 j  14 

After  24  hours, 44 

Not  given \  39 


Total, :   158 


Died 


Recov- 
ered 


Percentage  of  Recoveries 


25 

8.33 
25 
32 

28.57 
13-63 
30-74 


23-41 


1944     15 


30.76  I-  29.09 


Keen  also  formulates  the  rule  that  if  the  operation  is  not  done  within 
about  twenty-four  hours  after  the  perforation,  there  is  probably  no  hope  of  a 
recovery.  Nevertheless  an  operation  should  always  be  done  unless  the 
patient  is  in  extremis.  A  surgeon  should  therefore  be  immediately  called, 
and  if  collapse  is  not  too  profound  laparotomj'  should  be  done. 

For  sleeplessness  the  milder  soporifics  usually  answer;  10  to  15  grains 
(0.666  to  I  gm.)  of  sulphonal  generally  furnish  the  required  rest.  Trional 
15  to  30  grains  (i  to  2  gm.),  veronal  in  5  grain  doses,  or  chloral  in  10  to  15 
grains  (0.666  to  i  gm.)  may  be  used.  If  these  remedies  are  insufficient, 
morphin  must  be  used,  1/4  grain  (0.016  gm.)  being  given  by  the  mouth 
or  half  as  much  hypodermically,  or  more  if  necessary. 

Bed  sores  can  generally  be  averted  by  scrupulous  attention  to  cleanli- 
ness, the  thorough  drying  of  the  patient  after  washing,  remo\'ing  thus  all 
traces  of  urine  or  other  discharges,  and  by  sponging  the  patient  daily  with 
alcohol  or  whisky.  Above  all,  his  position  in  bed  should  be  frequently 
changed  and  all  inequalities  in  the  bed  clothing  should  be  smoothed  out, 
while  the  bed  should  be  kept  clear  of  crumbs  and  other  irritating  particles. 
Should  a  sore  appear  it  must  be'  aseptically  dressed,  while  the  part  should 
be  protected  from  pressure  by  pads  and  air-cushions.  In  cases  with  ex- 
treme emaciation  and  weakness,  a  water  bed  is  a  necessity,  and  will  cure 
or  prevent  bed  sores. 

For  hiccough  the  measures  effectual  are  counter-irritation  by  mustard, 
dry  cupping,  or  blistering  over  the  epigastritim;  the  various  anodyne 
measures,    including    Hoffmann's    anodyne,   chloroform,   and    the    hypo- 


TYPHOID  FEVER  31 

dermic  injection  of  morphin.  The  anti-spasmodics,  including  sumbul,  the 
oil  of  amber,  and  especially  musk,  have  been  useful.  Cannabis  indica  is  also 
recommended.  In  an  obstinate  case,  after  all  measures  had  failed,  including 
musk,  the  hypodermic  injection  of  i  grain  (0.06  gm.)  of  camphor  dissolved 
in  oil,  15  minims  (0.5  gm.)  repeated  hourly,  relieved  the  case  in  six  doses. 
A  second  case  has  been  relieved  in  the  same  hospital  by  like  treatment. 
In  other  cases  we  have  found  musk  useful  when  all  else  failed,  but  it  is  a 
most  costly  remedy  and  its  use  is  thus  necessarily  limited.  The  dose  is  5 
to  10  grains  (0.3  to  0.6  gms.). 

The  cystitis  sometimes  present  in  typhoid  fever  is  commonly  easily 
relieved  by  washing  out  the  bladder  with  boric  acid  solution,  a  dram 
(4  gm.)  to  a  pint  (0.5  liter)  of  sterilized  water;  or  instead  of  this  salol  may 
be  given  in  5  grain  (0.3  gm.)  doses  four  or  five  times  a  day,  as  a  urinary 
antiseptic.  The  best  remedy  is  hexamethjdenamine  which  is  a  derivative 
of  formaldehyd.  It  must  not  be  forgotten  that  large  doses  exceeding  i 
to  I  1/2  grams  a  day  maj^  cause  severe  irritation  of  the  kidnej^s  and  bladder. 
According  to  Mark  W.  Richardson  daily  doses  of  30  grains  (2  gm.)  wUl 
remove  typhoid  bacilli  permanently  from  the  luine  in  a  week. 

The  Management  0}  Convalescence. — In  no  disease  is  watchfulness  during 
convalescence  more  important.  The  effect  of  indiscretion  in  diet  in  pro- 
ducing relapse  and  recrudescence  has  been  referred  to.  But  there  are  other 
dangers  dtiring  convalescence.  It  is  to  be  remembered  that  the  complete 
have  disappeared  except  a  slight  elevation  of  temperature;  a  deep-seated 
healing  of  intestinal  ulcers  is  often  delaj^ed  after  all  other  symptoms 
ulcer  may  thus  remain  with  the  thin  peritoneimi  for  its  floor,  rendered 
weaker  by  reason  of  imperfect  nutrition.  Such  a  membranous  floor  is 
known  to  have  been  torn  by  simply  reaching  over  for  a  book  and  to  be 
followed  by  a  fatal  peritonitis.  These  are  reasons,  too,  for  putting  off  the 
use  of  a  table  diet  until  the  temperattire  has  maintained  the  normal  for  a 
considerable  time,  certainly  two  weeks.  Then  the  diet  should  be  changed 
most  gradually. 

Emotional  disturbance  is  a  well-recognized  cause  of  recrudescence,  and 
should  be  carefuUy  guarded  against. 

Constipation  should  be  corrected  by  enemata  only. 

During  convalescence  the  hair  is  very  apt  to  fall  out,  but  usuaU}'  returns 
in  a  natural  way.  It  may  be  desirable  to  cut  it  close,  though  scarceh^ 
necessary  to  shave  the  head,  as  some  recommend. 

Antityphoid  Inoculation. — The  experiments  of  A.  E.  Wright  and  his 
co-workers  show  that  both  the  incidence  and  mortality  of  tj^phoid  fever 
can  be  diminished  by  typhoid  inoculation  or  vaccination.  This  is  done 
by  injecting  subcutaneously  dead  cultures  of  the  typhoid  bacillus,  sterilized 
at  53°  C.  These  injections  are  made  in  convenient  parts  of  the  body  with 
the  usual  antiseptic  precautions;  they  are  given  the  first  500,000,000  dead 
bacterii,  the  last  two  1,000,000,000  each  at  intervals  of  three  days.  Both 
local  and  constitutional  symptoms  supervene  after  injection.  Local 
symptoms  may  appear  as  early  as  i  s  minutes  to  two  or  three  hours,  and  are 
severe  inversely  as  the  constitutional  symptoms  are  mild.  They  are  mani- 
fested when  they  occur  by  a  red  blush  and  more  or  less  serous  exudation 
at  the  site,  followed  .by  some  lymphangitis  upward  toward  the  axilla  or 


32  INFECTIOUS  DISEASES 

downward  toward  the  groin,  according  as  the  inoculation  is  made  above  or 
below  the  middle  line  of  the  body. 

Constitutional  symptoms  also  supervene  in  from  15  minutes  to  two 
or  three  hours,  and  are  increased  by  muscular  exertion  after,  or  fasting 
before  the  operation.  These  symptoms  include  some  headache  and  malaise 
in  mild  cases,  with  rigors  and  symptoms  of  collapse  in  severe  cases,  lasting 
five  or  six  hours.  Neither  the  local  nor  general  reaction  is  dangerous; 
60,000  men  have  been  vaccinated  in  India,  7000  in  Africa  and  85,000  in 
the  United  States,  without  mishap. 

The  general  good  effect  is  shown  by  Kunell  and  many  other  reporters. 
Spooner  reports  1588  inoculations  among  405  nurses  and  attendants  in 
hospitals  with  no  untoward  results.  The  incidence  of  typhoid  in  vacci- 
nated individuals  is  much  less  than  in  unvaccinated  under  the  same  conditions 
of  exposure.  After  the  vaccination  Widal  reaction  is  present  in  the  blood 
just  as  though  the  patient  had  passed  through  an  attack  of  typhoid  fever. 
As  to  mortality,  in  the  aggregate  the  proportion  of  deaths  to  cases  among  the 
inoculated  was  less  than  half  that  among  the  uninoculated.  The  duration 
of j  the  protection  conveyed  by  antityphoid  inoculation  persists  at  least 
through  the  second  year,  probably  during  the  third  year.  Major  Russell, 
of  the  U.  S.  Army  reports  the  vaccination  of  over  85,000  troops  with  the 
incidence  of  only  3  cases  of  typhoid  fever. 

Hunt,  American  Journal  of  Medical  Sciences,  June,  19 13,  reports  the 
result  of  vaccinations  in  an  epidemic  of  typhoid  fever  which  occurred  at 
Troy,  Pennsylvania.  1343  persons  are  known  to  have  used  the  water 
supply.  229  cases  of  typhoid  developed.  127  of  these  developed  the 
fever  before  the  vaccinations  were  begun,  and  103  afterward.  The  number 
of  persons  vaccinated  was  761.  Of  these  37  developed  typhoid  fever.  The 
number  of  persons  not  vaccinated  was  455.  Of  these  65  developed  typhoid, 
that  is  4.86  per  cent,  of  the  vaccinated,  and  14.28  per  cent,  of  the  unvac- 
cinated, developed  the  disease.  In  the  37  persons  who  developed  tj'^phoid 
fever,  28  developed  it  after  the  first  vaccination,  7  after  the  second,  and 
2  after  the  third.  The  onset  was  prolonged  in  every  case.  The  mortality 
among  the  vaccinated  was  0.28  per  cent.,  among  the  unvaccinated  8.85 
per  cent. 

Prophylaxis. — Very  important  in  the  management  of  typhoid  fever  is 
the  disinfection  of  the  excreta,  which  are  the  contagium  bearers,  through  the 
careless  handling  of  which  the  disease  is  communicated  to  others.  The 
same  is  perhaps  true  of  the  vomited  matters  and  also  of  the  urine. 

Among  the  most  suitable  disinfectants,  on  account  of  its  cheapness,  harm- 
lessness,  and  effectiveness,  is  chlorinated  lime  or  bleaching  powder,  also 
called  chlorid  of  lime,  which  contains  from  25  to  40  per  cent,  of  available 
chlorin.  A  solution  made  in  the  proportion  of  4  to  100  of  water,  containing, 
therefore,  at  least  one  to  i  .5  per  cent,  of  chlorin,  is  sufficiently  strong.  Some 
of  the  solution  is  placed  in  the  bed  pan  before  it  is  used,  and  the  remainder, 
in  all  sa}-  a  pint,  is  added  afterward.  Thorough  admixtiu-e  should  be  made, 
and  an  hour  allowed  to  elapse  before  the  stool  is  thrown  into  the  privy  or 
water-closet,  if  disposed  of  thus.  In  the  country  the  disinfected  stool  may 
be  buried.  Solution  of  chlorinated  soda,  or  Labarraque's  solution,  is  a  more 
elegant  but  not  more  effective  disinfectant.     As  it  contains  about  two  per 


TYPHOID  FEVER  33 

cent,  of  chlorin,  it  is  nearly  equivalent,  when  undiluted,  to  the  above  solution 
of  chlorinated  lime.  Chlorinated  lime  rapidly  loses  its  chlorin,  and  should 
be  kept  in  tight  vessels. 

Carbolic  acid,  in  the  proportion  of  one  part  of  the  commercial  acid  to  ten 
of  water,  is  an  efificient  disinfectant  for  this  ptirpose.  The  same  method 
as  that  described  for  chlorinated  lime  must  be  employed,  and  an  exposure 
of  twenty  minutes  to  half  an  hour  maintained.  Quite  as  good  a  disinfectant 
for  intestinal  evacuations  is  milk  of  lime  or  ordinary  "whitewash,"  com- 
posed of  lime  in  solution  and  in  suspension.  This  should  be  thoroughly 
mixed  with  the  evacuations  until  the  mass  is  distinctly  alkaline,  and  shoidd 
remain  in  contact  for  one  or  two  hours,  since  it  is  slower  in  its  action  than 
chlorinated  lime  or  carbolic  acid,  and  much  longer  exposures  are  required 
to  destroy  the  bacillus.  It  is  particularly  adapted  to  the  disinfection  of 
privy  wells  and  latrines,  into  which  it  may  be  thrown,  freshly  prepared  in  the 
proportion  of  i  part  by  weight  of  recently  burned  calcium  hydrate  to  8  of 
water,  or  about  1 2  per  cent.  It  is  not  harmful  to  water-closet  pipes  in  such 
quantities  as  required  to  disinfect  the  stools  of  a  single  case  of  typhoid 
fever. 

Acidulated  solution  of  corrosive  sublimate  1  to  500  is  an  admirable  dis- 
infectant for  stools,  but  is  not  altogether  harmless  to  plumbing,  whence  it 
is  less  satisfactory  when  excreta  are  thrown  into  city  water-closets. 

Sulphate  of  iron  or  copperas  is  a  good  deodorant,  but  not  a  true  disin- 
fectant. Above  all,  il  must  not  bs  forgotten  that  simple  hot  water  thoroughly 
mixed  with  the  fecal -discharges  is  an  efficient  disinfectant. 

Most  important  in  the  prophylaxis  of  typhoid  fever  is  drainage.  It 
seems  to  be  now  definitely  settled  that  the  fever  originates  in  every  instance 
from  the  ingestion  in  some  way  of  the  typhoid  bacillus,  commonly  in  drink- 
ing-water or  milk,  or  in  food  contaminated  with  it,  more  rarely  by  inhalation. 
Hence,  it  is  of  the  greatest  importance  that  the  sources  of  water  used  in 
domestic  economy  should  be  protected  against  contamination  by  discharges 
containing  the  specific  bacilli,  which  sometimes  find  their  way  into  weUs 
and  other  sources  of  water-supply. 

Nurses  should  be  enjoined  to  guard  against  their  own  infection  by  due 
attention  to  cleanliness  after  caring  for  the  discharges  of  a  patient  and  even 
after  tubbing,  while  watchful  care  should  be  taken  not  to  carry  the  hands  to 
the  mouth  during  the  bath.  Every  nurse  should  wear  rubber  gloves  when 
bathing  or  tubbing  a  patient.  On  the  other  hand,  the  infection  is  one  of  the 
easiest  controlled,  and  the  spread  of  typhoid  fever  can  be  effectually  pre- 
vented if  the  precautions  advised  are  followed.  Moreover,  it  cannot  be  too 
strongly  insisted  upon  that  any  infected  water  or  milk  may  be  rendered 
thoroughly  harmless  by  boiling  and  filtration.  Physicians  should  lose  no 
opportunity  to  inculcate  this  truth  as  well  as  that  limpidity  of  a  water  does 
not  guarantee  its  innocuousness,  whUe  it  may  even  be  slightly  turbid  and 
yet  harmless.  The  part  that  flies  and  other  insects  play  in  the  spread  of 
typhoid  fever  is  now  well  understood.  All  food  should  be  carefully  screened 
in  summer  time  to  prevent  the  approach  of  flies.  All  dejecta  must  be  care- 
fully protected  from  flies,  that  these  insects  may  not  become  contaminated 
by  the  infective  material. 


34  INFECTIOUS  DISEASES 

PARATYPHOID   FEVER. 

Definition. — A  form  of  infectious  fever  presenting  a  clinical  picture 
closely  resembling  that  usual  to  typhoid  fever,  but  usuall}'  the  symptoms  are 
less  severe.  It  is  due  to  a  bacillus  whose  characteristics  are  intermediate 
between  the  typhoid  and  colon  groups,  and  called,  therefore,  the  paratyphoid 
or  paracolon  baciUus. 

Morbid  Anatomy. — While  ulceration  of  Peyer's  patches  may  be  absent, 
recent  studies  have  shown  its  occurrence.  The  spleen  is  always  found  en- 
larged. The  ulcers,  when  present,  are  like  those  of  typhoid  while  there  is  a 
characteristic  absence  of  alteration  of  Peyer's  glands  and  of  the  solitary 
follicles.  Focal  necrosis  has  been  found  in  the  liver.  The  anatomic  lesions 
are  said  by  Osier'  to  be,  in  a  word,  those  of  typhoid  fever. 

Symptoms. — The  symptoms  are  those  of  typhoid.  Differences  observ^ed 
are,  in  general,  greater  mildness  and  more  favorable  prognosis;  greater 
frequency  of  diarrhea  and  more  frequent  termination  of  fever  by  crisis. 
Myositis  and  purulent  arthritis,  verj.'  rare  in  typhoid  fever,  are  among  the 
complications.  The  disease  does  not  respond  to  the  Widal  test  with  t^'phoid 
bacilli,  but  the  serum  reacts  upon  fresh  cultures  of  the  paracolon  or  para- 
thyphoid bacillus. 

Treatment  is  in  no  way  different  from  that  of  typhoid. 

ROCKY  MOUNTAIN  SPOTTED  FEVER. 

Definition. — Rockj'  Motuitain  spotted  fever  is  an  acute  infectious 
disease  common  in  the  valleys  of  the  Rocky  Mountains,  in  Idaho,  Montana, 
and  along  the  valleys  as  far  as  Mexico,  and  characterized  by  fever,  headache, 
muscular  pains  and  a  petechial  rash. 

We  owe  our  knowledge  of  this  disease  principallj'  to  Maxej'  and  to  Wilson 
and  Channing;  and  to  Ricketts  and  King  who  described  the  clinical  course 
of  the  fever,  and  the  latter  its  method  of  dissemination. 

Etiology. — The  actual  cause  of  the  disease  is  not  known.  King  and 
Ricketts  have  proven  bej^ond  question  that  it  is  spread  through  the  medium 
of  a  tick,  the  Dermacentor  Occidentalis;  the  latter  authors  have  transmitted 
the  disease  to  animals  by  means  of  bites  of  these  ticks;  they  also  found  that 
the  ova  and  young  of  the  ticks  contain  the  infective  material.  "A  certain 
percentage  of  the  female  ticks  which  have  acquired  the  disease  as  a  conse- 
quence of  feeding  on  animals,  the  latter  ha\'ing  been  infected  by  other  ticks, 
transmit  the  disease  to  their  offspring  through  the  egg.  The  new  generation 
during  the  process  of  feeding,  transfer  the  virus  to  certain  of  the  susceptible 
small  wild  animals  (ground  squirrel,  rock  squirrel,  chipmunks,  ground  hogs, 
and  perhaps  others)  and  this  may  take  place  either  during  the  larval,  nym- 
phal  or  adult  stage,  hence  at  various  times  of  the  j^ear.  During  the  infec- 
tion of  the  wild  animal  it  is  required  that  hitherto  normal  ticks  either  as 
larvcB,  nymphs  or  adults,  acquire  the  disease  by  feeding  simultaneously 
with,  or  shortlj'  after,  the  feeding  of  the  infected  ticks." 

Apparently  the  type  of  the  disease  varies  in  severity  in  the  various  areas 
where  it  occtirs.     The  disease  occurs  in  the  early  spring  months,  just  after 

>  Wills  and  Scott,  "Journal  of  Infectious  Diseases,"  Jan.  3,  Z904. 


ROCKY  MOUNTAIN  SPOTTED  FEVER  35 

the  snow  has  melted,  and  is  most  common  among  males  for  the  reason  that 
these  individuals,  particularly  herders,  are  lead  by  their  business  to  be  in 
the  meadow  lands  and  grasses  in  this  region  at  this  time  of  the  year,  and  thus 
have  an  opportunity  to  be  bitten  by  the  tick. 

Symptoms. — There  is  a  short  period  of  malaise,  followed  usually  by  a 
well-marked  chill.  These  chills  may  be  repeated  throughout  the  course  of 
the  attack.  At  the  beginning  there  is  severe  aching  of  the  bones  and  muscles, 
and  pains  in  the  joints,  and  severe  headache.  Constipation  is  the  rule. 
The  skin  is  dry ;  the  tongue  is  coated  and  sordes  appear  early,  and  the  case 
has  the  appearance,  except  for  the  chill,  of  a  typhoid  in  its  beginning.  The 
temperature  rather  rapidly  develops  and  soon  reaches  102  or  103  degrees 
on  the  third  or  fourth  day.  It  may  go  much  higher,  reaching  even  107 
degrees.  There  is  usually  a  slight  evening  increase  and  morning  decrease. 
When  recovery  occurs,  the  temperature  falls  by  lysis. 

Skin. — The  most  characteristic  part  of  the  disease  is  seen  upon  the  skin. 
From  the  second  to  the  fifth  day  after  the  chill,  a  macular  rash  which  rapidly 
takes  on  the  characteristic  petechial  appearance  appears  around  the  ankles 
and  upon  the  wrists,  and  then  extends  over  the  entire  body.  Occasionally 
the  rash  will  cover  the  entire  body  in  12  hours.  More  usually,  however, 
it  takes  a  longer  time.  A  desquamation  occurs  in  about  the  second  week  of 
the  disease,  which  is  best  seen  on  the  soles  of  the  feet  and  the  palms  of  the 
hands.  Occasionally  there  is  jaundice.  In  severe  cases  the  patients  become 
delirious  and  pass  into  a  typhoid  state.  However,  there  is  no  sign  of  menin- 
gitis. The  pulse  is  rapid,  out  of  proportion  to  the  temperature.  The  blood 
is  only  slightly  changed,  the  red  cells  being  normal,  the  white  cells  being 
from  twelve  to  thirteen  thousand.  Except  for  constipation,  there  is  no 
unusual  sign  of  disturbance  of  the  digestion.  The  urine  frequently  shows  the 
signes  of  a  severe  febrile  condition,  albunim  and  casts. 

Diagnosis. — The  diagnosis  is  usually  easy,  the  condition  occurring  in 
the  spring  in  the  mountain  valleys  of  the  Rocky  Mountains.  The  fever 
resembles  in  the  beginning  typhoid  fever  but  with  a  petechial  rash,  the 
absence  of  Widal  reaction,  the  rather  rapid  rise  of  temperature,  and  the 
geopraphical  and  seasonal  distributions,  it  scarcely  can  be  anything  except 
Rocky  Mountain  spotted  fever.  It  might  be  mistaken  for  typhus;  for 
dengue;  for  cerebrospinal  meningitis,  but  the  characteristics  of  these 
latter  diseases  are  so  marked,  and  the  geographical  distribution  of  this 
disease  is  so  certain,  that  there  is  scarcely  any  possibility  of  making  a 
mistake. 

Prognosis. — This  seems  to  be  different  in  different  localities.  Dr. 
Maxey's  cases  almost  all  recovered,  while  the  cases  described  by  Wilson  and 
Channing  show  a  high  percent,  of  mortality.  There  is  no  pathological  con- 
dition W'hich  is  peculiar  to  the  disease. 

Treatment. — The  treatment  is  entirely  symptomatic.  However,  the 
prophylaxis  is  an  important  part.  Persons  whose  business  calls  them  into 
these  valleys  in  the  spring  time,  should  be  warned  of  a  possibility  of  infec- 
tion, and  should  protect  themselves  against  the  bite  of  ticks  in  every  possible 
manner,  particularly  by  protecting  the  feet  and  hands.  General  principles 
should  govern  the  treatment.  The  patient  should  be  in  a  cool,  well-ven- 
tilated room;  the  diet  should  be  soft  and  properly  regulated.     Cold  sponging 


36  INFECTIOUS  DISEASES 

for  the  fever,  with  morphin  or  other  opiate  if  the  patient  becomes  extremely 
restless. 

As  a  tonic  afterward,  the  patient  can  be  given  nux  vomica  and  gentian. 

TYPHUS  FEVER. 

Synonyms,. — Typhus  Exantheniaticns;  Petechial  Fever;  Pestilential  or  Putrid 
Fever;  Ship  Fever;  Jail  Fever;  Camp  Fever;  Brill's  Disease. 

Definition. — An  acute  fever  frequently  occurring  where  human  beings 
are  crowded  together,  as  in  jails  and  ships  of  olden  times;  especially  charac- 
terized by  sudden  onset  of  high  fever,  by  a  petechial  eruption,  typhoid 
symptoms,  and  short  duration  as  compared  with  typhoid  fever ;  in  favorable 
cases  terminating  suddenly  at  the  end  of  the  second  week. 

Etiology. — Though  of  acknowledged  infectious  nature,  no  organism 
has  as  yet  been  isolated  that  can  be  held  responsible  for  typhus  fever.' 
Anderson  and  Goldberg  in  "N.  Y.  Med.  Journal,"  May,  1912,  have  proven 
by  careful  animal  experiments  that  typhus  fever  in  the  mild  form  of  Brill's 
Disease  is  common  over  the  United  States  and  Canada.  Fostered  by 
close  crowding,  filth,  and  famine,  it  each  year  becomes  more  infrequent 
as  the  conditions  favoring  it  are  eliminated,  and  there  is  reason  to 
believe  it  will  ultimately  be  stamped  out.  Thus,  in  1897  there  were  only 
three  cases  in  all  the  London  fever  hospitals.  Ireland  has  been  its  home  for 
centuries,  but  filthy  and  crowded  sections  and  the  almshouses  of  large 
cities  have  at  different  times  furnished  seats  for  its  lodgment.  Quite  a 
serious  epidemic  prevailed  in  New  York  City  in  188 1-2,  and  a  milder  one 
in  1892-93.  Nicolle  has  transmitted  typhus  fever  to  monkeys  by  inject- 
ing them  with  blood  of  typhus-fever  patients,  while  Anderson  and  Gold- 
berg have  done  the  same  with  typhus  fever  of  Mexico. 

Nicolle  also  proved  that  typhus  fever  in  France  could  be  transmitted 
from  monkey  to  monkey  by  the  common  body  louse.  Ricketts  and  Wilder 
confirmed  these  facts  in  regard  to  Mexican  typhus  (tabardillo)  and  also 
that  this  disease  can  be  transmitted  from  man  to  monkey  by  means  of  the 
louse  (Pedicullus  Vestimente).  These  writers  have  also  shown  that  the 
flea  and  the  bedbug  are  not  concerned  in  the  spread  of  typhus.  Anderson 
and  Goldberg  believe  the  disease  can  also  be  carried  by  the  head  louse. 

Typhus  fever  is  therefore  not  contagious,  but  great  care  should  be  taken 
to  destroy  all  the  clothing  from  an  infected  individual  as  well  as  all  vermin 
on  his  body.  Also  he  must  be  protected  from  vermin  in  order  that  the 
latter  may  not  be  infected.  Nurses  and  others  in  constant  attendance 
upon  typhus  patients  are  more  liable  to  be  attacked  than  those  who,  like  the 
physician,  merely  visit  them  daily,  although  perhaps  no  disease  in  the  past 
has  included  among  its  victims  so  many  medical  men. 

Morbid  Anatomy. — As  to  the  morbid  anatomy  of  this  disease,  there  is 
really  nothing  distinctive.  Rigor  mortis  is  apt  to  be  delayed.  The  pete- 
chial eruption  remains  after  death,  and  gangrenous  bed-sores  may  be  found 
on  the  body.     The  most  constant  lesion  is  very  moderate  enlargement  of  the 

1  For  a  summary  of  the  observations  thus  far  made  on  the  "  Micro-organisms  in  Typhus  Fever,"  see  a 
paper  with  this  title  by  J.  B.  Byron  and  Egbert  Le  Fevre.  in  vol.  ii.,  "Researches  of  the  Loomis  Laboratory," 
New  York,  1892,  p.  130. 


TYPHUS  FEVER 


37 


spleen,  and  in  this  enlargement  the  liver  and  kidneys  may  share,  and  their 
cells  be  the  seat  of  cloudy  swelling  due  to  fever  heat.  Indeed,  all  the  tissues, 
including  the  heart  muscle,  may  be  granular  from  this  cause.  The  splenic 
enlargement  is  mainly  due  to  vascular  engorgement,  but  there  may  also  be 
some  hyperplasia  of  lymph-cells.  The  lymph-follicles  of  the  intestine  may 
be  enlarged  from;  the  same  cause,  but  there  is  no  ulceration  of  these  or  of 
Payer's  patches.  The  blood  is  dark  and  liquid.  Hypostatic  congestion  of 
the  lungs  is  very  frequently  found;  likewise  bronchial  catarrh.  The  per- 
manence of  the  eruption  after  death  is  in  strong  contrast  with  that  of 
typhoid  fever,  which  disappears  after  death. 

Symptoms. — The  period  o]  incubation  is  usually  about   12   days.     It 
may  be  less.     There  is  seldom  any  prodrome,  the  invasion  being  sudden,  an- 


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Fig.  6. — Temperature  in  Typhus  Fever   ("Pepper's  American  Text-boolc    of    Medicine"). 


nounced  by  a  chill  or  chills  followed  by  headache  and  great  muscular  pain, 
especially  in  the  back,  and  by  high  fever,  the  temperature  rapidly  rising  to 
103°,  104°,  105°,  and  106°  F.  (39.4°,  40°,  40.5°,  41.1°  C.)  without  any  of  the 
tidal-wave  rise  characteristic  of  typhoid  fever.  The  pulse  is  at  first  full  and 
strong,  but  soon  weakens  and  becomes  frequent — 120  and  more.  There  is 
extreme  debility.  Almost  characteristic  are  the  red,  congested  conjunctives, 
the  dusky  face,  dull  expression,  and  low,  muttering  delirium,  which  contrasts 
strongly  with  the  sometimes  active  delirium  of  typhoid.  The  tongue  is 
early  coated  and  becomes  rapidly  dry.     The  bowels  are  constipated. 

On  the  third  to  the  fifth  day  the  eruption  presents  itself;  it  is  of  two 
kinds,  the  petechial  and  the  mottled.  The  petechial,  or  more  characteristic, 
is  at  first  not  unlike  that  of  typhoid  fever,  but  is  darker  in  hue  and  disappears 
less  readily  on  pressure;  a  little  later  it  is  barely  influenced,  and  still  later 


38  INFECTIOUS  DISEASES 

does  not  respond  at  all  to  pressure.  It  has  become  hemorrhagic  There 
may  be  spots  exhibiting  each  one  of  these  stages.  This  eruption  is  also 
more  scattered  than  that  of  typhoid  fever,  appearing  all  over  the  body, 
while  that  of  typhoid  is  limited  to  the  chest  and  belly.  In  addition  to  the 
petechial  eruption  there  is  also  a  peculiar  dark  mottling  of  the  skin,  an  alter- 
nation of  purple  blotches  with  others  of  a  light  hue,  generall}'  capable  of 
being  influenced  by  pressure,  but  these  blotches,  too,  may  become  blood 
extravasations. 

With  the  beginning  of  the  second  week  all  of  tlie  symptoms  become  more 
severe;  the  tongue  becomes  dry,  fissured,  and  leathery ;  sordes  collect  on  the 
teeth ;  stupor  deepens,  there  are  subsultus  and  nystagmus,  coma  vigil — the 
patient  is  unconscious,  but  the  eyes  are  wide  open — and  picking  at  the  bed- 
clothes. At  this  time,  too,  the  peculiar  disagreeable  odor  said  to  be  char- 
acteristic of  typhus  fever  makes  its  appearance.  It  is  variously  described : 
by  Gerhard,  as  pungent,  ammoniacal,  and  offensive;  by  the  late  George  B. 
Wood,  as  like  the  odor  of  badly  ventilated  rooms,  in  which  a  number  of 
persons  are  collected;  and  by  others,  as  like  the  odor  given  off  by  rotten 
straw  or  the  urine  of  mice.  The  breathing  becomes  more  rapid,  the  pulse 
weaker,  scarcely  appreciable,  and  the  patient  may  die  of  adynamia ;  or  at 
the  end  of  the  second  week  a  crisis  occurs,  he  falls  asleep,  the  tempera- 
ture declines  as  rapidly  as  it  rose,  and  often  after  a  long  sleep  the  patient 
wakes  up'refreshed  and  with  a  clear  head.  Convalescence  now  progresses, 
and  although  it  may  be  slow,  relapses  rarely  occur. 

A  few  symptoms  require  special  allusion :  First,  the  fever.  The  skin  is 
burning  hot  and  the  temperature  occasionally  rises  to  io6°  F.  (41.1°  C.)  and 
even  108°  F.  (42.2°  C.)  and  109°  F.  (42.7°  C.)  toward  a  fatal  termination. 
It  is  the  calor  mordax.  There  is  alwaj^s  hypostatic  congestion  of  the  lungs  and, 
along  with  this,  a  great  deal  of  bronchial  catarrh  and  cough.  Such  catarrh  may 
pass  into  a  broncho-pneumonia,  which  may  terminate  in  gangrene  of  the 
lungs. 

The  urine  is  concentrated,  as  in  all  high  fevers,  and  urea  and  luic  acid 
are  relatively  increased.  Albuminuria  is  also  common,  but  there  is  not 
usually  any  organic  change  in  the  kidney  beyond  the  cloudy  swelling 
referred  to.  Retention  of  urine  on  account  of  the  mental  hebetude  may 
occur,  and  should  be  guarded  against  by  frequent  examination  and  cath- 
eterization. Bed-sores  are  common,  and  there  may  even  be  gangrene  of 
the  extremities. 

Instances  of  the  ambulatory  form  of  typhus  fever  are  much  more  rare 
than  of  typhoid,  but  they  are  occasionally  met. 

Diagnosis. — How  does  typhus  fever  differ  from  typhoid  fever  ?  We  have 
referred  to  the  differences  in  the  eruption  in  the  two  diseases.  But  the 
temperature  of  typhus  fever  is  quite  as  characteristic  as  that  of  typhoid 
fever.  In  the  latter  disease  we  have  the  peculiar  tidal-wave  course  de- 
scribed. In  typhus  fever,  in  the  first  place,  the  average  maximum  tem- 
perature is  higher;  for,  while  a  temperature  of  106°  F.  (42.1°  C.)  is  not 
uncommon  in  typhus  fever,  105°  F.  (40.5°  C.)  in  typhoid  is  quite  high. 
The  temperature  in  typhus  qiiickly  reaches  the  maximum,  usually  from 
the  third  to  the  fifth  day,  continues  with  light  remissions  until  the  12  th 
or  14th,  then  there  is  a  sudden  decline.     The  ascent  is  steady  and  con- 


TYPHUS  FEVER  39 

tinuous,  and  only  marked  by  slight  morning  remissions,  while  in  typhoid 
fever  the  morning  remissions  are  decided.  The  pulse,  during  the  first  three 
days,  is  usually  about  loo;  after  that  it  becomes  more  frequent  and  feeble, 
running  up  to  120  or  higher,  until  the  drop  in  temperature,  when  there  is  a 
corresponding  fall  in  the  rate  of  the  pulse.  It  is  seldom  dicrotic,  as  in 
typhoid  fever.  Typhus  fever  more  frequently  begins  with  a  chill  than 
does  typhoid;  the  important  symptoms,  including  the  eruption,  appear 
earlier.     In  isolated  cases,  however,  there  may  be  difficulty  in   diagnosis. 

Malignant  measles,  hemorrhagic  smallpox,  cerebrospinal  fever,  bubonic 
plague  and  Rocky  Mountain  spotted  fever  are  diseases  for  which  typhus 
fever  may  be  mistaken.  The  eruption  of  malignant  measles  is  not  unlike 
that  of  typhus  fever,  and  it  appears  first  in  the  face.  The  extreme  adynamia 
and  the  typhoid  symptoms  are  very  similar.  There  is  bronchitis  in  both, 
but  the  coryza  and  acute  nasal  catarrh  are  not  found  in  typhus,  while 
concurrent  with  the  case  of  malignant  measles  are  others  of  a  milder  and  more 
typical  nature.  The  latter  fact  also  aids  the  diagnosis  in  variola,  where, 
too,  in  the  malignant  form  the  hemorraghic  tendency  is  more  marked  and 
occurs  early  in  the  disease. 

Meningitis  has  often  been  mistaken  for  typhus,  and  in  the  earljr  stage 
the  suddenness  of  onset,  the  eruption,  and  the  nervous  symptoms  are  all 
calculated  to  mislead.  Here  the  spinal  puncture  will  make  the  diagnosis. 
Bubonic  plague  has  been  confounded  with  typhus,  it  however  resembling 
typhus  only  in  its  fatality.  Bubonic  plague  is  characterized  by  the  same 
suddenness  of  onset,  the  chill,  high  fever,  and  prostration,  as  is  tj^phus  fever ; 
but  the  eruption  appears  earlier,  becomes  carbuncular,  while  the  course 
of  the  disease  is  much  shorter.  Rocky  Mountain  fever  might  easily  be 
mistaken  for  typhus,  the  symptoms  of  the  two  conditions  closely  resembling 
each  other.  The  non-occurrence  of  typhus,  however,  in  the  northern 
states  and  the  rare  occurrence  of  spotted  fever  in  the  region  where  typhus 
abounds,  is  a  good  diagnostic  point. 

Prognosis. — The  mortality  of  epidemic  typhus  is  high,  but  different 
epidemics  vary  in  this  respect.  There  is  practically  no  mortality  in  the 
mild  form  of  Brill's  disease.  During  the  epidemic  at  the  Camden  County 
Almshouse  (1880-81)  referred  to,  103  of  theofficers  and  inmates  were  attacked. 
Of  this  number  23  died,  giving  a  mortality  of  a  little  over  22  per  cent.  We 
might  add  that  of  the  officers  of  the  institution,  seven,  including  an  attend- 
ing physician,  the  steward,  the  matron,  the  assistant  matron,  and  two 
ntuses,  together  with  the  biiilder  of  a  new  hospital  building,  were  attacked, 
and  all  died.  In  some  epidemics  the  mortality  is  even  greater,  reaching 
50  per  cent.,  but  it  commonly  ranges  from  12  to  20  per  cent.  The  disease 
attacks  either  sex  at  any  age.  One  of  the  modes  of  death  is  by  acute  fatty 
degeneration  of  the  heart,  and  the  peculiar  dusky  complexion  sometimes 
seen  may  be  due  to  the  inability  of  a  weak  fatty  heart  to  propel  the  blood 
through  the  capillaries.  Sudden  death  is  not  unusual.  It  is  more  than 
likely  that  with  the  improved  niursing  and  hygiene  of  the  present  day  the 
mortality  of  typhus  would  be  less. 

Treatment. — Prophylaxis  is  highly  important.  The  knowledge  that 
the  body  louse  carries  the  disease  from  patient  to  healthy  individuals, 
makes  personal  cleanliness  and  the  destruction  by  fire  of  all  clothing  of  the 


40  INFECTIOUS  DISEASES 

patient,  imperative.  Likewise  the  patient  may  be  bathed  in  coal  oil  which 
will  destroy  the  louse.  Notwithstanding  the  fact  that  the  louse  adheres 
to  the  clothing  and  not  to  the  body  of  the  patient,  it  is  wise  to  take  these 
precautions.  Whenever  possible,  typhus  fever  should  be  treated  in  the 
open  air  (in  tents) ,  as  the  safety  of  attendants  as  well  as  recovery  of  patients 
is  favored  thereby.  No  patient  should  be  admitted  to  a  ward  or  tent 
for  treatment  until  divested  of  all  his  clothing,  and  given  a  scrub  and  bathed 
in  coal  oil.  Hydrotherapy  is  as  serviceable  in  typhus  as  in  typhoid,  but 
it  is  absolutely  necessary  that  free  stimulation  should  be  associated  with 
any  treatment.  We  know  that  the  greatest  danger  lies  in  the  asthenia, 
which  can  be  met  only  by  stimulants.  Aromatic  ammonia,  strychnin, 
caffein  and  camphor  are  here  of  the  greatest  value.  Strychnin  should  be 
given  in  0.002  (1/30  grain)  doses  every  three  hours,  hypodermically  if 
necessary;  ammonia  in  teaspoonful  doses;  caffein  in  0.060  to  0.120  (i  to  2 
grains)  doses  every  two  or  three  hours  hypodermically;  alcohol  should  be 
given  as  in  typhoid,  remembering  that  it  is  indirectly  a  stimulant  in  that 
it  may  be  used  as  food,  8  to  16  c.c,  2  to  4  drams,  maj^  be  given  as  necessary. 
If  the  pulse  becomes  full  and  strong,  the  alcohol  is  doing  good,  otherwise  it 
is  useless.  Quinin  is  also  strongly  indicated,  as  are  digitalis  and  strychnin 
as  heart  strengtheners.  When  the  temperature  becomes  high,  if  the  cold 
bath  be  not  used,  sponging  of  the  body  in  the  way  described  under  tj'phoid 
fever  may  be  substituted.  The  same  objection  exists  to  phenacetin  and 
antif ebrin  as  in  typhoid ;  that  is,  they  dare  not  be  relied  upon  as  a  means  of 
reducing  temperature.  Other  symptoms  should  be  treated  as  they  arise. 
Specific  antiseptic  treatment  has  proved  to  be  withrout  peculiar  advantage. 

After  the  crisis,  which,  as  has  been  said,  is  strikingly  well  marked  in 
this  disease,  it  is  simply  necessary  to  treat  symptoms  as  they  arise.  The 
accompanying  bronchitis  is  treated,  if  it  requires  treatment,  like  any  other 
bronchitis,  but  the  ammonium  salts  are  especially  indicated  on  account  of 
their  stimulating  qualities,  while  the  aromatic  spirit  of  ammonia  is  an 
especially  convenient  preparation  for  these  purposes.  Camphorated  oil 
may  be  given  hypodermically  to  tide  over  emergencies. 

The  patient  should  be  nourished  as  in  typhoid  fever — by  nutritious 
liquids,  including  milk,  milk  punches,  egg-nogg,  and  nutritious  broths, 
and  all  soft  foods  the  patient  can  swallow. 


RELAPSING  FEVER. 
Synonyms. — Febris  recurrens;  Famine  Fever;  Seven-day  Fever. 

Definition. — Relapsing  fever  is  an  acute  infectious  disease,  character- 
ized by  two  or  more  febrile  relapses  separated  by  periods  of  total  remission 
and  caused  by  the  inoculation  and  multiplication  of  the  spirocha;ta  of 
Obermeier. 

Etiology. — The  specific  cause  of  relapsing  fever  known  in  this  country 
is  the  spirochmta  Obermeieri.  It  was  first  discovered  by  Obermeier  in  the 
blood  of  victims,  it  is  known  by  his  name.  It  is  a  narrow  spiral  about  0.025 
to  0.05  mm.  (i/iooo  to  1/500  inch)  inlength — that  is,  its  length  is  three  to 


RELAPSING  FEVER  41 

six  times  the  width  of  a  red  blood-disc.  It  is  found  floating  among  the  blood- 
discs  during  the  fever.  In  the  intervals  the  organism  is  not  found,  but  small, 
glistening  spherules,  said  to  be  its  spores,  take  its  place.  Confirmation  of 
the  infectious  nature  of  the  disease  is  found  in  the  fact  that  it  has  been 
communicated  to  monkeys  by  inoculation  of  blood.  Transmission  from  one 
individual  to  another  is  undoubtedly  favored  by  overcrowding,  by  filth, 
and  by  destitution.  Yet  the  disease  is  not  confined  to  the  poorly  fed. 
This  was  especially  proved  in  the  Philadelphia  epidemic  of  1869,  when  a  con- 
siderable number  of  fairly  well-to-do  persons  were  affected,  although  they 
always  resided  in  crowded  districts.  Neither  age,  sex,  nationalit\',  nor 
season  is  a  factor  in  its  causation.  Bedbugs  are  unquestionably  carriers  of 
the  disease,  the  spirochasta  having  been  repeatedly  demonstrated  within 
the  bodies  of  these  pests  infesting  the  bedding  and  beds  upon  which  relapsing 
fever  patients  have  slept. 

There  are  relapsing  fevers  in  different  countries  of  much  the  same 
clinical  character  in  which  the  organism  is  of  a  different  species  from  that 
of  the  Obermeier  organism.  In  the  tick  fever  of  Africa  (which  see)  the 
disease  is  spread  by  ticks  and  repetition  has  a  high  mortality. 

F.  G.  Novyi  who  has  made  the  latest  study  of  relapsing  fever  has  con- 
cluded that  a  "plurality"  of  relapsing  fevers  is  very  probable.  This  con- 
clusion was  reached  after  a  study  of  the  blood  from  two  cases  of  the  disease, 
from  different  sources,  one  from  New  York,  and  one  from  Bombay,  and  is 
based  on  certain  anatomical  differences  in  the  spiriUum;  that  of  Bombay 
being  more  like  that  of  tick  fever  from  which  it,  however,  differs.  The 
spirochseta  of  tick  fever  (the  spiroch&ta  Dultoni)  is  composed  of  cells  16 
microns  long  while  the  s.  Obermeieri  is  but  eight  microns  long,  and  the  num- 
ber of  turns  in  each  cell  is  about  the  same.  Moreover,  the  width  of  the  spiral 
of  tick  fever  is  two  or  three  times  that  of  s.  Obermeieri,  being  two  to  2.7 
microns  as  compared  with  one  micron.  Clinically,  however,  the  diseases 
are  very  similar. 

Morbid  Anatomy. — There  is  no  essential  morbid  anatomy,  and  such  as 
is  found  corresponds  with  that  of  typhus.  Most  conspicuous  is  enlargement 
of  the  spleen. 

Symptoms. — The  period  of  incubation  varies  greatty,  so  that  it  is  put 
down  at  from  two  to  14  days.  According  to  Murchison,  there  may  actually 
be  no  interval  between  exposure  and  the  invasion.  The  latter  is  sudden 
by  a  chill,  fever ,  intense  pain  in  the  back  and  limbs,  vnth  dizziness.  This 
abrupt  invasion  is  a  distinctive  feature,  and  in  perhaps  none  of  the  contagi- 
ous diseases  is  it,  as  a  rule,  so  marked.  Exceptionally  only  is  there  a  short 
period  of  malaise  with  loss  of  appetite.  On  invasion  the  temperature  rises 
rapidly  and  quickly  reaches  104°  F.  (40°  C).  The  patient  cannot  remain 
on  his  feet,  and  promptly  takes  to  his  bed,  feeling  very  sick,  rather  than  pro- 
foundly weak.  There  may  be  nausea  and  vomiting  and  even  convulsions 
in  the  young ;  the  pulse  rises  rapidly,  more  rapidly  than  in  typhus,  reaching 
140  on  the  second  day,  and  later  150  and  160.  The  patient  may  be  delirious, 
but  the  typhoid  symptoms  are  not  usually  so  profound  as  in  typhus,  and  the 
tongue  remains  moist.     Jaundice  appears  in  a  certain  number  of  cases  on 


'Relapsing  Fever  and  Spirochetes,"  F.  G.  Novy  and  R.  E.  Knapp  "Trans.  Assoc.  Amer.  Physicians," 
Lxi.,  1906.     , 


42 


INFECTIOUS  DISEASES 


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RELAPSING  FEVER  43 

the  third  or  fourth  day,  usually  in  one  out  of  every  1 2  cases,  occasionally  as 
often  as  one  in  every  four  or  five.  The  temperature  during  the  paroxysm 
fluctuates  slightly,,  being  higher  in  the  evening.  Sweating  and  sudamina 
are  often  present,  and  occasionally  petechice,  but  there  is  no  characteristic 
eruption.  Rarely,  Murchison  says  in  eight  out  of  600  cases,  a  roseolar  rash 
appears,  or  there  may  be  a  mottling  like  that  of  typhus,  which,  however, 
always  disappears  on  pressure,  and  disappears  entirely  in  three  or  four 
days — differing  in  these  respects  from  the  similar  eruption  of  typhus. 
Herpes  may  be  present.  There  is  occasionally  abdominal  tenderness  in  the 
epigastric  or  iliac  region,  and  the  enlarged  spleen  may  be  easily  detected, 
but  there  are  no  active  intestinal  symptoms.  The  liver  may  be  also  slightly 
enlarged,  extending  lower  than  in  health. 

The  spirochcete  is  to  be  found  in  the  blood  and  should  always  be  looked 
for.  It  may  readily  be  detected  with  a  power  of  500  diameters  without 
any  special  preparation  of  the  blood,  care  being  simply  taken  to  secure  a 
thin  film. 

Crisis. — If  the  invasion  of  relapsing  fever  be  sudden,  its  termination  is 
no  less  so.  It  is  by  crisis,  beginning  usually  with  sweating.  After  five  or 
six  days  of  unabated  fever  sweating  sets  in,  which  soon  becomes  profuse,  the 
temperature  falls  rapidly  to  normal  or  even  subnormal,  the  various  discom- 
forts fade  away,  and  in  the  course  of  a  few  hours  the  patient  is  apparent^ 
well.  Rarely,  the  crisis  may  be  ushered  in  by  a  diarrhea,  an  epistaxis,  or 
the  appearance  of  menstruation. 

The  crisis  does  not  always  take  place  at  the  same  stage  of  the  disease. 
It  may  occur  as  early  as  the  third  day  or  not  until  the  tenth,  or  even  the 
fifteenth  but  most  commonly  on  the  seventh.  While  the  crisis  is  ordinarily 
followed  by  some  relaxation  and  faintness,  there  soon  ensues  a  rapid  recovery 
of  natural  and  healthful  feeling.  Occasionally,  however,  the  depression  is 
greater  and  a  sensation  as  of  collapse  occurs,  especially  in  delicate  or  elderly 
persons. 

Relapses. — Again,  in  a  week  from  the  crisis,  generally  on  the  fourteenth 
day  from  the  primary  chUl,  another  occurs,  or  a  series  of  them,  with  fever, 
and  the  paroxysm  repeats  itself,  to  be  again  succeeded  by  a  crisis  at  a  some- 
what shorter  interval.  There  may  be  a  third  or  even  a  fourth  and  fifth 
paroxysm;  more  commonly  they  are  limited  to  two  or  at  most  three.  Each 
succeeding  attack  is  shorter  than  the  previous  one.  Occasional!}^  there  is  no 
relapse,  the  disease  terminating  with  the  first  crisis.  Convalescence,  usually 
rapid,  is  sometimes  prolonged,  and  the  duration  of  the  entire  illness  may  be 
put  down  at  from  18  to  90  days,  and  the  patient  rarely  retvims  to  work 
within  six  weeks.     One  attack  does  not  secure  immunity  from  another. 

Complications. — Among  the  complications  may  be  mentioned  bronchitis, 
pneumonia,  nephritis  and  hematuria.  The  spleen  may  enlarge  until  it 
rupttires.  It  may  attain  a  weight  of  four  and  one-half  pounds  (10  kilos), 
and  may  be  the  seat  of  infarcts.  Albuminuria  occurs  as  in  other  fevers 
characterized  by  high  temperatures.  Pregnant  women  usually  abort  in  the 
relapse,  and  the  child,  if  not  still-born,  siu-vives  but  a  few  hours.  Post- 
febrile paralysis  may  occur,  and  troublesome  ophthalmia  succeeds  in  some 
epidemics. 

Diagnosis. — In  its  early  stages  relapsing  fever  is  not  unlike  typhus.     In 


44  IXFECriOUS  DISEASES 

suddenness  of  onset,  rapid  rise  of  temperature,  habitat,  and  subjects,  the 
resemblance  is  close.  The  readiness  with  which  a  patient  takes  his  bed  is 
characteristic  of  each,  but  in  relapsing  fever  the  adynamia  is  not  so  great  as 
in  typhus,  and  it  is  rather  because  of  a  dizziness  that  he  cannot  keep  about. 
Examination  of  the  blood  will  show  the  spirochaete  in  relapsing  fever. 
The  crisis  cuts  short  all  doubt  on  this  point  of  confusion  with  tj'phus.  In 
the  intense  muscular  pains,  especially  in  the  back,  relapsing  fever  resembles 
smallpox,  but  the  eruption  in  the  latter  disease  sets  doubt  at  rest. 

Malaria  fever  may  be  suggested  by  the  relapse,  but  the  presence  of  an 
organism  in  the  blood  of  each  of  these  affections,  widely  different  in  appear- 
ance, permits  the  settlement  of  such  confusion  by  the  microscope.  The 
prevalence  of  an  epidemic  is,  of  course,  of  great  assistance  in  the  diagnosis 
between  relapsing  fever  and  any  of  the  diseases  with  which  it  may  be  con- 
founded. 

A  diagnosis  can  certainly  be  made  diuing  the  febrile  paroxysm  by  finding 
the  spirochete  in  the  peripheral  blood.  During  the  apyrexia  the  organisms 
are  not  found  in  the  blood.  According  to  Lowenthal  a  sero-diagnosis  may 
be  made  during  this  period.  The  serum  of  a  relapsing-fever  case  will 
immobilize  the  spirochaete  of  Obermeier  and  thus  a  diagnosis  may  be  made. 

Prognosis. — The  prognosis  of  relapsing  fever  is  not  unfavorable.  The 
higher  mortality  reported  in  some  of  the  earlier  epidemics  in  Great  Britain 
and  Ireland  was  doubtless  due  to  an  admixture  of  typhus.  An  average  for 
several  j'ears  in  a  number  of  cities  in  Great  Britain  and  Ireland,  according  to 
Murchison,  has  been  4.3  per  cent.;  in  the  epidemic  at  Bombay  in  1877-78. 
Vandyke  Carter  estimated  the  mortality  at  18.02  per  cent.;  while  in  the 
Philadelphia  epidemic  the  studies  of  William  Pepper,  2d,  and  Edward 
Rhoads  found  it  14  per  cent.  It  is  sure  that  in  private  practice  during  this 
epidemic  the  mortality  was  not  so  great.  There  are  some  accidents,  which 
have  been  already  alluded  to,  that  are  responsible  for  a  few  deaths.  Thus, 
the  spleen  has  ruptured  from  extreme  congestion.  Pneumonia  sometimes 
causes  a  fatal  termination.  It  has  been  said  that  the  crisis  sometimes  termi- 
nates in  collapse  with  its  characteristic  clammy  coldness,  pulselessness, 
unconsciousness,  and  fatal  end.  A  fatal  nephritis  occasionally  complicates 
the  disease,  death  being  preceded  by  uraemic  convulsions.  Certain  cases 
associated  with  jaundice,  called  by  Griesinger  "bilious  typhoid,"  are  often 
fatal.  Some  striking  cases  of  this  kind  were  noted  by  Pepper  at  the  Phila- 
delphia Hospital  in  the  epidemic  of  1869-70. 

Treatment. — Prophylaxis  here  plays  a  great  part  in  the  treatment.  All 
bedbugs  should  be  destro}'ed  in  or  about  the  rooms  of  the  patient  %\ath  this 
disease.  The  patient  being  freed  of  all  bedbugs  should  at  once  be  trans- 
ported to  a  room  known  to  be  free  from  infection  by  bedbugs.  The  febrile 
paroxysm  demands  much  the  same  treatment  as  in  typhus — careful  nursing, 
sponging  or  cool  bathing,  nutritious,  easil}^  assimilable  food,  and  stimulation, 
although  the  latter  is  less  important  than  in  typhus.  According  to  Meltzer' 
salvarsan  can  completely  destroy  the  spirillum  of  relapsing  fever  in  the 
animal  body.  Hence  this  drug  or  the  neo-salvarsan  should  be  tried  in  every 
case  of  relapsing  fever.  No  drug  has  the  power  to  prevent  the  recurrence 
of   the  relapse,  although  quinin  is  indicated,  and,  as  in  other  adynamic 

*  "Transactions,  Assoc.  Amer.  Phys.,"  vol.  xxvi.,  1911,  p.  300. 


MALTA  FEVER  45 

fevers,  is  useful  only  as  a  tonic.  It  is  reasonable  to  expect  that  acetyl- 
salicylic  acid,  phenacetin,  antifebrin,  or  antipyrin  will  relieve  the  muscular 
pains.  Should  they  not  suffice,  morphin,  hypodermically,  can  be  relied  upon. 
The  studies  of  Novy  go  to  show  that  the  serum  treatment  will  probably  be 
ultimately  successful. 

MALTA  FEVER. 

Synonyms. — Mediterranean  Fever;  Neapolitan  Fever;  Rock  Fever;  Undulant 

Fever. 

Definition. — An  anomalous  fever,  characterized  by  irregular  remissions 
and  relapses,  copious  sweats  and  rheumatoid  pains,  and  caused  by  a  bacUlus 
known  as  micrococcus  melitensis. 

Distribution. — The  various  names  of  Malta  fever  Indicate  its  distribu- 
tion on  the  Mediterranean  littoral,  outside  of  which  it  has  been  thought  infre- 
quent; but  in  1898  J.  J.  Kinyoun'  suggested  its  presence  on  the  Southern 
Atlantic  coast  of  America  and  the  islands  of  the  Gulf  of  Mexico,  a  suggestion 
•confirmed  by  the  report  of  J.  H.  Musser  and  Joseph  Sailer  of  a  case  originat- 
ing in  Cuba.^  It  is  also  reported  from  Africa  and  South  America. 

Etiology. — The  micrococcus  melitensis,  the  cause  of  this  peculiar  fever, 
has  been  studied  by  Bruce,  whose  results  have  been  confirmed  b^'^  Hughes. 
Its  morphological  and  biological  features  have  been  accurately  studied  by 
H.  E.  Durham.  It  is  found  in  large  numbers  in  the  spleen,  but  has  not  been 
isolated  from  the  blood.  The  disease  is  spread  through  the  milk  of  goats. 
It  is  not  definitely  known  how  the  micrococcus  leaves  the  body,  but  the  urine 
of  about  10  per  cent,  of  patients  contains  the  organism;  the  feces  also  in  a 
certain  number.  No  intermediary  host  save  the  goat  is  known,  though 
Bruce  claims  that  mosquitoes  may  be  the  conveying  medium.  Pure 
cultures  have  been  obtained,  the  disease  has  been  reproduced  in  monkeys, 
and  the  micrococcus  isolated  from  the  infected  animal.  A.  E.  Wright  and 
F.  Smith  have  shown  that  the  blood  of  Malta  fever  patients  reacts  with  pure 
cultures  of  the  micrococcus  melitensis.  This  would  seem  to  settle  its  inde- 
pendent nature.     The  disease  attacks  mostly  the  young. 

Morbid  Anatomy. — Our  knowledge  of  the  morbid  anatomy  of  Malta 
fever  is  not  definite.  Thus,  Bruce  says  no  characteristic  lesion  of  Malta 
fever  is  found. 

Symptoms. — There  is  usually  a  period  of  incubation  of  from  six  to  ten 
days.  The  onset  is  gradual,  with  headache,  sleeplessness,  and  thirst,  loss 
of  appetite,  without  chilliness  or  high  fever  at  first.  There  is  no  diarrhea; 
spots  are  not  found.  These  symptoms,  more  or  less  pronounced,  last  from 
three  to  four  weeks,  when  the  first  remission  sets  in,  simulating  convales- 
cence. It  lasts  a  few  days  only,  when  the  first  relapse  appears,  this  time 
with  rigors,  high  fever,  and  often  diarrhea,  and  the  symptoms  of  the  first 
attack  intensified.  This  relapse  lasts  for  from  five  to  six  weeks,  to  be  fol- 
lowed by  another  remission  of  from  ten  days  to  two  weeks.  Then  follows 
the  second  relapse,  when  recur  the  symptoms  of  the  first  relapse,  to  which 


'  "Gaceta  de  Caracas,"  July  is,  1898,  and  "Philadelphia  Med.  Jo 
'  "Philadelphia  Med.  Jour."  December  31,  1898. 


46 


INFECTIOUS  DISEASES 


~^. 


i: 


m 


tp^t 


MALARIAL  FEVER  47 

are  superadded  great  debility,  night-sweats,  pain  in  the  larger  joints,  includ- 
ing hips,  knees,  and  ankles,  and  in  the  testicles— one  or  both — -lasting  three 
or  four  weeks.  Then  follows  a  third  temission,  which  may  last  for  a  month 
or  six  weeks.  Then  a  third  relapse  of  shorter  duration,  adding  to  the  other 
symptoms  a  heavily  coated  tongue,  a  high  temperature,  105°  F.  (40.5°  C.) 
and  above  in  the  evening,  but  normal  in  the  morning,  the  night-sweats, 
and  especially  the  joint  pains,  being  markedly  severe.  All  the  joints 
now  seem  to  be  involved,  and  motion  is  an  agony.  The  fibrous  tissues  are 
also  often  involved  in  this  relapse,  especially  the  tendo  Achillis  and  fibrous 
structures  about  the  anlcle;  also  the  lumbar  aponeuroses  and  sheaths  of 
the  nerves  from  the  sacral  plexus. 

Diagnosis. — The  rarity  of  the  disease  and  the  peculiarity  of  its  symp- 
toms may  cause  it  to  be  overlooked  for  some  time.  It  may  at  first  be  mis- 
taken for  typhoid  fever,  but  there  are  no  rose  spots  and  no  diarrhea,  the 
course  is  much  longer.  The  serum  reaction  is,  however,  characteristic, 
cultures  of  the  specific  bacillus  responding  to  the  serum  of  the  blood  of  the 
disease  as  does  the  typhoid  bacillus  in  typhoid  fever. 

Prognosis. — This  is  generally  favorable,  not  more  than  two  per  cent, 
perishing. 

Treatment. — Prophylaxis  is  the  most  important  part  of  the  treatment. 
The  milk  of  goats  in  infected  regions  should  not  be  used  or  when  its  use  is 
imperative  should  be  boiled.  The  actual  treatment  is  symptomatic,  being 
directed  to  the  relief  of  the  symptoms  and  the  support  of  the  patient  against 
the  exhaustive  effect  of  the  disease.  A  case  seems  to  have  been  successfully 
treated  with  Malta  fever  antitoxin  by  Fitzgerald  and  Ewart.^ 

THE  MALARIAL  FEVERS. 

Synonyms. — Ague;  Fever  and  Ague;  Chills  and  Fever;  Marsh  Fever;  Swamp 
Fever;  Paludal  Fever;  Miasmatic  Fever;  Intermittent,  Remittent,  and 
Pernicious  Remittent  Fever;  Bilious  Fever;  Estivo-autumnal  Fever. 

Definition. — Malarial  fever  is  an  infectious  disease,  of  intermittent  or 
remittent  type,  due  to  an  organism  known  as  the  Plasmodium  or  hcemocy- 
tazoa  of  malaria. 

A  chronic  cachectic  condition  due  to  the  same  cause  is  known  as  ' '  chronic 
malaria"  or  "malarial  cachexia."  Chronic  malaria  has  really  a  more 
definite  morbid  anatomy  than  the  acute  malarial  fevers.  The  term '  'malaria' ' 
— meaning,  in  the  Italian,  bad  air — was  originally  applied  to  the  supposed 
specific  cause  of  the  fever,  but  it  is  also  used  to  express  the  consequences  of 
such  cause. 

Varieties  of  Malarial  Fever. — The  clinical  varieties  of  malarial  fevers  are 
intermittent  (tertian  or  quartan)  or  remittent  (estivo-autumnal).  The  former 
is  characterized  by  paroxysms  of  fever,  between  which  there  are  total 
intermissions.  In  the  remittent  form  there  are  remissions  or  abatements 
in  the  fever,  but  not  intermissions.  The  remittent  fevers  exhibit  much  less 
regularity  than  the  intermittent  fevers,  even  in  their  remissions,  and  in 
consequence  of  their  prevalence  in  the  later  summer  and  fall  have  among 


''The  Lancet,"  April  is,  I8 


48  INFECTIOUS  DISEASES 

other  irregular  types  been  included  under  the  head  estivo-autumnal.  The 
latter  term  embraces  also  all  the  malignant  types,  which  are  rarely  seen  in 
the  spring  months. 

The  paroxysms  of  fever  maj^  come  on  daily  at  the  same  hour,  when 
they  are  called  quotidian;  they  may  occur  every  other  day,  when  they  are 
known  at  tertian;  or  they  may  occur  every  third  day — that  is,  skip  two 
days — when  they  are  called  quartan.  More  rarely  occur  quintan,  sextan, 
septan,  and  octan  fevers,  with  inter\rals  of  four,  five,  six,  and  seven  days, 
respectively.  It  will  be  noted  that  in  naming  these  periods  the  daj'  of  the 
paroxysm  and  that  of  the  following  paroxysm  are  both  counted.  The 
"double  tertian"  is  a  fever  in  which  paroxj'sms  occur  each  day  but  at  differ- 
ent hoiurs,  the  hours  on  alternate  days  corresponding  w4th  each  other.  In 
these  cases  the  alternate  paroxysms  may  also  be  of  different  intensities. 
The  quotidian  is  really  a  double  tertian,  the  paroxysms  occurring  at  the 
same  hour  or  nearly  the  same  hour  each  day.  In  like  manner  there  may 
be  double  quartans  and  even  double  quotidians. 

Although  the  paroxysms  in  true  intermittent  fever  commonly  occur  at 
the  same  hour,  they  may  happen  a  little  earlier  each  day,  when  they  are 
called  "anticipating"  or  they  may  happen  a  little  later  when  they  are 
called  ' '  retarding. ' '  The  former  is  apt  to  occur  when  the  disease  is  becoming 
more  severe,  the  latter  when  it  is  abating.  The  paroxysm  varies  in  length 
in  the  different  varieties.  In  the  quotidian  form  it  lasts  from  ten  to  12 
hours,  in  the  tertian  six  to  eight  hours,  and  in  the  quartan  four  to  six  hours. 

Malarial  cachexia  referred  to  in  the  definition,  also  known  as  chronic 
malaria,  will  be  fully  considered  later. 

Etiology. — The  malarial  fevers  are  caused  by  a  protozoon  known  as 
the  Plasmodium  malaricB,  or  hmnacytozoa  malaria;. 

Hasmacytozoa  or  parasites  of  the  red  corpuscles  are  not  confined  to 
man  but  are  met  in  the  blood  of  birds,  fish,  frogs  and  such  mammals  as 
monkeys,  bats  and  cattle  as  well.  In  birds  and  frogs  they  are  especially 
numerous  and  apparently  harmless  unless  very  abundant. 

To  Study  the  Malarial  Organism  in  Man. — The  malarial  organism  is 
best  studied  from  fresh  preparations  as  follows : 

A  drop  of  blood  is  taken  from  the  finger  or  lobe  of  the  ear  during  the 
chill,  or  an  hour  or  two  previously,  while  the  temperature  is  gradually 
rising.  It  should  be  placed  on  a  perfectly  clean  cover  glass,  which  should 
be  allowed  to  fall  gently  on  a  glass  slide,  without  pressure,  and  carefully 
examined  with  an  oil  immersion  lens.  Careful  searching  will  show  certain 
red  corpuscles  (Plate  I,  Figs.  2,  3,  4,  5),  containing  minute  hyaline  bodies 
with  an  ameboid  movement.  Later  the  ameboid  bodies  are  seen  to  con- 
tain pigmented  granules,  having  a  BrowTiian  movement.  (Plate  I,  Figs. 
6i  7i  8,  9).  These  bodies  stain  with  a  Wright's  stain.  Later  the  Plasmo- 
dium fills  the  entire  body  of  the  corpuscle,  its  ameboid  movements  cease, 
and  the  granules  become  more  or  less  stationary.  The  pigment  now  tends 
to  mass  itself  into  clumps  near  the  center,  (Plate  II,  Fig.  9).  Very  soon 
this  larger  complete  pigmented  body  begins  to  segment,  making  a  Mulbery 
mass  (Plate  I,  Fig.  11)  of  from  twelve  to  twenty  segments,  with  the  pig- 
ment granules  in  the  center.  At  the  same  time  a  body  similar  to  the  one 
within  the  corpuscle  may  be  seen  upon  the  slide  outside  of  the  corpuscle. 


10     .  11 


The  Tertian  Parasite. 


1.  Normal  erythrocyte. 

2,  3,  4,  5.   Intracellular  hyaline  forms. 

6,  7.  Young  piginejited  intracellular  forms.  In  6  two  distinct  parasites  inhabit  the  ery- 
throcyte, the  larger  one  being  actively  ameboid,  as  evidenced  by  the  long  tentacular 
process  trailing  from  the  main  body  of  the  organism.  This  ameboid  tendency  is 
still  better  ilhistrated  in  7.  by  the  ribbon-like  design  formed  by  the  parasite.  Note 
the  delicacy  of  the  pigment  granules,  and  their  tendency  towar<d  peripheral  arrange- 
ment in  6,  7,  and  8. 

8.  Later  developmental  stage  of  7.    In  7,  8,  and  g  enlargement  and  pallor  of  the  infected 

erythrocyte  become  conspicuous. 

9.  Mature  intracellular  pigmented  parasite. 

10.  II,  12.   Segmenting  forms.     In  10  is  shown  the  early  stage  of  sporulation— the  develop- 

ment of  radial  striations  and  peripheral  indentations  coincidentally  with  the  swarm- 
ing of  the  pigment  toward  the  center  of  the  parasite.  The  completion  of  this  process 
is  illustrated  by  11  and  12. 

13.  Large  swollen  extracellular  foi-m.      Note  the  coarse  fused  blocks  of  pigment.     (Com- 

pare size  with  that  of  normal  erythrocyte,  i.) 

14.  Flagellate  form. 

15.  Shriinkeyi  and  fragmenting  extracellular  forms. 

16.  Vacuolation  of  an  extracellular  form. 

Note.— The  original  water-color  drawings  were  made  from  fresh  blood  specimens,  a 
I^itz  ^g-inch  oil-immersion  objective  and  4  ocular,  with  a  Zeiss  camera-lucida,  being  used. 


(E.  F.  Faber./^c.) 
(From  Da  Costa's  "Clinical  Hematology.") 


MALARIAL  FEVER  49 

These  extracorpuscular  forms  frequently  can  be  seen  to  develop  flagellas, 
which  whip  around  on  the  slide,  causing  the  corpuscles  to  be  active!}^ 
moved  about.  The  same  cycle  of  successive  steps  is  kept  up  from  par- 
oxysm to  paroxysm.  The  conclusion  reached  by  all  obser^i-ers  is  that 
the  large  intracorpuscular  body  (Plate  I,  Fig.  9)  is  the  mature  parasite  ready 
for  sporulation,  and  the  mulberry  mass  presents  the  sporules  perfectly 
formed,  which  a  few  seconds  later  become  free  spherical  spores.  These 
attach  themselves  to  the  red  disks,  penetrate  them,  and  grow  at  the 
expense  of  the  hemoglobin,  leaving  the  black  granular  residue  as 
excrementitious  substance,  which  is  let  loose  in  the  blood  at  the 
time  of  sporulation.  As  a  consequence  of  this,  the  presence  of  pigment 
in  the  blood  and  tissues  is  one  of  the  most  characteristic  features  of 
malaria. 

The  time  required  to  attain  the  perfect  growth,  from  the  free  sporule  to 
the  stage  of  sporulation,  varies  in  the  different  varieties  of  malarial  fever. 
During  this  period  certain  groups,  perhaps  numbering  mjTiads  of  cor- 
puscles, pass  through  the  same  stages,  and  the  final  sporulation  of  such  a 
group  of  parasites  is  always  followed  by  the  malarial  paroxysm.  This  is 
probably  due  to  some  toxic  substance  developed  at  the  time  of  sporulation. 
Thus,  with  the  typical  tertian  type,  sporulation  takes  place  every  other  day 
at  the  same  hour,  the  quartan  type  every  72  hours.  If,  however,  two 
groups  ripen  at  different  hours,  we  have  the  double  forms,  be  it  double 
tertian  or  double  quartan.  Or  two  groups  of  tertian  parasites  may  mature 
on  alternate  days,  causing  a  quotidian  paroxj^sm,  though  at  different  hours. 
The  typical  quotidian  is  the  result  of  matiu"ation  of  two  groups  of  tertian 
organisms  at  the  same  hour  on  alternate  daj's  making  a  daily  paroxj-sm. 
A  paroxysm  may  be  expected  at  once  in  the  tertian  form,  if  radiating  lines 
appear  in  the  organism  with  concentration  of  pigment.  The  cycle  of 
existence  of  the  estivo-autumnal  tj^pe  has  an  undetermined  duration,  and 
probably  varies  from  24  to  48  hours.  The  irregidar  ripening  of  different 
groups  would  explain  the  irregularity  of  the  estivo-autumnal  forms  of  fever, 
which  may  begin  as  regular  types.  Three  distinct  forms  of  parasites  arc 
recognized,  the  tertian,  the  quartan,  and  the  estivo-autumnal  forms. 
The  full-grown  parasite  of  tertian  fever,  plasinodium  vivax,  is  about  as 
large  as  a  normal  red  blood-corpuscle,  beginning  its  cycle  of  development 
as  a  much  smaller  hyaline  ameboid  body,  corresponding  ver\'  closely 
with  the  spores  of  the  rosette-body.  It  acquires  rapidl}'  at  the  ex- 
pense of  the  surrounding  blood-disc,  fine,  brown  pigment  granules  which 
sharply  outline  its  "ring"  shape  and  subsequentl}^  fill  it  completeh'.  The 
blood-disc  itself  becoming  gradually  decolorized,  grows  larger  and  more 
indistinct  until  it  disappears.  The  granules  exhibit  active  movement. 
In  the  sporule  stage  the  segments  number  from  15  to  20,  or  even  more. 
The  parasite  has  a  cycle  of  48  hours,  but  the  segmentation  is  often  seen 
between  the  20th  and  24th  hours. 

The  parasite  of  quartan  fever,  Plasmodium  malarice,  is  very  similar,  but  it 
is  smaller;  its  ameboid  movements  are  slower,  and  the  pigment  granules 
fewer,  coarser,  darker,  more  frequently  arranged  about  the  periphery,  and 
less  active  in  motion.  The  red  corpuscle  embracing  it,  instead  of  becoming 
larger  and  paler,  shrinks  about  the  parasite  and  assumes  a  deeper,  greenish 


50  INFECTIOUS  DISEASES 

hue.  The  sporulation  segments  are  fewer,  only  from  five  to  ten  in  number, 
and  are  arranged  with  great  regularity  about  the  central  pigment  (Plate  II, 
Fig.  lo).     Its  cycle  is  72  hours. 

The  parasite  oj  the  estivo-autumnal  fever,  Plasmodium  falciparum,  is  still 
smaller,  being,  when  fully  developed,  often  less  than  half  the  size  of  a  red 
blood-corpuscle,  and  the  quantity  of  pigment  is  much  smaller.  Only  the 
early  stages  of  its  development,  represented  by  small  hyaline  bodies,  often 
with  one  or  two  pigment  granules,  are  found  in  the  peripheral  circulation, 
the  later  stage  being  seen  in  the  blood  of  internal  organs,  such  as  the  spleen 
and  bone-marrow.  The  scarcity  of  the  pigment  granules  is  characteristic. 
The  corpuscles  containing  the  parasite  are  also  often  shruiiken,  crenated, 
and  brassy  in  color.  After  a  week  or  more,  larger,  crescentic,  ovoid  and 
round  bodies  with  central  clumps  of  pigment  make  their  appearance,  and 
are  characteristic  of  this  form  of  fever.  This  is  also  a  gametocyte  or  sexual 
form.     The  cycle  of  this  parasite  is  also  about  48  hours. 

The  large  exiracorpuscular  body  (Fi,  F2,)  which  presents  the  same  pig- 
mentation and  other  features  of  the  intracorpuscular  body,  is  the  latter 
escaped  from  the  corpuscle.  It  is  the  gametocyte  or  sexual  form.  It  is 
found  in  preparations  watched  with  the  microscope  for  some  minutes  after 
being  taken. 

The  crescent-shaped  body  (Plate  III,  Figs.  15,  16,  17,  iS,  19)  is  a  striking 
object.  The  crescent  develops  in  the  interior  of  the  red  corpuscle  from  the 
small  hyaline  forms,  which  gradually  increase  in  size,  lose  their  ameboid 
movement,  and  assume  a  crescentic  shape,  while  pigment  granules  collect 
in  a  group  at  the  center.  The  corpuscle  itself  gradually  becomes  decolorized 
and  ultimately  destroyed,  though  for  some  time  a  delicate  line  can  be  seen 
running  between  the  horns  of  the  crescent,  a  shell,  as  it  were,  of  the  corpuscle 
in  which  the  parasite  is  developed.  The  crescentic  and  ovoid  forms  are 
incapable  of  sporulation,  they  are  the  gametocyte,  corresponding  to  the 
round  extracorpuscular  body  of  tht  tertian  and  quartan  variety;  they  do 
not  segment. 

The  flagellate  body  {G\,  d)  {Micro  gametocyte)  may  also  come  into  view  on 
the  slide  some  15  or  20  minutes  after  the  blood  is  mounted,  but  is  never 
seen  on  slides  "fixed"  immediately  after  the  blood  is  drawn.  It  develops 
from  the  fiill-grown  tertian  and  quartan  parasites  and  from  the  round 
bodies  with  central  pigment  in  estivo-autumnal  infections.  It  is  a  very 
interesting  object,  the  tentacular  prolongations  lashing  about  the  central 
mass  and  agitating  the  surrounding  corpuscles  in  a  seemingly  violent 
manner,  throwing  the  latter  and  its  own  melanin  particles  into  a  state  of 
extreme  commotion.  Sometimes  portions  of  these  tentacles  break  loose 
and  float  away  in  the  blood  plasma. 

The  Parasite  in  the  Mosquito. — Though  the  mosquito  theorj-  of  malaria 
is  by  no  means  new,  it  was  not  until  1894  that  Patrick  Manson  gave  it 
definiteness  by  suggesting  the  mosquito  might  be  the  intermediate  host  for 
the  extracorporeal  forms  of  the  parasite,  of  which  the  flagellate  form  is  the 
first  stage;  and  that  the  flagella,  brealving  off  from  the  residual  body,  may 
penetrate  the  cells  of  some  organ  of  the  insect.  He  first  claimed  that  the 
crescentic  form  of  estivo-autumnal  malaria  and  the  tertian  and  quartan 
spherical  forms  from  which  develop  flagella  are  the  "  extracorporeal  sporu- 


%     ^ 


24      ^ 
9» 


The  Estivo-Autumnal  Parasite. 


1.  Nnrmal  erythrocyte. 

2,  3.    Yonyig  hyaline  ring-forms. 

4,  5,  6.   Intracellular  hyaline  forms.     In  4  the  parasite  appears  as  an  irregularly  shaped  disc 
with  a  thinned-out  central  area.     In  5  and  6  its  ameboid  properties  are  obvious. 

7.  Youjig  pigmented  intracellular  form.      Note  the  extreme  delicacy  and  small  number  of 

the  pigment  granules.     (Compare  with  6,  Plate  VI,  and  with  3,  Plate  VII.) 

8,  g.   Later  developynental  stages  of  7. 
10,  II,  12.   Segmenting  forms. 

13,  14.    Crescentic  forms  at  early  stages  of  their  develop?nent. 

15,  16,  17,  18,  ig.   Crescentic  forms.    In  15  and  19  a  distinct  "  bib  "  of  the  erythrocyte  is  visible. 
Vacuolation  of  a  crescent  is  shown  in  18,  and  polar  arrangement  of  the  pigment  in  17. 
20.    Oval  form. 
21,22.  Spherical  forms, 

23.  Flagellate  form. 

24.  Vacuolation  and  deformity  of  a  spherical  form. 

25.  Vacuolated  leucocyte  apparently  enclosing  a  dwarfed  and  shrunken  crescent. 

26.  Remains  of  a  shrunken  spherical  form. 

(E.  F.  Faber./^c.) 
(From  Da  Costa's  "Clinical  Hematology.") 


MALARIAL  FEVER  51 

lating  homologues of  the  intracorporeal  organism;  that  the  flagellam  is  the 
extracorporeal  homologue  of  the  intracorporeal  spore."  Both  types  of 
sporulating  plasmodium  possess  the  same  function — the  propagation  of  the 
parasite — one  in  the  human  body;  the  other,  outside  of  it.  Surgeon- 
Major  Ronald  Ross,  whose  studies  were  stimulated  by  Manson,  found  the 
flagellate  form  in  the  stomach  of  mosquitoes  that  had  fed  on  subjects  suffering 
with  estivo-autumnal  fever  whose  blood  contained  large  numbers  of  crescents, 
thus  confirming  Manson's  observations.  Again,  Daniels,  working  in  Cal- 
cutta under  Ross's  direction,  was  able  to  confirm  all  the  latters  observations. 
Angelo  Celli,  while  admitting  that  Ross  partly  saw  the  first  stages  of  de- 
velopment of  the  estivo-autumnal  parasites  in  the  body  of  a  dapple-winged 
mosquito,  holds  that  Grassi,  Bastianelli,  and  Bignami  have  given  us  all  the 
details  of  its  development.^  To  whomever  be  the  credit,  and  it  is  probably  a 
divided  one,  it  is  admitted  that  the  hsemocytoa  of  malaria  in  man  as  in  birds 
has  two  life  cycles;  the  one  asexual  in  the  blood  of  malarial  subjects,  the 
other  sexual  in  the  body  of  special  mosquitoes. 

The  above  observations  are  the  confirmed  results  of  many  different  ob- 
servers, whence  it  follows  that  inoculation  is  the  only  mode  by  which  the 
infection  is  carried  from  the  mosquito  to  man  and  from  man  back  to  the 
mosquito.  Nay,  more,  the  very  genus  and  species  of  mosquito  responsible 
have  been  isolated.  They  are  the  genus  anopheles,  species  claviger,  and  spe- 
cies pictus  (dapple- winged  mosquito  of  Ross) ,  both  conveying  the  estivo-au- 
tumnal form,  while  the  former  is  the  conveyer  of  tertian  infection.  The  A. 
quadrimaculatus  of  this  country  has  been  shown  to  be  identical  with  the  A. 
claviger,  the  insect  chiefly  responsible  for  the  spread  of  the  disease  on  the 
continent  of  Europe.  In  addition  to  the  A.  guadrimaculatus ,  only  two  spe- 
cies of  anopheles  have  been  positively  recognized  in  this  countrj"-,  viz.,  A. 
punctipennis  and  A.  crucians.  The  mosquito  genus  culex  is  not  a  host  for 
the  parasite  of  malaria. 

It  does  not  follow  that  every  anopheles  is  infected,  as  it  may  infest  a 
region  where  malaria  does  not  prevail  or  the  locality  may  be  too  cold  to 
permit  the  development  of  the  organism,  warmth  being  an  essential  con- 
dition. 

The  harmless  culex  is  comparatively  easUy  distinguished  from  the 
malaria-breeding  anopheles,  both  of  which  are  shown  in  the  annexed  figures 
from  the  description  of  L.  O.  Howard,  Entomologist  of  the  United  States 
Department  of  Agriculture. 

The  anopheles,  (Fig.  i,  Plate  i)  has  wings  which  are  more  or  less  spotted, 
while  culex  (Fig.  2)  has  clear  wings.  The  palpi  or  projections  on  either  side 
of  the  beak  in  anopheles  are  very  long,  nearly  as  long  as  the  beak;  in  culex 
they  are  very  short.  Moreover,  when  culex  is  resting  on  a  wall  it  is  more  or 
less  hump-backed,  that  is,  the  head  and  beak  are  not  in  the  same  plane  with 
the  body  and  wings,  the  body  and  wings  being  parallel  with  the  wall.  With 
the  anopheles  (Fig.  3  on  the  left)  the  head  and  beak  are  practically  in  the 
same  plane  with  the  body  and  the  body  itself  is  usually  placed  at  an  angle 
with  the  wall  and  especially  when  resting  on  a  horizontal  wall  such  as  the 
ceiling  of  the  room  its  body  is  at  a  marked  angle  with  the  surface,  as  con- 


1  Celli,  "Malaria,"  2d  ed.     Translated  by  John  Joseph  Eyre,  London, 


52 


IN  FELT  10  US  DISEA  SES 


Fig.  8. — Anopheles  piinctipennis — female, 
with  male  antenna  at  left,  and  wing-top 
showing  venation  at  left,  enlarged. 


Fig.  9. — Culex  taniorhynchus — female, 
showing  the  short  palpi  which  distinguish 
culex  from  anopheles;  toothed  front  tarsal 
claw  at  right,  enlarged. 


Fig.  10. — Resting  position  of  anopheles, 
enlarged. 


Fig.  II. — Resting  position  of  culex, 
enlarged. 


Made  up  of  drawings  from  Dr.  L.  O.  Howard's  "Notes  on  the  Mosquitoes  of  the  United  States.' 
Go\ernment  Printing  Office,  Washington,  1900. 


MALARIAL  FEVER  53 

trasted  with  culex  (Fig.  4).     This  difference  is  well  shown  in  the  appended 
drawings  from  Howard's  pamphlet.' 

The  studies  of  Ross,  Grassi,  Bastianelli,  Bignami,  Stephens,  Christo- 
phers and  Daniels  have  determined  the  following  stages  in  the  evolution 
of  the  sporozoon  in  the  body  of  the  mosquito.  When  the  anopheles  has 
"bitten"  the  malarial  subject  and  drawn  into  its  stomach  the  blood  con- 
taining sex-ripe  forms  (gametocytes) ,  the  male  elements  or  microgame- 
tocytes  send  out  their  fiagella  (microgametes)  which  penetrate  and  fecun- 
date the  female  forms  or  macrogametes.  These  fertilized  bodies  or  zygotes 
known  also  as  oocysts  and  sporoblasts,  migrate  as  far  as  the  muscular  coat 
of  the  mosquito's  stomach  and  begin  there  a  cycle  of  development.  After 
40  hours  appear  small  round  refracting  bodies  which  contain  pigment  gran- 
ules like  those  contained  in  the  malarial  parasite.  These  grow  until  the)- 
have  reached  a  diameter  of  60  to  70  microns  at  the  end  of  seven  or  eight  days 
and  are  much  larger  than  those  seen  in  malarial  blood.  At  this  time  they 
exhibit  a  delicate  striation,  due  to  innumerable  small  fusiform  sporoblasts 
or  sporozoids  (polynuclear  multiplication  of  the  uninuclear  parasite). 
With  the  complete  formation  of  the  sporoblasts  the  oocyst  ruptures  and  the 
sporoblasts  escape  in  large  numbers  into  the  general  cavity  of  the  mosquito's 
body  and  by  the  lacunar  circulation  reach  the  salivary  glands  and  ducts 
where  they  accumulate  also  in  large  numbers  to  be  discharged  into  the 
blood  of  the  bitten  victim,  where  they  develop  into  young  asexual  parasites. 
The  sporozoid  thus  developed  in  the  oocyst  corresponds  to  the  spore 
resulting  from  the  asexual  segmentation  of  the  full-grown  parasite  in  the 
blood.  Either  one  of  these  fastening  on  a  red  blood-corpuscle  may  develop 
the  asexual  or  sexual  cycle.  As  a  rule,  in  the  human  body,  in  the  first 
generations  of  parasites  the  asexual  cycle  is  followed,  the  sexual  form 
developing  later.  The  sexual  forms,  sterile  while  in  the  human  host,  are  the 
forms  through  which  the  life  of  the  parasite  is  preserved,  spreading  infection 
through  the  mosquito  bite. 

Favoring  Causes  and  Geographical  Distribution. — These  views  are 
further  confirmed  by  the  conditions  which  favor  malarial  fever,  and  these 
notwithstanding  exceptions,  are  hot  climates  and  hot  seasons  plus  decom- 
posing vegetable  matter,  low  river  banks  frequently  covered  and  uncovered 
with  water  and  exposed  to  the  sun — in  a  word,  conditions  that  favor  the 


1  A  vocabulary  of  terms  has  been  created  to  cover  the  requirements  of  our  new  knowledge  of  this  sub- 
ject, some  of  which  are  here  appended; 

Gamete,  a  sexually  capable  element,  including  macrogamete,  the  female,  cell  and  microgamete,  the  male 
element  (a  flagellum  originating  from  a  microgametocyte,  the  parent  male  cell). 

Gametocyte,  a  cell  capable  of  developing  into  or  producing  the  gametes;  including  the  macrogametocyte 
or  cell  capable  of  development  into  the  female  gamete,  and  the  microgametocyte,  the  cell  from  which  arise 
the  male  elements  or  microgametes. 

Hyaline  Body,  a  nonpigmented  young  form  of  the  hematozoon. 

Ring  Form,  a  shape  any  young  parasite  may  assume,  not  a  "kind"  of  organism. 

Pigment,  the  transformed  hemoglobin,  or  "melanin,"  appearing  as  brown  granules  in  the  parasite  (not 
chromatin  granules). 

Prcsegmenters,  fully  grown  parasites,  with  pigment  accumulated  in  masses,  before  segmentation  occurs. 

Schizogony,  the  asexual  multiplication,  seen  in  the  human  host. 

Spozogony,  the  sexual  multiplication,  occurring  in  the  mosquito. 

Mcirozoit,  or  segment,  one  of  the  offspring  of  the  asexual  generation,  in  the  human  blood  (one  of  the 
products  of  segmentation). 

Sporozoit,  one  of  the  offspring  of  the  sexual  generation,  produced  in  the  mosquito,  and  inoculated  by 
it  into  the  human  host  where  it  becomes  one  of  the  hyaline  forms  of  parasite,  and  subsequently  grows  into 
the  mature  form. 

Schizont  or  monont,  an  adult  parasite  capable  of  or  engaged  in  asexual  reproduction  or  schizogony. 

Gametoschizont,  an  adult  parasite  of  the  sexual  generation. 

Copula,  the  female  cell  or  macrogamete  fertilized  by  the  male  element  or  microgamete. 

V ermiculus  or  ookinet,  the  motile  stage  of  the  copula  in  which  it  penetrates  the  alimentary  wall  of  the 
mosquito. 

Zygote,  oocyst,  sporoblast,  sporocyst,  names  given  to  the  copula  in  the  production  sporozoits  upon  the 
alimentary  wall  in  the  body  cavity  of  the  mosquito. 


54  INFECTIOUS  DISEASES 

breeding  of  mosquitos.  Wherever  these  conditions  occur,  malaria  is  rife. 
Especially  are  they  found  in  the  southern  borders  of  the  north  temperate 
zone,  as  in  Southern  United  States,  Southern  Italy,  and  along  the  lower 
Danube;  the  northern  border  of  the  south  temperate  zone,  in  the  tropics,  as 
Central  America,  the  West  Indies,  Central  Africa  and  Southern  Asia.  A 
freshly  upturned  soil  may  furnish,  under  a  sufficiently  high  temperature,  a 
minimum  of  60°  F.  (15.6°  C),  as  favorable  a  focus  almost  as  a  marshy  river 
bank.  All  ages  are  susceptible,  but  children  are  especially  liable  to  take  the 
disease.  More  men  have  it  than  women,  for  evident  reason.  Currents  of 
air  are  thought  to  have  less  influence  than  was  formerly  supposed,  since  the 
mosquitoes  laden  with  the  extracorporeal  forms  do  not  as  a  rule  come  out  of 
their  hiding  places  when  the  wind  blows.  Water  ingested  cannot  be  a 
cause  of  malarial  infection,  according  to  modern  views,  nor  can  it  be 
inhaled. 

Morbid  Anatomy. — The  morbid  anatomy  of  malaria  includes  mainly 
changes  in  the  blood,  the  liver,  and  the  spleen — changes  that  vary  with  the 
duration  and  intensity  of  the  disease,  to  which,  however,  they  do  not  always 
correspond. 

As  to  blood  changes  in  acute  malaria:  In  the  true  intermittent  fevers  there 
is  a  loss,  sometimes  considerable,  of  red  corpuscles  after  each  paroxysm, 
which  is  made  up  during  the  intermission.  In  the  estivo-autumnal  form 
the  blood  losses  are  greater  and  more  permanent.  The  absence  of  leukocy- 
tosis is  characteristic.  In  remittent  and  pernicious  malaria — the  latter  a 
form  characterized  by  the  intensity  of  the  poison  and  severity  of  the  symp- 
toms— the  morbid  changes  may  not  be  very  stril-cing  if  the  patient  die  in 
the  first  attack,  but  more  marked  after  a  second.  The  blood  is  described  as 
hydremic,  the  serum  is  sometimes  tinged  with  hemoglobin,  and  the  cor- 
puscles, while  containing  the  parasite,  present  all  stages  of  destruction.  In 
chronic  malaria  the  blood  changes  are  even  more  marked.  There  is  a  positive 
secondary  anemia  in  which,  as  usual,  the  hemoglobin  is  decreased  rather 
more  than  the  corpuscles.  The  leukocytes  are  almost  invariably  diminished, 
the  polynuclear  leukocytes  most,  while  the  larger  mononuclear  forms  are 
relatively  increased.  Pigment  deposits  are  abundant,  especially  in  the 
spleen,  which  is  enlarged  and  hard. 

The  spleen  is  enlarged,  but  not  nearly  so  much  as  in  chronic  recurring 
forms.  It  is,  moreover,  soft  and  its  pulp  is  dark  from  accumulated  pig- 
ment in  the  intervascular  cords.  In  chronic  malaria,  of  whatever  form, 
the  enlarged  spleen  is  the  most  characteristic  morbid  product.  It  may 
weigh  as  much  as  ten  pounds  (4.5  kilos.)  and  measure  ten  inches  (25  cm.) 
long  and  four  (10  cm.)  to  six  (15  cm.)  in  width;  its  capsule  is  thickened, 
its  substance  firm,  and  the  trabeculae  prominent.  Pigmented  areas  abound, 
due  to  the  plugging  with  pigment  of  the  intercommunicating  lymphoid 
spaces  of  the  pulp,  and  in  some  cases  the  melanosis  is  general.  The  pig- 
ment particles  resulting  from  the  disintegration  of  the  hemoglobin  in  the 
vessels  are  retained  in  the  spleen,  as  by  a  filter. 

The  liver  is  enlarged  and  dark-hued,  sometimes  described  as  bronze  and 
sometimes  slate-color.  Even  when  not  visibly  altered  to  the  naked  eye, 
there  may  be  no  difficulty  in  recognizing  the  excess  of  pigment  within 
and  without  the  small  vessels,  some  of  which  may  be  occluded.     In  fact, 


MALARIAL  FEVER  55 

by  the  aid  of  a  microscope,  almost  all  the  tissues  may  be  found  abnormally 
pigmented,  even  the  brain,  some  small  vessels  of  which  may  also  be  occluded. 

In  chronic  malaria  the  liver  is  also  enlarged,  to  a  less  degree,  however, 
than  the  spleen.  It  is  indurated  and  presents  various  degrees  of  pigmenta- 
tion, which  may  reach  a  slate-gray  tint.  The  pigment  is  contained  in  the 
portal  canals  and  beneath  the  capsule. 

The  kidneys  may  be  similarly  pigmented,  the  pigment  lying  about 
the  smaller  blood-vessels  and  the  Malpighian  bodies,  and  in  the  cells 
lining  the  tubules.  In  protracted  cases  of  malarial  cachexia  other  tissues 
may  be  pigmented.  Thus,  the  small  vessels  of  the  brain  may  be  surrounded 
by  pigment  and  even  occluded,  so  that  hemorrhagic  infarcts  may  occur. 
Even  the  mucous  membrane  of  the  stomach  and  the  peritoneum  may  be 
pigmented  in  extremely  chronic  cases. 

CLINICAL  VARIETIES. 

The  chief  varieties  of  malarial  fever  admit  of  easy  separation  by  their 
symptoms. 

Tertian  or  Quartan  Fever  {Intermittent  Fever). 

Definition. — This  form  of  malarial  fever  is  characterized  bj-  a  total 
remission  of  fever  between  paroxysms. 

Symptoms. — This,  the  well-known  fever  and  ague,  characterized  by 
distinct  paroxysms  of  chill,  fever,  and  sweat,  has  a  distinct  period  of  incuba- 
tion, which  may  be  as  short  as  24  hours  or  even  less,  though  usually  it 
is  from  a  week  to  14  days.  Sometimes  it  is  very  much  longer,  and  even 
months  are  said  to  elapse  after  exposure  before  the  first  paroxysm  sets  in. 
The  paroxysm  is  usually  preceded  by  a  prodrome  of  uneasiness  and  dis- 
comfort, sometimes  languor  and  yawning,  sometimes  headache,  some- 
times nausea,  which  forewarns  the  patient  of  its  coming.  As  often  as  not 
there  is  no  such  prodrome.  The  paroxysm  consists  of  the  chill  or  cold 
stage,  the  fever,  and  the  sweat. 

The  chill  commonly  begins  gradually.  First  there  is  a  creep,  then 
another  a  little  more  severe,  then  another,  each  growing  in  severity  until 
the  teeth  chatter  and  the  body  shakes  violently.  There  is,  however,  great 
difference  in  the  severity  of  the  chill.  It  may  be  a  barely  noticeable  creep 
or  such  a  chill  as  will  cause  the  bed  and  even  the  windows  of  the  room  to 
shake.  At  the  same  time  the  patient's  lips  are  blue,  his  face  is  pale  and 
pinched,  and  he  looks  very  cold.  Yet  he  has  fever.  Even  before  the 
chill  there  is  a  slight  rise  in. temperature,  and  during  it  the  latter  may  reach 
105°  F.  (40.5  C.)  and  106°  F.  (4i.i°C.)  in  the  axilla  or  mouth.  A  surface 
thermometer  may  show  a  lower  temperature  of  the  skin,  but  the  internal 
heat  is  in  strong  contrast  with  the  apparent  coldness.  There  may  be  nausea 
or  vomiting  and  severe  headache.  The  pulse  is  small,  hard  and  frequent. 
The  hands  are  pale,  cold  and  the  nails  blue.  The  urine  is  increased,  light- 
hued,  of  low  specific  gravity,  though  before  the  chill  it  may  be  concentrated 
and  the  specific  gravity  high.  The  duration  of  the  chill  varies  from  a  few 
minutes  to  an  hour  or  more. 

To  the  chill  succeeds  the  fever.     The  skin  is  intensely  hot  and  dry  and 


56 


INFECTIOUS  DISEASES 


the  face  flushed.  There  is  intense  thirst.  The  mouth  is  dry,  the  tongue 
coated,  the  breath  foul.  There  is  no  mistaking  this  stage  an}'  more  than 
the  first.  Yet  the  actual  temperature  is  but  little  higher  than  during  the 
chill,  which  is  well  shown  in  the  appended  chart,  in  which  it  will  be  seen 
that  the  temperature  during  the  chill  at  two  successive  observations  was 
104.2°  F.  (40°  C.)  and  104.4°  F-  (40.18°  C);  dvuing  the  succeeding /^er  it 
reached  at  the  first  observation  104.8°  F.  (40.4°  C.),  and  at  the  second, 
105°  F.  (40.45°  C).  The  duration  of  this  stage  is  from  halj  an  hour  to  four 
or  six  hours. 

The  sweating  stage  follows,  with  the  appearance  of  drops  of  sweat  on 
the  face,  whence  it  extends  all  over  the  body  and  is  various  in  quantity. 


Fig.  12. — Temperature  Chart  in  Intermittent  Fever,  showing  Paro.xysms  and  Intermissions. 

It  will  be  noted  that  the  temperature  has  been  taken  during  the  chill,  and  during  the  fever 
just  after  the  chill,  and  that  although,  as  is  well  known  the  fever  is  very  high  during  the 
chill  while  the  patient  feds  cold,  it  is  still  a  little  higher  during  the  fever  just  after  the 
chill. 


"With  it  comes  relief  to  all  the  symptoms.  Indeed,  a  sense  of  great  comfort 
supervenes.  It  may  be  a  mere  suggestion  of  moisture,  or  it  may  be  ver\- 
profuse,  drenching  the  patient's  clothing  and  even  wetting  the  bed.  It  is 
commonly  proportionate  to  the  severity  of  the  chill.  During  the  sweat  the 
temperattu-e  falls  rapidly,  but  if  the  paroxysm  is  severe  several  hours  elapse 
before  it  attains  the  normal.  It  lasts  for  half  an  hour  to  two  hours,  after 
which  the  patient  feels  comfortable  and  well. 

It  is  not  easy  to  give  a  satisfactory  rationale  of  the  three  stages.  The 
first  and  second  are  undoubtedly  the  direct  result  of  the  same  cause — a 
toxin  generated  by  the  Plasmodium,  since  the  actual  fever  which  character- 
izes both  is  irritative.  The  superficial  coldness  and  sense  of  cold  of  the  first 
stage  may  be  the  result  of  vasomotor  spasm  contracting  the  blood-vessels  of 


MALARIAL  FEVER 


57 


the  surface  and  due  to  an  irritation  of  vasomotor  centers  by  the  toxin;  the 
second  stage  to  a  derangement  of  the  heat-reguJating  centers.  The  third 
stage  is  probably  a  reactive  vasomotor  paralysis,  with  the  usual  leakage 
from  the  sldn  incident  to  it. 

The  total  duration  of  the  paroxysm  is  from  eight  to  twelve  hours,  and 
usually  between  the  paroxysms  the  patient  feels  perfectly  well.  During  the 
paroxysm  the  spleen  becomes  enlarged  and  the  malarial  patient  has  often 
herpes  lahialis.     The  size  of  the  spleen  subsides  after  the  paroxysm,  although 


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Fig.  13. — Temperature  Chart  in  Intermittent  Fever,  Showing  the  Paroxysms  and 
Intermissions. 


with  its  repetition  there  is  a  disposition  to  permanent  enlargement,  result- 
ing finally  in  the  ague  cake.  In  48  hours  or  72  hours  the  same  attack 
occurs. 

The  types  of  the  paroxysm  so  characteristic  of  intermittent  fever  have 
already  been  referred  to.  The  order  of  frequency  is  quotidian  or  double 
tertian,  tertian,  and  quartan;  the  first  being  by  far  the  most  frequent. 

Diagnosis. — The  diagnosis  of  intermittent  fever  is  most  easy,  and  a 
typical  case  should  be  easily  recognized  after  the  second  paroxysm,  if  not 
after  the  first.     The  presence  of  the  Plasmodium  in  the  blood  makes  a 


58  INFECTIOUS  DISEASES 

positive  diagnosis  of  malaria  while  its  absence  is  not  always  a  positive  sign 
of  the  absence  of  malaria.  If  the  case  be  less  typical  and  the  chill  omitted 
or  so  slight  as  to  escape  recognition,  a  certain  resemblance  between  such  a 
paroxysm  and  the  hectic  fever  of  tuberculosis,  with  its  subsequent  sweat, 
must  be  admitted,  and  it  not  infrequently  happens  that  such  fevers  are 
declared  to  be  malarial  by  the  attending  physician. 

The  attacks  of  chills  and  fever  accompanied  by  jaundice  in  ball-valve 
gall  stone  frequently  require  examination  of  the  blood  to  rule  out  malaria, 
but  the  jaundice  and  abdominal  pain  should  suggest  gall  stones. 

Still  more  close  is  the  resemblance  of  the  paroxysm  to  the  chills,  fever, 
and  sweats  of  septicemia  and  pyemia,  while  suppuration  is  frequently  ushered 
in,  and  its  progress  associated  with  like  symptoms.  Other  conditions  cal- 
culated to  produce  these  symptoms  may  generally  be  discovered  on  careful 
inquiry,  though  they  may  escape  notice  for  a  time.  In  addition  to  sup- 
puration, surgical  operations,  catheterization,  puerperal  fever,  the  incidence 
of  empyema,  and  the  like,  all  produce  chill,  fever  and  sweat.  Then,  as  a 
rule,  the  blood  culture  is  at  the  present  day  an  easy  solution.  The  strepto- 
coccus being  easily  isolated  in  the  septic  cases,  empyema  and  puerperal 
fever,  etc. 

The  so-called  nervous  chill  is  easily  distinguished,  because  with  it 
there  is  no  rise  of  temperature — at  least  nothing  at  all  comparable  to  that 
of  the  malarial  chill.  The  possible  combination  of  malaria  with  other 
causes  of  chill  and  sweats  is  to  be  remembered.  A  search  for  the  Plas- 
modium may  under  such  circumstances  prove  imperative. 

Prognosis. — The  prognosis  of  tertian  or  quartan  simple  intermittent 
fever  is  always  favorable.  Very  frequently,  if  the  disease  is  not  treated 
by  medicine,  it  will  exhaust  itself  in  a  couple  of  weeks  and  disappear, 
while  the  administration  of  suitable  doses  of  quinin  always  puts  an  end  .to 
it.  The  worst  that  can  happen  is  the  conversion  of  the  disease  into  chronic 
malaria  or  the  malarial  cachexia.  This  may  occur  when  treatment  is 
neglected,  or  when  constant  exposure  to  the  cause  operates  to  produce 
such  a  state  notwithstanding  suitable  treatment. 

EsTivo-AUTUMNAL  Fever. — Remittent  Fever. 

Definition. — Remittent  fever  is  the  form  of  malarial  fever  characterized 
by  a  continued  fever  with  paroxysmal  exacerbations.  It  is  also  known  as 
bilious  fever.  It  has  become  rare  at  the  present  day  in  the  North  Atlantic 
States  of  America,  and  is  confined  mainly  to  the  South  Atlantic  States,  to 
Italy,  the  lower  Danube  sections  in  Europe,  and  to  tropical  countries.  It 
occurs  in  the  late  summer  and  fall,  and  hence  is  included  among  the  estivo- 
auiumnal  fevers. 

Symptoms. — It  generally  begins  with  a  chill  after  a  period  of  incubation 
analogous  to  that  of  intermittent  fever.  It  is  more  likely  to  be  preceded  by 
prodromal  symptoms  than  is  intermittent.  There  are  malaise,  intense 
headache,  a  coated  tongue,  and  often  obstinate  nausea  and  vomiting. 
Vomiting  of  bilious  matter  is  a  conspicuous  symptom.  These  gastric 
symptoms,  formerly  ascribed  to  gastritis,  are  probably  caused  b}'  central 
nervous  irritation  due  to  the  toxin.     There  may  be  jaundice  resulting  from 


MALARIAL  FEVER  59 

obstructing  cholangitis;  the  Hver  may  be  tender  on  pressure.  The  chill 
may  be  less  severe,  and  the  other  stages  of  the  paroxysm  less  characteristic. 
The  fever  does  not  pass  off,  but  continues  with  a  full,  bounding  pulse  and  a 
temperature  of  102°  to  103°  F.  (38.9°  to  39.5°  C).  There  are  daily  remis- 
sions, as  in  typhoid  fever,  but  they  do  not  follow  the  same  rule  of  tidal  rise. 
Yet  the  two  diseases  are  very  similar,  and  often  thoroughly  try  the  diagnos- 
tic skill,  even  of  those  who  are  accustomed  to  meet  estivo-autumnal  fever. 
The  temperature  rises  quite  as  high  as  in  typhoid  fever,  and  the  patient  is 
usually  very  ill.  The  two  diseases  occur  at  the  same  time  of  the  year — the 
autumn.     It  is  not  impossible  for  them  to  be  concurrent. 

There  is  little  else  that  is  peculiar  in  the  symptomatology  of  the  common 
forms  of  remittent  fever  besides  the  prodrome,  the  malarial  organism,  and 
the  peculiar  paroxysmal  character.  In  prolonged  remittent  fever  the  ty- 
phoid state  is  sometimes  assumed,  manifested  by  dry  tongue,  hebetude, 
stupor,  and  feeble,  frequent  pulse. 

The  urine  is  high-colored,  with  high  specific  gravity,  depositing  a  copious 
sediment  of  urates,  and  sometimes  contains  biliary  coloring-matter.  Not 
infrequently'  it  contains  blood-corpuscles  or  hemoglobin. 

Diagnosis. — As  intimated,  it  is  with  typhoid  fever  that  remittent  fever 
is  most  likely  to  be  confounded.  Occasionally  in  the  South  there  has  been 
confusion  with  yellow  fever.  To  us  who  study  typhoid  fever  in  the  North  it 
seems  surprising  that  there  should  be  any  confusion  with  this  disease.  It  is 
ordinarily  so  easy,  after  watching  the  temperature  chart  for  a  few  days,  to 
recognize  typhoid  fever.  In  the  South  it  is,  however,  different,  and,  before 
the  discovery  of  Laveran's  Plasmodium,  the  therapeutic  test — administra- 
tion of  quinin — was  frequently  needed  to  settle  the  question;  for  remittent 
fever,  like  intermittent  fever,  yields  to  quinin.  In  such  cases  a  successful 
search  for  the  hemocytozoa  will  settle  the  question  promptly.  This  is  the 
variety  in  which  we  have  the  small,  actively  motile  hyaline  forms  of  organ- 
ism, while  the  larger  crescentic,  ovoid  bodies  are  to  be  looked  for  as  soon  as 
the  disease  has  existed  over  a  week.  An  unsuccessful  search  may  still  leave 
the  matter  in  doubt,  but  if  the  nasal  hemorrhage,  the  typhoid  spots,  the 
diarrhea  of  typhoid,  and  the  temperature  are  not  sufficiently  characteristic, 
the  qmnin  test  ought  to  put  an  end  to  all  doubt.  The  Widal  test  has  come 
to  our  aid,  also,  and  if  responded  to  affords  conclusive  evidence  of  the 
presence  of  typhoid  fever.  Study  and  observation  impels  us  to  say,  with 
Osier,  that  all  of  the  continued  endemic  fevers  of  the  South  may  be  resolved 
into  typhoid  or  malarial  fever,  or  the  two  diseases  existing  at  the  same  time 
in  the  same  individual. 

The  diagnostic  distinction  between  remittent  fever  and  yellow  fever  will 
be  given  when  considering  the  latter  disease. 

Prognosis. — This  is  usually  favorable  when  treatment  can  be  promptly 
applied. 

Pernicious  Malarial  Fever — The  Congestive  Chill. 

Definition. — This  variety  of  malarial  fever  is  characterized  by  the  ex- 
treme severity  of  its  paroxysms. 

Occurrence. — It  still  presents  itself  occasionally  in  the  North,  but  is 
much  rarer  than  it  was  50  years  ago.     Up  to  a  few  years  ago  it  was  not  un- 


60  I XF  EC  nous  DISEASES 

common  to  hear  of  the  death  from  this  cause  of  a  prominent  citizen  at  his 
country  seat  on  the  banks  of  the  Delaware  above  Philadelphia.  Later,  the 
cases  became  confined  to  the  servants  and  others  out  late  at  night  or  early 
in  the  morning,  and,  more  recently  still,  even  such  cases  as  these  are  seldom 
reported,  although  the  milder  forms  of  malaria  prevail.  It  is  still  prevalent 
in  the  Southern  United  States,  in  Italy,  the  lower  Danube,  the  Niger  delta, 
and  other  parts  of  tropical  Africa.  Pernicious  malarial  fever  is  a  form  of 
estivo-autumnal  fever. 

Two  principal  types  present  themselves — the  comatose  and  the  algid. 
Other  adjective  terms  based  on  special  features  more  or  less  characteristic, 
are  the  hematuric,  the  bilious  and  ansthmatic.  As  malarial  hematuria  is  not 
confined  to  the  pernicious  variety,  it  will  receive  separate  consideration. 
The  bilious  type  is  that  of  the  ordinary  severe  form  of  remittent  fever,  while 
asthma  characterizes  the  comatose  and  algid  types. 

1.  The  comatose  type  may  or  may  not  begin  with  a  chill,  but  in  its  more 
serious  forms  the  chill  is  a  conspicuous  feature,  being  severe.  To  it  succeeds 
the  comatose  state,  whence  the  term  congestive  chill  often  used  in  the  South, 
where  the  popular  notion  prevails  that  if  the  first  paroxysm  does  not  kill,  the 
second  will.  This  is  an  exaggerated  idea  of  its  seriousness,  although  it  is 
certainly  a  very  grave  affection  and  often  terminates  fatally.  A  low,  mut- 
tering delirium  may  supervene,  the  eyes  are  bloodshot,  the  skin  is  hot  and 
dry,  the  temperature  rising  to  105°  or  106°  F.  (40.6°  or  41.1°  C).  The 
comatose  condition  is  the  result  of  occlusion  of  the  small  vessels  of  the 
brain  with  the  organism,  and  lasts  until  a  partial  elimination  of  the  poison 
has  taken  place,  usually  from  12  to  24  hours  later.  The  patient  may,  how- 
ever, perish  without  return  to  consciousness,  or  consciousness  may  return 
to  be  followed  in  a  short  time  b}'  fatal  relapse. 

2 .  The  algid  type  is  characterized  by  gastric  symptoms,  extreme  nausea 
and  vomiting,  which  are  mostly  followed  by  collapse,  for  there  is  intense 
prostration,  with  coldness  of  the  surface  and  extremities.  The  symptoms 
are,  indeed,  comparable  to  those  of  the  collapse  of  cholera.  There  are  the 
same  small,  feeble  pulse,  frequent,  shallow  breathing,  cramps,  vomiting, 
purging,  husky  voice,  and  thirst  with  suppressed  urine,  and  with  these  the 
same  clearness  of  intellect  until  death  steps  in — the  last  scene  in  the  drama, 
in  which  asthenia  also  plays  a  leading  role. 

In  these  cases  there  may  or  may  not  be  a  chill,  while  the  patient  feels 
cold  and  the  surface  temperature  is  never  high,  rarely  exceeding  101°  F. 
(38.3°  C),  and  falling  as  low  as  96°  F.  (35.6°  C).  The  internal  temperature 
is,  however,  high. 

Diagnosis. — Pernicious  malarial  fever  is  to  be  distinguished  in  its  coma- 
tose form  from  typhoid  fever,  and  in  its  algid  type  from  yellow  fever.  The 
presence  of  the  Plasmodium  and  pigment  in  the  blood  are  the  distinctive 
features  to  be  carefully  sought. 

Irregular  Forms  of  Malarial  Fever. 

It  sometimes  happens  that  the  paroxysm  in  intermittent  fe-\'er  omits  one 
or  more  of  its  stages.  Especially  is  this  the  case  with  the  chill  in  which  event 
the  disease  has  received  the  characteristic  name  of  "dumb  ague."     Fre- 


MALARIAL  FEVER  61 

quently,  however,  what  receives  the  name  of  "dumb  ague"  is  something 
altogether  different.  The  "malarial  cachexia,"  for  instance,  is  sometimes 
spoken  of  as  "dumb  ague."  Like  malarial  cachexia  "dumb  ague"  is  found 
among  the  older  residents  of  a  malarial  district. 

Quite  often  it  happens  that  the  malarial  paroxysm  consists  of  nothing 
but  a  state  of  drowsiness,  which  recurs  at  regular  intervals  and  is  very  char- 
acteristic. The  temperature  in  these  cases  is  elevated,  but  not  very  high, 
ioo°  F.  (37.8°  C.)  or  perhaps  101°  F.  (38.3°  C.) ;  there  may  be  slight  delirium. 

The  term  latent  intermittent  fever  is  applied  to  a  combination  of  symp- 
toms affecting  persons  living  in  malarial  districts — consisting  in  a  weary, 
languid  feeling,  associated  with  want  of  appetite,  headache,  nausea,  vomit- 
ing, constipation,  and  coated  tongue.  Sometimes  the  so-called  "bilious 
attacks,"  which  exhibit  the  above  symptoms  in  an  aggravated  form, 
especially  the  headache  and  vomiting,  are  malarial  in  their  origin,  and  may 
be  broken  up  with  quinin.     Such  attacks  may  be  called  malarial  migraine. 

Irregularity  of  fever  or  chills,  or  both,  may  be  caused  bj'  infection  -n-ith 
more  than  one  group  of  the  same  kind  of  parasite  occurring  at  different 
times,  or  there  may  be  infections  of  different. kinds  of  parasite  maturing  at 
their  own  specified  time. 

Much  harm  results  from  a  diagnosis  of  malaria  with  vague  symptoms 
quoted  above.  Such  a  diagnosis  should  never  be  made  unless  the  malarial 
organism  is  found  in  the  blood  or  the  disease  responds  promptly  to  qiiinin. 

Malarial  Hematuria,  or  Hemaglobinuria,  or  Intermittent  Hema- 
turia— Blackwater  Fever. 

This  form  of  hematuria  or  hemaglobinuria  is  the  direct  result  of  malarial 
poison.  The  first  account  of  it  in  this  country  was  published  by  George 
Troup  Maxwell  in  the  "Oglethorpe  Medical  and  Surgical  Journal,"  Savan- 
nah, Ga.,  July,  i860.     It  occurs  in  two  varieties,  a  mild  and  severe. 

The  Mild  Form. — While  it  is  a  very  frequent  symptom  of  the  pernicious 
or  malignant  type  of  malarial  fever,  hematuria  also  occurs  as  a  symptom, 
and,  indeed,  sometimes  the  sole  symptom,  of  the  milder  varieties  of  malaria, 
such  as  occur  in  the  Middle  States  of  the  United  States.  Rarely  are  they 
accompanied  by  a  chill,  and  there  may  be  no  symptoms  whatever  except 
the  bleeding.  More  frequently  there  is  a  cold  feeling,  the  tips  of  the  nose 
and  of  the  fingers  become  cold,  and  the  lips  become  blue,  immediately  after 
which  the  urine  is  found  to  be  bloody.  Microscopic  examination  of  the 
urine  will  recognize  in  some  instances  blood-disks,  in  others  no  corpuscles 
can  be  found.  It  is  a  hemoglobinuria.  The  hemorrhage  occurs  daily  or 
on  alternate  days,  more  rarely  at  longer  intervals.  Sometimes  it  is  con- 
tinuous, with  exacerbations  at  regular  intervals.  In  all  cases  of  unex- 
plained hematuria  the  blood  should  be  examined  for  the  malarial  organism. 

The  Grave  Form — Blackwater  Fever. — When  a  symptom  of  pernicious 
malarial  fever,  the  condition  is  more  apt  to  be  hemoglobinuria  than  hema- 
turia; it  is  more  aggravated  and  more  continuous,  although  still  intermittent. 
It  may  also  be  associated  with  hemorrhages  from  the  nasal  and  oral  mucous 
membranes,  and  even  from  the  stomach,  which  add  much  to  the  gravity  of 
the  case. 


62  INFECTIOUS  DISEASES 

To  the  grave  form  of  malarial  hemoglobinuria  the  name  blackwater  fever 
has  been  given. 

The  organism  causing  blackwater  fever  is  usually  the  estivo-autumnal 
organism  but  the  tertian  and  quartan  may  also  cause  it. 

William  Krauss,  of  Memphis,  has  furnished  a  description  of  the  mode 
of  onset  and  symptoms  of  malarial  hemoglobinuria  as  it  occurs  in  Ten- 
nessee, from  which  is  condensed  the  following: 

After  a  variable  period  of  neglected  intermittent  or  remittent  fever, 
especially  in  a  subject  already  cachectic,  there  occurs  suddenly  a  violent 
cliill,  with  the  usual  high  temperature.  The  face  is  anxious,  and  cyanotic, 
and  (in  from  i  s  minutes  to  2  hours)  there  ensues  more  or  less  vesical  tenes- 
mus, and  a  small  quantity  of  luine  of  a  port  wine  to  inky  black  hue  is  voided. 
This  may  occur  at  very  short  intervals  during  the  day  (the  onset  is  usually 
before  sundown)  and  in  favorable  cases  the  quantity'  of  urine  increases 
while  the  color  becomes  lighter.  There  is  great  shock,  the  pulse  is  100  to  150 
and  very  small,  the  breathing  is  embarrassed  and  hurried,  often  sighing  in 
character.  The  stomach  becomes  irritable,  and  projectile  vomiting  sets  in, 
the  vomited  matter  being  of  a  spinach-green  color.  In  the  morning  of  the 
second  day  a  very  intense  icterus  is  first  recognized.  The  vomiting  may 
continue  in  spite  of  all  measures  looking  to  its  control,  the  parasites  are  still 
in  the  blood  and  the  temperature  is  usually  high,  io3°-ios°  F.,  although  if 
the  toxemia  is  extreme  there  may  be  great  depression  and  the  temperature 
may  be  subnormal.  A  hardening  pulse  at  this  stage  indicates  grave  renal 
involvement  and  the  subsequent  history  is  that  of  fatal  lu-emia.  A  sub- 
sidence of  the  restlessness  indicates  re-established  permeability  and  a 
favorable  prognosis.  The  triple  symptoms — hemoglobinuria,  vomiting 
and  icterus-^are  essential  for  diagnosis. 

As  to  the  hemolj^sis,  there  is  reason  to  believe  it  takes  place  in  the 
spleen  and  kidneys.  The  excessive  waste  hemoglobin  discharged  by  the 
spleen  into  the  portal  vein  furnishes  the  liver  with  more  material  for  bili- 
rubin, hydrobilirubin,  etc.,  and  the  irritative  hyperactivity  of  this  organ 
results  in  an  excess  of  both  internal  secretion  and  excretion,  the  latter 
being  represented  by  an  imperfect  bile,  engorging  the  bile  capillaries  and 
causing  an  overflow  into  the  lymphatics.  A  hemo-hepatogenous  jaundice 
is  the  result.  The  disease  is  not  paroxysmal  and  lasts  about  four  days  in 
favorable  cases.  Some  recent  authors  believe,  Craig,  for  instance,  that 
true  hemoglobinuric  fever  is  due  to  another  organism  than  malaria,  and 
hence  is  a  different  disease. 

Chronic  Malaria  and  Malarial  Cachexia. 

Definition. — This  is  a  condition  which  often  supervenes  in  cases  imper- 
fectly or  ineftectually  treated,  or  in  persons  li\dng  in  malarial  districts  where 
there  is  constant  exposure  to  the  cause  and  consequent  repeated  attacks. 

Symptoms. — The  most  striking  symptom  of  this  condition  is  anemia  of  a 
peculiar  kind.  The  incident  changes  in  the  blood  have  been  referred  to  on 
page  S4-  The  skin  exhibits  a  dirty-yellow  or  sallow  appearance,  often 
erroneouslj^  characterized  as  "bilious,"  as  though  it  were  a  form  of  jaundice, 
which  it  is  not,  although  there  may  be  sometimes  slight  jaundice  also. 


MALARIAL  FEVER  63 

Such  persons  have,  in  addition,  deranged  digestion.  The  tongue  is  pale, 
flabby,  and  coated  and  the  breath  sometimes  foul.  Tlje  bowels  ar  con- 
stipated. The  hands  and  feet  are  cold,  the  circulation  is  generally  bad,  and 
the  temperature  is  subnormal,  though  it  may  alternate  with  the  feverish 
state.  In  consequence  of  the  hydremic  blood  there  is  sometimes  edema  of 
the  feet,  and  even  general  anasarca.  The  spleen  is  enlarged,  often  extending 
as  low  as  the  ilium. 

Some  very  unusual  symptoms  are  included  in  the  symptomatology  of ' 
this  form  of  malaria — as,  for  example,  paraplegia  and  orchitis.  The  former 
condition  may  be  the  result  of  deranged  circulation  in  the  spinal  cord,  but 
it  is  difhcult  to  regard  the  latter  as  anything  except  a  coincidence.  A 
remarkable  case  of  malaria  with  symptoms  of  disseminated  sclerosis  was 
reported  by  William  G.  Spiller  in  the  "American  Journal  of  the  Medical 
Sciences"  for  December,  1900.  The  autopsy  disclosed  sclerosis  of  the  right 
crossed  pyramidial  tract  throughout  the  spinal  cord,  not  intense,  but 
unmistakable. 

The  Plasmodium  is  found  in  this  form  of  malaria  also,  and  the  crescent 
is  said  to  be  the  form  more  or  less  characteristic  of  it.  The  recognition  of 
the  organism  is  of  value  in  the  diagnosis  although  the  history  of  the  case  and 
the  presence  of  enlarged  spleen  are  also  important  aids  to  diagnosis,  es- 
pecially as  the  Plasmodium  may  elude  detection  altogether.  In  leukemia 
there  is  also  enlarged  spleen,  but  the  microscopic  examination  of  the  blood 
reveals  at  once  in  the  latter  disease  the  excess  of  colorless  corpuscles. 

Prophylaxis  of  Malarial  Fever. — Much  may  be  done  to  avert  malarial 
infection.  It  is  not  possible  for  the  organism  to  enter  the  system  by  the 
stomach  or  respiratory  passages.  This  being  established,  prophylaxis 
must  consist  in  measures  to  destroy  the  mosquito  or  escape  its  bite.  To 
exterminate  the  adult  mosquito  is  manifestly  impossible.  Yet  it  is  not 
chimerical  to  look  forward  to  the  possibility  of  destroying  the  insect  in  the 
larval  state  as  it  exists  in  pools  and  ponds,  uncovered  rain  barrels,  old  tins 
containing  water,  in  the  axils  of  leaves  of  tropical  plants,  indeed  in  any 
collection  of  stagnant  water  large  or  very  small.  Attention  need  only  be 
called  to  the  wonderful  work  of  Gorgas  and  his  associates  in  the  Canal  Zone 
which  has  made  possible  the  practical  completion  of  the  Panama  Canal. 
Formerly,  continued  work  was  impossible  on  the  isthmus  because  of  the 
blighting  effects  of  malaria.  Now  the  disease  is  rare  in  the  Canal  Zone 
due  to  the  destruction  of  the  mosquito  and  screening  of  houses.  A  most 
important  measure  is  the  protection  of  the  malarial  patient  from  the  bite 
of  the  mosquito.  Every  malarial  patient  should  live  in  a  thoroughly 
screened  house  free  from  mosquitoes,  until  his  blood  is  entirely  free  from 
organisms  of  malaria. 

In  addition  to  killing  mosquitoes  our  prophylactic  measures  must  consist 
in  protecting  against  mosquito  bites  by  netting,  and  in  making  the  blood  as 
uncomfortable  a  habitat  for  the  Plasmodium  as  possible  by  charging  it  with 
quinin — quinin  prophylaxis.  To  this  end  a  few  grains  of  quinin,  say  five 
to  ten  (0.333  to  0.666  gm.),  should  be  taken  daily,  especially  by  newcomers 
in  malarial  districts  and  by  all  residents  at  times.  No  less  efficacious  is  the 
arsenical  prophylaxis  as  conclusively  shown  by  experiments  on  the  Adriatic 
railways  reported  by  Celli  in  his  book  on  "  Malaria."     It  seems  pretty  well 


64  / A7-7-X  •  TIO  US  DISEA  SES 

founded,  loo,  that  the  cause  of  malaria  is  more  active  after  nightfall.  This 
is  consistent  with  the  mosquito  theory.  Hence,  exposure  at  these  times 
should  be  avoided. 

Further  prophylactic  treatment  consists  in  measures  to  prevent  inunda- 
tions, and  stagnant  waters  in  any  form. 

Treatment  of  the  Different  Forms  of  Malaria. — The  treatment  of  inter- 
mitient  Jevcr  is  preeminently  by  quinin.  The  dose  required  varies,  but  in 
mild  tertian  variety  15  to  30  grains  (i  to  2  gm.)  are  usually  sufficient  for  an 
adult.  Sometimes  larger  doses  may  be  needed  in  inveterate  cases,  and  always 
larger  doses  in  the  estivo-autumnal  types  of  fever.  It  matters  not  much  how 
the  drug  is  administered,  but  there  is  a  best  way  for  each  case.  A  good  rule,  is 
to  give  an  hourly  dose  of  10  grains  (.70  gram),  beginning  long  enough  before 
the  expected  paroxysm  to  get  the  quantity  previously  decided  upon  into  the 
blood  at  least  two  hours  before  the  chill  is  expected.  If  the  dose  first  selected 
fails,  the  second  should  be  made  larger.  It  is  to  be  remembered,  however,  that 
quinin,  like  other  drugs,  acts  more  efficiently  after  a  free  aperient,  while  con- 
stipation decidedly  interferes  with  its  prompt  and  efficient  action.  Some 
prefer  a  mercurial,  as  8  to  10  grains  (0.55  to  0.666  gm.)  of  blue  mass,  or  5 
to  10  grains  (0.33  to  0.66  gram)  of  calomel,  but  provided  a  free  movement  is 
secured,  it  does  not  matter  much  how  it  is  accomplished.  Having  broken 
the  paroxysm,  it  is  well  to  continue  the  quinin  for  a  few  days  in  smaller  doses, 
and  to  anticipate  the  seventh  day  subsequent  to  the  last  chill  by  another  full 
dose  of  the  drug,  and  to  do  so  at  intervals  of  seven  days  for  some  weeks. 
Under  ordinary  circumstances  the  freshly  prepared  pill  of  quinin  made 
with  aromatic  sulphuric  acid  is  to  be  preferred,  or  the  quinin  may  be  given 
in  capsules.  This  is  easily  soluble  and  is  not  so  unpleasant  to  take  as  the 
solution,  which  is,  however,  more  readily  absorbed.  The  sugar-coated  and 
gelatin-coated  pills  are  not  so  certainly  efficient,  as  they  sometimes,  especially 
with  deranged  digestion,  pass  through  the  bowel  undissolved. 

Some  physicians  prefer  to  administer  quinin  during  the  decline  of  the 
fever.  This  was  the  practice  of  Sydenham  in  giving  the  bark.  Among 
modern  physicians  disposed  to  follow  this  method  are  Bacelli,  A.  Plehn, 
Maclean,  Manson  and  other  East  Indian  physicians;  and  in  this  countr\- 
George  Dock. 

The  treatment  of  the  paroxysm  itself  is  by  measures  calculated  to  com- 
bat each  stage.  During  the  chill,  to  satisfy  the  patient  artificial  warmth 
should  be  supplied,  and  will  give  comfort;  during  the  fever,  if  the  tempera- 
ture is  above  102°  F.  (38.9°C.),  the  body  may  be  sponged  to  reduce  the  heat, 
and  during  the  "sweat"  the  patient  should  be  carefully  dried.  If  there  be 
any  reason  why  quinin  shovdd  not  be  exhibited,  the  other  alkaloids  of 
cinchona,  as  cinchonidin,  are  equally  effectual  in  doses  about  one-fourth 
larger.  No  substitute  for  cinchona  or  its  alkaloids  has  ever  been  suggested 
which  has  stood  the  test  of  trial. 

The  treatment  of  remittent  fever  is  essentially  that  of  intermittent  fever. 
It  is  in  this  form  that  the  mercurial  aperient  is  deemed  especially  valuable 
as^a  preliminary  by  those  ha\dng  wide  experience  in  its  treatment.  The 
continued  nature  of  the  fever,  and  the  tendency  to  a  typhoid  state  which 
often  develops,  demands  a  liquid  diet,  with  the  careful  addition  of  stimulants. 


MALARIylL  FEVER  05 

The  pernicious  forms  of  malarial  fever  are  treated  by  quinin,  as  arc  the 
other  varieties  of  the  disease.  Sixty  grains  or  more  may  be  necessary,  and 
advantage  must  be  taken  of  hypodermic  injections.  Soluble  salts  should 
be  used,  such  as  the  bisuphate,  hydrochlorate,  and  hydrobromate,  of  which 
IS  grains  (i  gm.),  dissolved  in  distilled  water,  are  a  dose.  Double  this  dose 
may  be  given.  The  bisulphate  of  quinin  may  also  be  administered  hypo- 
dermically  in  solution  with  tartaric  acid,  30  grains  (2  gm.)  of  the  quinin  to 
S  grains  (0.333  gm.)  of  the  tartaric  acid.  The  muriate  of  quinin  and  urea 
may  also  be  given  hypodermically  in  10,  15  or  20-grain  (0.666,  i,  and  1.33 
gm.)  doses.  It  is  especially  commended  by  Solomon  Solis-Cohen,  who 
advises,  as  soon  as  the  diagnosis  is  established,  and  without  reference  to  the 
time  of  paroxysm,  a  single  injection  of  from  10  to  15  grains  (0.66  to  i  gm.) 
of  the  salt,  dissolved  in  a  syringeful  (20  to  30  minims)  of  boiling  water. 
Should  a  paroxysm  recur  at  the  following  period,  a  second  injection  is  given, 
and  should  further  paroxysms  occur,  injections  are  given  in  corresponding 
number;  otherwise  but  three  injections  are  given  the  first  seven  days,  and 
two  injections  during  the  second  seven  days.  Bass  suggests  the  use  of 
nitroglycerine  in  comatose  forms  in  order  to  dilate  the  smaller  blood  vessels 
and  allow  the  large  malarial  bodies  to  pass  through  the  capilaries  and  become 
exposed  to  the  quinin  which  is  in  the  circulating  blood.  It  may  also  be 
given  by  the  mouth  in  capsules  in  the  same  doses. 

Even  the  intravenous  injection  of  quinin  has  been  recommended  in 
intractable  cases,  and  for  this  purpose  the  soluble  bimuriate  is  most  suitable. 
Fifteen  grains  (i  gm.)  with  i  grain  (0.066  gm.)  of  sodium  chlorid  are  dis- 
solved in  2  drams  (8  c.c.)  of  distilled  water  and  injected. 

Methylene  blue  (methylthioninse  hydrochloridum,  U.  S.  P.)  was  in- 
troduced by  Ehrlich  and  Gutmann  in  1891  in  the  treatment  of  the  malarial 
fevers;  and  H.  C.  Wood,  Jr.,  collected  425  cases  up  to  1906,  in  362  of  which 
final  cures  were  affected.  It  is  given  in  3  grains  (o.i  gm.)  doses  every  three 
hours  in  pill  or  capsule.  Its  peculiar  staining  qualities  constitute  its  chief 
objection. 

In  addition  to  the  use  of  quinin,  prompt  measures  must  be  taken  to  com- 
bat all  symptoms  which  add  to  the  dangers  of  the  situation — stimulants  for 
the  asthenia;  artificial  heat  for  low  temperature;  morphin  hypodermically, 
,  to  relieve  the  pain  and  allay  nausea ;  cool  sponging  or  bathing  to  reduce  the 
temperature,  and  saline  cathartics  to  relieve  congestion  in  the  comatose 
form. 

I.'  L.  Van  Zandt  of  Fort  Worth,  Texas,  recommends  atrophin,  hypo- 
dermically in  i/60-grain  doses  repeated  in  20  minutes  if  necessary,  for  the 
symptoms  of  collapse  so  characteristic  of  the  algid  type.  He  associates  this 
drug  with  1/30  to  1/20  doses  of  strychnin  similarly  administered. 

The  treatment  of  the  milder  varieties  of  hematuria  is  most  satisfactory. 
The  administration  of  quinin  in  almost  any  way,  say  3  grains  (0.19  gm.) 
every  three  hours  for  several  days,  will  effectually  break  up  the  paroxysms, 
and  its  use  in  smaller  doses  for  some  time  longer  will  prevent  a  return. 

Not  all  practitioners,  even  those  residing  in  districts  where  it  is  most 
rife,  are  agreed  upon  the  treatment  of  the  graver  forms  of  malarial  hematuria 
as  it  occurs  in  Southern  latitudes.     While  some  do  not  hesitate  to  use  quinin. 


66  INFECTIOUS  DISEASES 

in  the  way  it  is  used  in  ordinary  forms,  many  of  the  most  experienced  physi- 
cians in  the  Southern  United  States  object  to  this  drug,  on  the  ground  that 
it  may  even  cause  hemoglobinuria,  a  belief  endorsed  by  such  authorities  as 
Tomaso  Celli,  who  was  the  first  to  direct  attention  to  it,  Marchiafava, 
Bignami,  Bastianelli,  the  brothers  Plehn  and  Robert  Koch  abroad.  I  can- 
not better  express  the  views  of  the  Southern  physicians  referred  to,  than  by 
quoting  one  of  their  number,  Krauss,^  already  mentioned,  who  says: — 
"We  are  therefore  forced  to  the  conclusion  that  hematuria  once  begun, 
quinin  has  no  place  in  its  therapy."  And  again,  "Only  so  long  as  the 
sporulating  parasites  are  in  the  peripheral  blood  and  there  is  no  hematuria, 
is  it  fit  to  be  used." 

It  seems  that  malarial  hemoglobinuria  is  brought  about  by  a  hemo- 
lytic substance  or  anti-alexin  set  free  in  the  blood-plasma.  The  hemo- 
lysis may  be  precipitated  by  an  unusual  sporulation  of  plasmodia  on 
the  one  hand  or  anti-malarial  treatment  on  the  other.  In  the  normal 
blood,  quinin  will  not  cause  hemoglobinuria.  Moreover,  it  is  held  that  a 
long  continued  action  of  the  malarial  toxin  is  necessary  and  such  is  the  ex- 
perience of  our  Southern  physicians,  who  found  it  especially  prone  to  occur 
in  neglected  intermittent  and  remittent  fevers.  It  is  especially  important  to 
note  that  the  quinin  and  malarial  toxin  are  simply  the  agents  which  liberate 
the  hemolytic  substance  and  are  comparable  to  the  "  addiments"-  of  Ehrlich 
and  Morgenroth. 

The  effect  of  quinin  on  susceptible  subjects  is  due  entirely  to  the  amount 
of  hemolytic  stored  up,  and  this  varies  with  different  individuals.  Some  set 
free  their  storage  after  a  single  dose,  and  subsequent  doses  can  do  no  harm. 
Others  eliminate  their  storage  after  a  few  days'  duration  of  the  syndrome, 
and  in  some  it  persists.  In  these,  all  treatment  must  be  suspended  and  they 
must  be  allowed  to  immunize  themselves.  As  small  a  dose  as  3/4  of  a  grain 
(48.6  mgr.)  has  produced  hemoglobinuria.  Hemoglobinuria,  being  there- 
fore a  consequence  of  malaria  and  not  a  cause,  it  does  not  per  se  call  for 
quinin  which,  on  the  other  hand,  may  precipitate  it. 

It  is  evident  that  the  treatment  of  the  graver  fonns  of  hematuria  be- 
comes a  much  more  complex  problem  if  these  new  views  be  accepted.  Again 
quoting  Krauss,  "So  long  as  sporulating  parasites  are  present  in  the  blood 
and  there  is  no  hematuria,  push  it  (quinin)  to  the  limit.  If  oral  administra- 
tion is  not  practicable  give  the  neutral  chlorid  in  very  dilute  solution  with  an 
antitoxin  syringe."  Otherwise  the  use  of  quinin  must  be  cautious  and  tenta- 
tive. If  the  urine  redden  or  a  chill  supervene  the  drug  must  be  omitted. 
On  the  other  hand,  before  hematuria  has  occurred  quinin  may  be  given, 
because  "a  further  neglect  of  an  already  neglected  malaria  is  more  provoca- 
tive of  a  hemoglobinuria  than  any  amount  of  quinin  before  the  attack." 
If  well  borne  the  dose  may  be  increased.'     In  a  word  blackn-ater  fever  (ma- 

•  "Memphis  Medical  Journal.'*  April,  ig02.     Page  177. 

2  Addiment,  Ehrlich  and  Morganroth's  term  (1899)  for  an  active  thermolabile  substance  (destroyed 
by  a  temperature  of  56°  C.)  contained  in  normal  serum  and  capable  of  liberating  the  immune  body  of 
Ehrlich  and  setting  up  bacteriolysis  and  hemolysis. 

*  Krauss  has  written  in  further  detail  the  treatment  as  he  would  practise  it  in  such  a  case  and  he  has 
furnished  me  with  the  following: 

1.  If  the  onset  follows  the  use  of  quinin  I  would  suspend  the  use  of  it  until  the  urine  has  cleared  up, 
then  bepin  it  cautiously,  and  if  there  is  no  hemolytic  reaction,  proceed  (intramuscularly,  of  course)  until 
it  is  believed  that  30  grains  of  it  is  in  the  blood  at  one  time.  If  a  reaction  (rigor  and  dark  urine)  follows, 
wait  a  few  days  and  begin  still  more  cautiously. 

2.  If  the  patient  has  had  no  quinin,  and  the  symptoms  are  not  those  of  a  malarial  paroxysm,  I  would 
do  the  same. 

3.  If  there  are  distinct  paroxysms  of  fever  without  a  quinin  history,  the  physician  may  elect  to  take 


YELLOW  FEVER  67 

larial  hematuria)  does  not  occur  in  individuals  who  have  not  had  malaria. 
Quinin  may  be  given  if  the  malarial  infection  is  severe — otherwise  it  often 
does  more  harm  than  good. 

Treatment  is  otherwise  symptomatic  usually  eliminative  and  restorative. 
Elimination  is  secured  by  water  drinking  and  rectal  injection  of  normal 
salt  solution,  or  if  not  retained,  by  hypodermoclysis  or  even  intravenous 
injection,  one  object  being  to  prevent  inspissation  of  the  blood,  favored  by 
the  sharp  purging  and  vomiting.  The  skin  must  be  kept  active  by  cautious 
doses  of  pilocarpin,  by  hot  packs  and  by  the  use  of  woolen  clothing.  Stimu- 
lating diuretics  are  strongly  disadvised.  Vomiting  may  be  controlled  b}'' 
morphin  injection  and  cold  drinks,  such  as  champagne,  carbonated  waters 
and  AppoUinaris  water.     Strychnin  may  be  given  hypodermically. 

It  is  in  chronic  malaria  especially  that  arsenic  becomes  a  useful  remedy. 
Fowler's  solution  being  the  best  preparation.  It  should  be  given  in  ascend- 
ing doses .  Arsenic  may  be  given  in  the  form  of  ' '  Neo-salvarsan ' ' — Ehrlich's 
preparation,  orthecacodylateof  sodium,  which  maybe  given  hypodermically 
in  2  grain  (0.132  gm.)  doses  in  obstinate  cases.  Iron  is  often  advantage- 
ously associated  with  it,  and  for  such  a  combination  the  solution  of  the 
chlorid  of  arsenic  and  the  tincture  of  the  chlorid  of  iron  are  especially  suit- 
able. Here,  the  constipating  effect  of  iron,  so  justly  complained  of, 
would  be  obviated  by  giving  doses  little  in  excess  of  what  can  be  ab- 
sorbed. For  it  is  this  excess  remaining  in  the  alimentary  canal  that 
works  the  mischief.  Three  minims  (0.333  gi^-)  of  the  tincture  of  the 
chlorid,  combined  with  as  many  of  the  solution  of  the  chlorid  of  arsenic, 
are  a  proper  dose,  but  the  arsenic  should  be  increased  until  a  slight 
puffiness  of  the  face  results.  The  carbonate  of  iron  or  the  reduced  iron 
sulphate  may  be  given  in  doses  not  exceeding  one  grain  (0.066  gm.).  A 
modified  Blaud's  pill  containing  in  addition  to  the  carbonate  of  iron,  arsenic 
in  1/30  grain  (0.0026  gm.)  doses  is  a  very  efficient  and  convenient  remedy. 
The  administration  of  iron  should  be  kept  up  a  long  time. 

Quinin  should  not  be  omitted  in  this  form  of  malaria,  but  there  is  no 
advantage  in  giving  it  in  large  doses.  It  should  rather  be  kept  up  a  long 
time.  Strychnin  and  mineral  acids  are  also  useful  remedies  for  the  gastric 
derangement,  while  constipation  may  be  treated  by  an  occasional  mercurial 
purge,  say  a  couple  of  grains  (0.132  gm.)  of  blue  mass,  to  which  may  be 
added  as  much  compound  extract  of  colocynth,  and  as  much  extract  of 
hyoscamus,  or  1/8  grain  (0.008  gm.)  of  extract  of  belladonna. 

YELLOW  FEVER. 

Synonyms. — Febris  flava;  Bilious  Remittent  Fever  (Rush);  Kendall's  Fever; 
Barbadoes  Distemper ;  Elodes  icterodes;  Typhus  icterodes;  Typhus  tropicus. 

Definition. — Yellow  fever  is  an  acute  infectious  disease,  characterized 
by  a  febrile  paroxysm  succeeded  by  a  brief  remission  and  a  relapse.     It  is 

his  chances  with  quinin,  by  giving  four  simultaneous  injections  in  different  places  of  s  grains  each.  If, 
coincident  with  the  time  of  absorption,  a  rigor  occurs,  its  use  is  discontinued  even  though  the  case  appear 
hopeless,  else  proceed  to  saturation.     Time  this  dose  so  as  not  to  meet  a  sporulation. 

4.  In  comatose  cases  a  blood  examination  may  differentiate  between  active  sporulation  and  other 
s  and  treatment  given  according  to  rule  3. 
During  convalescence  an  attempt  to  get  one  good  "saturation"  should  be  made. 


68  IXFECTIOUS  DISEASES 

associated  more  or  less  constantly  with  jaundice,  and  tendency  to  hemor- 
rhage especially  into  the  stomach,  whence  the  blood  is  vomited  constituting 
"black  vomit."  Neither  jaundice  nor  black  vomit  is  essential  to  the  disease. 
The  infecting  organism  is  not  known,  but  is  dessimated  through  the  medium 
of  the  mosquito  stegomayia  fasciata. 

It  is  in  a  sense  an  American  disease,  and  except  in  Spanish  ports  it 
has  been  limited  in  Europe  to  ports  to  which  it  has  been  carried.  It  is, 
however,  endemic  on  the  west  coast  of  Africa  as  well  as  in  the  West  Indies 
until  modern  regulations  succeeded  in  almost  stamping  it  out. 

Distribution. — John  Guiteras  makes  three  areas  of  infection:  (i)  The 
focal  zone,  in  which,  up  to  igoi,  the  disease  was  never  absent,  including 
Havana,  Vera  Cruz,  Rio  de  Janeiro,  and  other  Spanish-American  ports. 
(2)  Perifocal  zone,  or  region  of  periodic  epidemics,  including  the  ports  in 
the  tropical  Atlantic,  in  America,  and  Africa.  (3)  The  zone  of  accidental 
epidemics,  between  the  parallels  of  45  degrees  north  and  35  degrees  south 
latitude. 

A  very  interesting  fact  in  connection  with  yellow  fever  is  its  limitation 
to  the  sea  and  the  seacoast,  as  it  rarely  invades  interior  cities  or  altitudes 
higher  than  1000  feet  (300  meters). 

Etiology. — Reed  and  Carroll  have  shown  that  the  infective  agent 
is  probably  an  ultra-microscopic  organism,  a  member  of  the  animal  king- 
dom, in  the  blood  of  the  infecting  person.'  These  results  are  confirmed  by 
the  yellow  fever  commission  of  the  Pasteur  Institute.  The  Pasteur  commis- 
sion has  further  shown  that  the  organism  can  be  separated  from  the  serum 
and  the  latter  rendered  innocuous  by  passing  through  the  finest  grade  of 
Pasteur  filter.  As  to  the  propagation  of  the  disease,  the  same  observ^ers 
with  Aristides  Agramonte,  all  of  the  United  States  Army  Medical  Depart- 
ment,- have  placed  the  mosquito  theory  of  the  origin  of  yellow  fever  on  so 
substantial  a  basis  that  further  discussion  of  other  theories  may  as  well  be 
laid  aside.  This  theory,  which,  it  will  be  remembered,  makes  the  mosquito 
the  host  of  the  unknown  parasite  of  yellow  fever,  was  first  advanced  by 
Carlos  J.  Finlay,  of  Havana,  as  far  back  as  1881,'  but  made  little  im- 
pression. The  studies  of  Reed  and  his  colleagues  made  in  the  island  of 
Cuba  in  1900,  are  most  convincing.  They  included  two  divisions:  First, 
the  exposure  of  non-immunes  to  the  bites  of  mosquitoes  which  had  bitten 
yellow  fever  subjects ;  and  second,  exposure  of  another  group  of  non-immunes 
to  fomites  by  handling  and  sleeping  in  clothing  saturated  wath  the  discharges 
of  yellow  fever  patients.  Their  conclusions  are  as  follows:  i.  The  mos- 
quito— Stegomyia  fasciata — serves  as  the  intermediate  host  for  the  parasite 
of  yellow  fever.  2 .  Yellow  fever  is  transmitted  to  the  non-immune  individual 
by  the  bite  of  a  mosquito  that  has  previously  fed  on  the  blood  of  those 
sick  vnfh  this  disease.  3.  An  interval  of  about  12  days  or  more  after 
contamination  appears  to  be  necessary  before  the  mosquito  is  capable 
of  conveying  the  infection.  4.  The  bite  of  the  mosquito  at  an  earlier 
period  after  contamination  does  not  appear  to  confer  any  immunity  against 
a  subsequent  attack.     5.  Yellow  fever  can  also  be  experimentally  produced 

>  "Etiology  of  Yellow  Fever:  A  Supplement.il  Note."     "Am.  Medicine."  February  22,  1902. 
'  "  Etiology  of  Yellow  Fever."  "  Philadelphia  Medical  Journal."  October  27.  1900.     "  Etiology  of  Yellow 
Fever:  An  Additional  Note."  "Journal  of  .American  Medical  Association,"  February  16.  1901. 
2  "Annalcs  de  la  Real  Academia,"  vol.  xviii.,  tSSi.  pp.  i47-l'>0. 


YELLOW  FEVER  69 

by  the  subcutaneous  injection  of  blood  taken  from  the  general  circulation 
during  the  first  and  second  days  of  this  disease.  6.  An  attack  of  yellow 
fever  produced  by  the  bite  of  a  mosquito  confers  immunity  against  the 
subsequent  injection  of  the  blood  of  an  individual  suffering  from  the  non- 
experimental  form  of  this  disease.  7.  The  period  of  incubation  in  13  cases 
of  experimental  yellow  fever  has  varied  from  41  hours  to  five  days  and 
17  hours.  8.  Yellow  fever  is  not  conveyed  by  fomites,  and  hence  disin- 
fection of  articles  of  clothing,  bedding,  or  merchandise  supposedly  con- 
taminated by  contact  with  those  sick  with  the  disease  is  unnecessary. 
9.  A  house  may  be  said  to  be  infected  with  yellow  fever  only  when  there 
are  present  within  its  walls  contaminated  mosquitoes  capable  of  conveying 
the  parasite  of  this  disease.  10.  The  spread  of  yellow  fever  can  be  most 
effectually  controlled  by  measures  directed  to  the  destruction  of  mosquitoes 
and  the  protection  of  the  sick  and  well  against  the  bites  of  the  insects. 
1 1 .  While  the  mode  of  propagation  of  yellow  fever  has  now  been  definitely 
determined,  the  specific  cause  of  this  disease  remains  to  be  discovered. 

Yellow  fever  attacks  all  races,  both  sexes,  and  all  ages  except  the  very 
young.  Yet  it  is  through  the  young  that  the  disease  is  maintained  in  a 
native  population,  because  protection  is  secured  by  a  previous  attack  or 
long  residence  in  a  locality  in  which  it  is  endemic,  and  it  is  the  young  who, 
as  they  grow  up,  furnish  the  pabulum  for  fresh  cases.  The  negro  and  the 
Creole,  although  not  immune,  are  comparatively  so.  More  males  are  attacked 
than  females,  because  of  their  frequent  exposure.  Strangers  are  'especially 
liable. 

Morbid  Anatomy. — Intense  yellow  coloration  and  hemorrhagic  extra- 
vasations under  the  skin  are  present.  The  yellow  coloration  is  due  to  a 
mixed  hepatogenous  and  hematogenous  jaundice.  The  serum  of  the  blood 
is  red-tinted,  because  of  its  containing  dissolved  hemoglobin.  The  liver 
is  the  organ  which  has  always  been  regarded  as  exhibiting  the  most  char- 
acteristic change.  Yet  this  is  not  always  so.  It  becomes  ultimately  fatty, 
when  its  color  resembles  the  yellow  of  admixed  coffee  and  milk — a  cafe  au 
lait  appearance — as  contrasted  with  the  more  bronzed  appearance  of  the 
liver  of  remittent  fever.  Earlier  in  the  disease  the  organ  may  be  slightly 
enlarged  from  hyperemia.  It  may  be  a  nutmeg  liver.  The  liver-cells 
present  various  stages  of  fatty  degeneration,  with  necrotic  masses  in  and 
between  the  liver-cells,  described  by  George  M.  Sternberg.  The  gall-bladder 
is  generally  empty.  The  kidney  may  exhibit  cloudy  swelling  of  even  acute 
nephritis,  and  pale,  fatty  areas  may  be  seen  at  the  bases  of  the  pyramids. 
Various  bacteria  are  found  in  the  liver  and  kidney. 

The  stomach  after  death  contains  more  or  less  of  the  "black  vomit," 
which  is  a  mixture  of  transuded  serum  and  altered  blood  pigment.  The 
mucous  membrane  of  the  stomach  is  hyperemic  and  more  or  less  swollen, 
and  there  are  blood  extravasations. 

Surgeon  Eugene  Wasdin,^  in  a  paper  on  the  postmortem  findings  of 
yellow  fever,  says  the  morbid  appearances  postmortem  cannot  be  regarded 
as  sufficiently  distinctive  to  admit  a  diagnosis  from  them  alone. 

Symptoms. — Yellow  fever  has  a  period  0}  incubation  of  from  24  hours 
to  five  days,  very  rarely  exceeding  the  latter.     It  is  usually  three  or  four 

1  "United  Skates  Marine  Hospital  Reports  for  the  Fiscal  Year  1898." 


70 


INFFX:  no  US  DISEA  SES 


days.  (See  Reed  and  Carroll's  conclusions.)  After  this  follows  the 
stage  of  invasion  or  febrile  stage,  with  sudden  onset  and  generally  a  chill, 
promptly  followed  by  headache  and  severe  pain  in  the  back  and  limbs. 
The  patient  may  be  seized  at  any  time,  day  or  night.  Surgeon  R.  D. 
Murray,'  of  the  United  States  Marine  Hospital  Service,  emphasizes  the  fact 


2  g 


that  yellow  fever  usually  begins  at  night  when  the  patient  is  relaxed,  while 
malarial  fever  attacks  him  more,  frequently  when  at  work.  The  fever  rises 
rapidly  to  102°  F.  (38.9°  C.)  and  as  high  as  105°  F.  (40.5°  C).  The  pulse 
corresponds,  until  the  second  or  third  day  when  it  begins  to  fall  even  while 
the  fever  keeps  up.     The  skin  feels  hot  and  dry,  but  less  pungently  so  than 


'Marine  Hospital  Reports,"  1895.  p.  303- 


YELLOW  FEVER  71 

in  typhus.  Even  on  the  first  day  the  face  is  flushed,  the  eyes  are  injected, 
the  lids  perhaps  slightly  tumid,  the  tongue  furred  but  moist  the  throat 
sore,  the  bowels  constipated,  the  urine  is  scanty  and  often  albuminous, 
though  albumintiria  does  not  generally  appear  until  the  evening  of  the  third 
day.  So,  too,  at  this  early  stage  there  may  he  slight  jaundice,  and  Guiteras 
says  this  "early  manifestation  of  jaundice  is  undoubtedlj'  the  most  char- 
acteristic feature  of  the  facies  of  yellow  fever."  There  maj'  be  nausea  from 
the  beginning,  but  it  is  not  untU  the  second  or  third  day  that  it  is  aggravated 
and  the  characteristic  "black  vomit' '  makes  its  appearance.  This  resembles 
an  infusion  of  coffee,  and  deposits  a  sediment  comparable  to  coffee  grounds, 
and  which  consists  of  broken-down  red  corpuscles  and  hematin.  In  the 
worst  cases  the  vomited  matter  may  be  tar-like  in  appearance  and  con- 
sistence. On  the  other  hand,  "black  vomit"  is  not  always  present,  being 
generally  confined  to  the  severe  cases.  In  some,  the  vomited  matter  is 
watery  or  bilious.     This  stage  lasts  from  a  feiv  hours  to  two  or  three  days. 

Then  follows  the  second  stage,  or  stage  of  calm,  in  which  there  is  a  decline 
in  the  fever  and  of  the  other  symptoms  generally.  This  may  be  the  begin- 
ning of  convalescence  in  the  mUd  cases.  But  in  severe  cases  this  stage  is 
of  short  duration — from  a  few  hours  to  one  or  two  days. 

Then  the  third  stage,  or  stage  of  febrile  reaction,  sets  in,  lasting  one, 
two,  or  three  days.  The  temperattu-e  now  rises  again,  although  the  pulse 
may  continue  to  fall;  the  nausea  and  vomiting  return — the  latter  becomes 
again  hemorrhagic  and  may  be  accompanied  by  abdominal  pain.  Black 
and  offensive  stools  occur.  Jaundice,  if  not  previously  present,  now  makes 
its  appearance,  the  tongue  becomes  dry  and  brown,  and  there  may  be 
bleeding  of  the  gums — indeed,  from  all  the  mucous  membranes.  To 
albuminuria  may  be  added  hematuria.  The  strength  rapidly  fails,  the  pulse 
grows  weaker,  there  is  nervous  trembling,  suppression  of  urine,  mental 
wandering,  convulsions  or  stupor,  and  death. 

Such,  however,  is  not  always  the  termination,  even  when  there  has  been 
"black  vomit."  The  symptoms  may  all  gradually  subside  and  the  patient 
recover,  although  the  jaundice  may  persist  for  a  long  time.  In  mild  cases 
the  calm  stage,  as  stated,  may  be  succeeded  by  convalescence. 

Guit^ras'^  regards  as  the  three  characteristic  symptoms  of  yellow  fever: 
First,  the  facies,  including  especially  early  jaundice.  Second,  albuminuria, 
which,  he  says,  is  rarely  so  early  in  other  fevers,  unless  of  an  unusually 
severe  type.  "Even  in  the  mild  cases,  that  do  not  go  to  bed —  cases  of 
'walking  yellow  fever' — on  the  second,  third,  or  fourth  day  of  the  disease 
albumimuia  will  show  itself,"  though  it  may  be  quite  transient.  Third, 
a  peculiar  slowing  of  the  pulse,  with  a  steady  or  even  rising  temperature. 
This  symptom  was  first  pointed  out  by  Paget,  of  New  Orleans.  It  is 
noted  more  particularly  on  the  second  or  third  day,  when  the  fever  is 
still  keeping  up,  that  the  pulse  begins  to  slow,  dropping  as  much  as  20 
beats,  while  the  temperature  has  risen  i  1/2°  to  2°.  On  the  evening  of  the 
third  day  there  may  be  a  temperature  of  103°  to  104°  F.  (39.4°  to  40°  C), 
with  a  ptdse  running  from  70  to  80.  During  defervescence  the  pulse  may  • 
become  still  slower — down  to  50,  48,  45,  or  even  30. 

Diagnosis. — The    three    characteristic    symptoms    of    Guiteras    above 

'  "Diagnosis  of  Yellow  Fever."  "U.  S.  Marine  HospitarReports  for  the  Fiscal  Year  1898." 


72 


IXFEC  no  VS  DISE.  1 SES 


pointed  out  should  be  borne  in  mind,  viz.,  facies,  early  albuminuria,  and  slow 
pulse.  As  to  differential  diagnosis,  yellow  fever  is  most  likely  to  be  con- 
founded with  severe  fever  of  malarial  remittent  type.  Indeed,  the  resem- 
blance is  sometimes  very  close,  especially  when  the  latter  is  accompanied 
by  hematuria.  But  the  remission  occurs  earlier  in  remittent  fever  and 
the  chill  is  of  much  longer  duration,  while  the  presence  of  Laveran's  Plasmo- 
dium in  the  blood  settles  the  question  in  favor  of  the  latter.  Acute  yellow 
atrophy  of  the  liver  is  a  disease  more  insidious  in  its  approach  and  less 
febrile.     The  urine  in  acute  yellow  atrophy  is  loaded  with  bile. 

Relapsing  fever  resembles  yellow  fever  only  in  the  symptoms  of  the 
relapse,  but  this  occurs  much  earlier  in  yellow  fever.  The  presence  of  the 
spirochete  in  the  blood  of  relapsing  fever  makes  the  diagnosis.  The  simi- 
larity of  the  mild  forms  of  yellow  fever  to  thermic  fever  has  been  emphasized 
by  Guiteras. 

Dengue,  or  break-bone  fever.  The  question  is  one  which  presents 
difficulties,  for  both  jaundice  and  hemorrhage,  including  black  vomit, 
have  been  in  the  past  credited  to  dengue,  while  in  the  disputed  cases 
black  vomit,  at  least,  was  wanting.  In  favor  of  yellow  fever  were  the 
authoritative  names  of  Guiteras  and  H.  A.  West,  of  Galveston.  The  fol- 
lowing table  of  contrasted  symptoms  was  kindly  prepared  by  H.  A.  West: 


Yellow  Fever. 

1.  One  febrile  paroxysm,  characterized 
by  a  steady  rise  and  lasting  usually  about 
three  days.  The  temperature  rises  rapidly, 
the  acme  is  often  reached  within  a  few  hours 
from  the  onset. 

2.  The  pulse  rate  is  characterized  by  ab- 
normal slowness  and  want  of  correspond- 
ence with  the  temperature;  while  the  latter 
is  rising  from  three  to  four  degrees  the  pulse 
continues  to  diminish  in  frequency. 

3.  There  are  cutting  pains  through  the 
forehead,  the  eyes  ache,  the  muscles  of  the 
back,  loins,  thighs,  and  calves  are  sore  and 
often  ache  severely,  even  in  mild  cases. 
The  pain  is  muscular  rather  than  articular. 

4.  There  is  no  glandular  involvement. 


5.  The  face  is  turgid,  not  infrequently  a 
dusky  red.  The  upper  eyelid  is  often 
swollen.  The  appearance  is  that  of  typhus 
or  of  measles  before  the  eruption,  with  the 
addition  of  .slight  or  well-marked  jaundice. 
The  conjunctivae  are  congested  and  shiny 
with  a  slight  yellow  tinge,  the  eyes  some- 
times intensely  red  and  sensitive  to  light. 
The  jaundice  becomes  more  distinct  after 
the  first  or  second  day,  the  skin  showing  the 
same  combination  of  capillary  stasis  with  an 
icteroid  hue  as  the  eyes.  As  the  ca.se  pro- 
gresses, jaundice  may  become  intense. 

6.  The  tongue  is  whitish  in  the  center 
with  red  tip  and  edges,  and  is  pointed;  gums 
swollen  and  disposed  to  bleed.  Epigastric 
tenderness  and  pain,  nausea  and  vomiting 
are  common;  in  the  stage  of  depression 
black  vomit  is  not  infrequent;  it  is  alarming 
and  often  of  fatal  import. 


De.ngue. 
I.  Usually  one  febrile  paroxysm,  but 
sometimes  two,  a  steady  rise  of  tempera- 
ture until  the  acme  is  reached;  a  short 
stadium,  followed  by  a  remission,  then  not 
infrequently  a  second  rise.  Duration  four 
to  eight  days. 

2.  The  pulse  usually  increases  in 
rapidity  with  rise  of  temperature,  though 
an  abnormally  slow  pulse  may  sometimes 
be  observed. 

3.  Headache  is  more  or  less  intense, 
pains  in  the  limbs  and  back  are  severe  and 
apparently  involving  the  bones  and  joints. 
The  latter  arc  not  only  painful  and  stifl- 
ened,  but  in  many  instances  swollen. 

4.  The  lyrhphatic  glands  are  enlarged 
with  varying  degrees  of  frequency  in 
different  epidemics. 

5.  The  face  is  generally  flushed,  the 
eyeUds  swollen,  the  eyes  injected  and 
watery;  there  may  be  a  slight  jaundice, 
but  this  symptom  is  extremely  suspicious 
of  yellow  fever. 


6.  The  tongue  at  first  is  covered  with 
a  white  fur;  it  is  swollen  and  the  edges  are 
red,  and  as  the  case  progresses  the  coating 
increases  in  thickness  and  becomes  a  dirty 
yellow.  In  many  cases  there  is  nausea, 
but  vomiting  is  rare. 


YELLOW  FEVER  73 

7.  Eruption  absent,  or  extremely  rare  7.  An  eruption  occurs  in  quite  a  large 
and  insignificant.                                                     number    of   cases;    it    may    be    a    simple 

erythema  or  resemble  that  of  scarlatina, 
measles,  lichen,  or  urticaria. 

8.  Urine  scanty,  albumin  usually  found  8.  The  urine,  except  in  rare  instances, 
within  seventy-two  hours;  there  may  be  is  free  from  albumin;  if  present  at  all,  it  is 
only  a  trace  in  the  evening  urine.  In  the  evanescent.  There  is  no  evidence  what- 
second  stage  albumin  may  be  abundant  and  ever  that  serious  kidney  complications 
accompanied  by  all  tlie  evidences  of  a  severe  belong  to  the  pathology  of  dengue. 
nephritis,  the  presence  of  casts,  hematuria, 

disposition  to  anuria  and  uremia.  In  every 
severe  case  nephritic  complications  dominate 
Jhe  clinical  picture. 

9.  Tendency  to  hemorrhages  common,  9.  Hemorrhages  from  mucous  mem- 
from  nose,  gums,  bowels,  uterus,  kidneys,  branes,  nose,  gums,  intestines,  uterus  and 
and  stomach,  the  last  often  fatal.                       kidneys    not    infrequent,    but    rarely    of 

serious  import. 

10.  Disease  often  fatal.  10.   Prognosis  proverbially  favorable. 

11.  One  attack  protects  from  another.  11.  One  attack  does  not  protect  from 

another. 

12.  Not  protective  again^  dengue.  12.  Not  protective  against  yellow  fever. 

Prognosis. — Yellow  fever  is  a  grave  disease,  and  in  its  severe  forms  one 
of  the  most  fatal  of  the  infectious  diseases.  The  mortality  ranges  from  1 5 
per  cent,  to  85  per  cent.  Among  the  dissipated,  the  worn-out,  the  poor, 
and  in  hospitals  the  mortality  is  higher ;  it  is  less  in  the  colored  race.  ' '  Black 
vomit"  is  not  necessarily  a  fatal  symptom.  Many  malignant  cases  termi- 
nate in  a  couple  of  days.  Modem  studies  go  to  show  the  ravages  of  yellow 
fever  will  be  greatly  diminished  in  the  near  future,  emphasized  by  the 
statement  of  Gorgas's  work  on  the  Isthmas  of  Panama.  Here  the  yellow 
fever  no  longer  exists. 

Treatment. — Prophylaxis  is  more  efficient  than  direct  treatment,  and 
modern  etiology  has  overthrown  rules  formerly  supposed  well  established 
and  resolved  it  chiefly  into  (i)  Guarding  nonimmunes  against  infection  by 
the  mosquito.  (2)  Screening  the  house  of  the  infected  person  against  the 
insect  in  order  to  prevent  the  spread  of  the  disease.  (3)  The  destruction  of 
as  many  mosquitoes  as  possible,  by  drainage,  by  covering  breeding  places 
with  insecticides  and  larvicides,  the  best  of  which  is  petroleum.  (4) 
Depopulation  of  infected  places — that  is,  the  removal  of  all  susceptible 
persons  whose  presence  is  not  necessary  for  the  care  of  the  sick.  Earlj? 
diagnosis  is  of  the  utmost  importance  in  a  prophylactic  measure.  The 
mosquito  can  become  infected  only  by  biting  a  patient  during  the  first  three 
days  of  illness,  hence  every  suspicious  case  must  be  protected  against  mos- 
quitoes at  the  very  earliest  moment.  There  is  no  specific  treatment  for 
yellow  fever,  and  the  symptoms  are  to  be  met  as  they  arise.  The  practice 
quite  general  in  the  Southern  United  States  to  give  an  initial  dose  of  castor 
oil  is  justified.  Some  prefer  calomel  5  to  10  grains  (0.33  to  0.66  gm.) ;  others 
compound  cathartic  pills,  i,  2,  or  3  at  a  dose  followed,  if  necessary,  by  a 
saline  such  as  cold  citrate  of  magnesia,  Epsom  salt,  or  Glauber  salt.  The 
last  is  preferred  by  some  who  have  had  the  longest  experience.  These 
measures  are  followed  by  efforts  to  cause  perspiration,  in  which  the  hot 
foot-bath  is  included.  We  may  seek  to  stop  vomiting  by  ice  internally  and 
externally  and  hypodermic  injections  of  morphin,  by  cold  dry  champagne 
and  cold  effervescing  waters.  Food  should  be  withheld  for  from  three  to 
five  days,  and  then  be  of  the  simplest  kind,  of  which  a  mixture  of  equal  parts 


74  IXFECTIOUS  DISEASES 

of  milk  and  Vichy  is  the  type.  The  hemorrhagic  tendency  may  be  combated 
by  astringents,  including  iron.  Washing  out  the  rectum  by  warm  water  and 
soap  enemas,  carried  high  up  in  the  bowel,  is  highly  recommended  by 
Marine  Hospital  Surgeon  H.  D.  Geddings.^  Two  or  three  pints  must  be 
used.  Normal  salt  solution  may  be  thus  used  with  a  view  to  its  being 
retained  and  absorbed. 

The  failing  strength  is  to  be  supported  by  alcohol,  strychnin,  and 
digitalis;  the  high  temperature  reduced  by  sponging  and  cool  baths.  Nu- 
trient enemas  are  to  be  relied  on  when  vomiting  is  uncontrollable. 

The  following  line  of  treatment  laid  down  by  Surgeon-General  Stem- 
berg  appears  to  have  been  especially  satisfactory  in  cases  treated  in  United 
States,  Cuba,  and  Brazil,  with  a  mortahty,  according  to  Carroll,  of  only  7.3 
per  cent.  In  addition  to  sodium  bicarbonate  7  1/2  grains  (0.5  gm.),  mer- 
cury bichlorid  1/60  grain  (0.00 1  gm.)  every  hour,  he  advises  a  hot  mustard 
foot-bath  during  the  first  24  hours,  cold  sponging,  cold  applications  to  the 
head,  protection  from  currents  of  air,  sinapisms  over  the  stomach  and 
lumbar  region,  the  promotion  of  perspiration,  withholding  of  food  during  the 
first  three  days,  and  stimulants,  in  the  form  of  iced  champagne  or  good 
brandy,  after  the  fourth  day.  If  the  stomach  be  irritable  he  advises  milk 
and  lime  water,  and  if  these  do  not  agree,  nutrient  enemas.  Later  on  he 
allows  milk  punch,  ale,  porter,  etc. 

Good  judgment  should  be  exercised  in  discriminating  against  the  overuse 
of  drugs. 

DENGUE. 
Synonyms. — Break-bone  Fever;  Dandy  Fever. 

Definition. — Dengue  is  an  epidemic,  infectious,  disease,  characterized  by 
paroxysms  of  extreme  pain  in  the  joints  and  muscles,  accompanied  by  fever 
and  sometimes  eruptions  on  the  skin. 

Etiology. — Dengue  spreads  extremelyrapidly  by  the  routes  and  means  of 
travel.  It  attacks  both  sexes  and  all  ages,  regardless  of  season,  although 
warm  climates  are  its  natural  habitat,  and  it  is  rather  more  common  in 
summer.  It  is  not  usual  to  have  more  than  one  attack.  No  morbid  ana- 
tomical changes  have  been  found  associated  with  the  disease. 

Symptoms. — Dengue  is  usually  sudden  in  its  onset,  after  a  period  of 
incubation  lasting  from  three  to  five  days,  at  the  end  of  which  there  may  be 
some  sense  of  discomfort,  more  frequently  there  is  not,  headache,  and  even 
chilliness.  Suddenly,  often  at  night,  the  patient  is  struck  with  pain  in  the 
muscles  and  joints,  and  especially  the  muscles  of  the  back  and  loins.  The 
pain  is  searching,  as  though  extending  into  the  bones  themselves.  The 
small  as  well  as  the  large  joints  are  affected,  and  the  pain  is  aggravated 
on  motion.  The  suffering  is  extreme,  and  it  may  be  said  that  the  patient 
is  literally  racked  wnth  torture. 

Simultaneously  there  are  headache  and  fever,  the  former  serve  and  the 
latter  quite  high,  rising  rapidly  to  102°,  103°,  105°  F.  (38.9°,  39.4°.  40.5° 
C),  and  even  106°  or  107°  F.  (41.1°  or  41.6°  C),  reaching  its  maximum 

>  "United  States  Marine  Hospital  Reports  for  Fiical  Year  1898." 


DENGUE  75 

from  the  second  to  the  fourth  day,  then  declining,  reaching  the  normal 
about  the  fifth  day.  The  face  is  flushed,  the  conjunctivse  are  congested, 
commonly  less  so  than  in  yellow  fever;  the  pulse  is  frequent,  loo  to  120, 
rising  and  falling  with  the  fever.  Delirium  is  not  a  marked  feature,  save  in 
children.  The  tongue  is  coated  and  red  at  the  tip  and  edges;  there  are  loss  of 
appetite,  slight  naiisea,  and  extreme  thirst,  scanty  urine,  and  constipation; 
at  times,  however,  the  urine  is  copious  and  clear.  Hemorrhage  from  the  nose 
and  gums  has  been  noted,  and  both  Eugene  Foster  and  D.  C.  Holliday  have 
seen  black  vomit  similar  to  that  of  yellow  fever;  and  in  one  case  copious 
hemorrhage  from  the  bowels,  which  persisted  three  months  and  terminated 
in  death,  was  observed. 

The  paroxysm  lasts  three  or  four  days,  at  the  end  of  which  the  tem- 
perature falls,  the  pain  subsides,  and  a  short  period  of  comparative  comfort, 
though  one  also  of  great  prostration,  succeeds  that  of  great  suffering.  It 
is  during  this  remission  that  an  erythematous  rash  makes  its  appearance  on 
the  face,  neck,  and  shoulders,  and  thence  over  the  whole  body  in  two  or 
three  days.  At  the  same  time'  the  lymphatic  glands  at  the  back  of  the  head 
and  neck,  in  the  axillae  and  groins,  swell,  with  some  return  of  fever.  The 
eruption  is  not  constant  or  always  uniform.  It  lasts  from  a  few  hours  to 
a  couple  of  days,  when  it  subsides  with  the  beginning  of  the  second  febrile 
movement,  which  is  milder  and  shorter,  after  which  true  convalescence  sets 
in.     The  eruption  may  also  reappear,  though  rarel}'. 

Diagnosis. — The  resemblance  of  dengue  to  yellow  fever  has  been  referred 
to  under  the  latter  disease,  where,  too,  the  two  conditions  are  contrasted. 
On  account  of  the  joint  involvement,  associated,  as  it  often  is,  with  redness, 
dengue  has  not  inexcusably  been  mistaken  for  acute  rheumatism;  but  the 
decided  remission  in  three  days,  the  altogether  short  duration  of  the  disease, 
and  its  epidemic  character,  should  soon  resolve  all  doubt.  The  absence  of 
any  glandular  swelling  or  eruption  in  rheumatism  and  the  more  close  limita- 
tion of  the  pain  to  the  joints  aid  in  the  discrimination. 

After  rheumatism,  influenza  is  perhaps  the  next  disease  with  which 
dengue  may  be  confounded.  It,  too,  is  epidemic,  and  is  attended  often  by 
extreme  and  sudden  muscular  pains,  but  the  sudden  intermission  charac- 
teristic of  dengue  does  not  occur  in  influenza,  nor  does  the  eruption  or 
glandular  swelling. 

Prognosis. — Notwithstanding  the  extreme  suffering,  recovery  is  the 
invariable  rule . 

Treatment. — Nothing  can  be  done  to  cut  short  the  disease.  The  most 
satisfactory  method  to  control  the  pain  is  by  the  hypodermic  injection,  of 
morphin  and  atropin.  One-fourth  grain  (0.016  gm.)  of  the  former  and 
1/150  grain  (0.00044  gm.)  of  the  latter  may  be  given,  supplemented  by  phe- 
nacetin,  acetyl-salicylic  acid  and  antipyrin,  in  doses  of  10  grains  (0.66  gm.) 
of  the  former  and  5  grains  (0.33  gm.)  of  the  latter,  every  two  hours,  when  the 
hypodermic  injection  may  be  repeated  if  relief  has  not  been  obtained.  The 
coal-tar  derivatives  are  also  the  best  remedies  for  the  fever,  but  they  may 
be  supplemented  by  sponging  with  cool  water,  or  the  cold  bath  in  extreme 
cases.     Prostration  must  be  met  by  alcoholic  preparations. 


76  IXI'ECTIOiS  DISEASES 

CHOLERA. 

Synonyms. — Cholera  asiatica;   Cholera   algida;   Cholera   maligna;   Cholera 
infectiosa;  Epidemic  Cholera. 

Definition. — Cholera  is  an  acute  infectious  disease  cause  by  a  toxine 
evolved  by  a  pathogenic  organism  known  as  the  comma  bacillus  or  spirillum 
of  Koch,  named  after  its  discoverer.  It  is  characterized  especially  by 
vomiting,  purging,  painful  cramp,  and  collapse. 

Etiology. — It  is  now  generally  acknowledged  that  cholera  owes  its 
existence  to  the  comma  bacillus  or  spirochete,  a  semispiral  rod-bacillus  dis- 
covered by  Koch  in  1884.  It  is  thicker,  but  not  more  than  half  as  long  as 
the  tubercle  bacillus.  Sometimes,  by  the  apposition  of  two  bacilli,  an  S-  or 
a  corkscrew-shape  is  produced.  Its  multiplication  is  favored  by  heat,  mois- 
ture, and  filth.  It  is  easy  of  destruction,  even  by  weak  acids  and  a  tempera- 
ture of  140°  F.  (60°  C).  It  can  produce  cholera  only  when  it  is  taken  in  by 
the  stomach,  whence  it  quickly  passes  into  the  intestine,  where  the  alkaline 
reaction  of  the  secretions  favors  its  multiplication  in  enormous  numbers. 
Bacilli  are  rarely  found  in  vomited  matters,  but  are  numerous  in  the  fecal 
discharges,  and  are  found  in  the  intestines  after  death.  They  may  invade 
the  follicles  and  intestinal  wall,  but  some  time  is  required  for  this,  and  such 
invasion  does  not  occur  in  cases  speedily  fatal.  Nor  has  the  comma  ba- 
cillus been  as  yet  isolated  from  the  blood.  The  symptoms  are  caused  by 
an  endotoxin  which  is  liberated  after  solution  of  the  bacterial  cells.  Koch's 
conception  is  that  cholera  is  an  acute  infectious  process  of  the  intestinal 
epithelium  and  the  general  condition  is  an  acute  intoxication.  He  believes 
that  the  primary  intoxication  comes  from  the  organisms  v.'hich  have 
penetrated  between  and  beneath  the  epithelial  cells  and  here  have  under- 
gone solution.' 

Medium  of  Injection. — Drinking-water  and  contaminated  food  are  the 
acknowledged  media  through  which  the  bacillus  is  commonly  introduced 
into  the  human  organism,  but  it  may  be  conveyed  in  clothing  or  food,  on  the 
hands,  and  may  even  enter  the  mouth  while  floating  in  the  air,  or  it  may 
be  spread  through  the  medium  of  flies.  The  postal  service  is  regarded  as  a 
means  of  infection.  It  frequently  follows  in  the  train  of  moving  masses 
of  human  beings,  such  as  emigrants  and  pilgrims,  but  it  prefers  the  sea- 
level  and  lower  altitudes,  especially  less  than  100  feet  (305  meters)  above 
the  sea. 

Anything  that  enfeebles  digestion  favors  its  permanent  lodgment  and 
multiplication.  Hence,  general  ill-health,  fatigue,  the  alcoholic  habit, 
depression  of  spirits,  fright,  or  anxiety,  any  one  or  all  may  be  predisposing 
causes.  All  ages  and  sexes  arc  liable  to  be  infected,  but  young  children 
seem  most  vulnerable. 

Morbid  Anatomy. — The  appearance  of  a  man  dead  of  cholera  may- 
present  no  peculiarity.  More  commonly,  there  is  a  shrunken  aspect  of 
the  whole  frame,  the  skin  of  the  exposed  and  nondependent  parts  is  gray 
or  ashen  hued,  while  the  dependent  portions  are  livid.  The  eyes  are 
deeply  sunken,  the  temples  hollow,  the  nose  is  pinched,  and  the  skin  clings 


'  "Ricketts  and  Dick,  Infection  Immunity  and  Serum  Therapy. 


CHOLERA  77 

closely  to  the  bones  beneath  it.  The  appearances  of  such  a  body,  in  brief, 
are  those  of  a  wasted  cadaver  long  immersed  in  the  pickling  vats  of  the 
dissecting  room. 

Very  striking  are  the  postmortem  elevations  of  temperature  and  the 
phenomena  of  postmortem  muscular  contraction.  The  former  has  reached 
109°  F.  (42.8°  C.)  and  higher.  The  latter  include  movements  of  the  lower 
jaw,  rotation  of  the  eyes,  contraction  of  the  arms  and  legs,  sometimes 
startlingly  life-like. 

On  section  of  the  body  the  subcutaneous  tissue  is  found  dry,  the  blood 
in  the  vessels  thick  and  dark.  The  condition  of  the  stomach  and  bowels 
differs  somewhat  with  death  at  different  stages  of  the  disease.  If  death 
takes  place  early  the  stomach  is  commonly,  but  not  always,  filled  with  a 
turbid  liquid  grayish-white  in  color,  resembling  rice  water.  In  this  the 
microscope  may  recognize  columnar  epithelial  cells,  isolated  and  in  flakes; 
also  the  remnants  of  partially  digested  food,  such  as  disintegrating  muscular 
fasciculi  and  oil  globules.  The  mucous  membrane  of  stomach  appears  con- 
gested, and  the  course  of  the  larger  vessels  can  be  readily  traced  in  con- 
sequence of  their  being  full  of  thick  blood.  A  papillated  appearance  as- 
cribed to  enlargement  of  the  solitary  follicles  is  often  present.  The 
epithelium  is  detached  in  places;  in  others,  intact. 

The  mucous  membrane  of  the  small  intestine  may  also  be  much  con- 
gested; the  bowel  is  filled  with  rice-water  fluid.  On  its  surface  lie  numerous 
patches  or  flakes  of  detached  epithelium,  while  the  papillated  appearance 
produced  by  the  enlarged  lymphadenoid  follicles  is  everywhere  present. 
The  villi  are  largely  denuded  of  epithelium,  but  in  places  they  are  intact. 

If  death  takes  place  during  imperfect  reaction,  the  gastro-intestinal 
mucous  membrane  is  still  more  congested  and  dark-red  in  color  from  hypere- 
mia and  hlood  extravasation.  At  such  times,  too,  the  solitary  glands  are 
conspicuous  and  cause  also  a  papillated  appearance  even  more  striking 
than  that  in  the  stomach.  Peyer's  patches  may  also  be  swollen,  and  the 
same  denudation  of  epithelium  from  the  villi  and  elsewhere  is  present. 
The  signs  that  suggest  an  inflammatory  process  are  a  slight  cellular  in- 
filtration of  the  intestinal  walls  and  the  enlargement  of  the  solitary  follicles ; 
also,  at  times,  a  diphtheritic  exudate. 

The  liver  is  natural  in  size,  but  may  be  congested  and  darker  hued  than 
in  health,  while  the  cells  exhibit  cloudy  swelling,  and  in  places  small  areas 
of  fatty  change.     The  spleen  is  usually  small,  certainly  not  enlarged. 

The  condition  of  the  kidneys  varies  with  the  stage  at  which  the  patient 
dies.  If  early  in  the  disease  the  organ,  superficially,  is  not  much  altered; 
it  may  be  somewhat  enlarged.  The  veins  are  slightly  overfilled,  but  there 
is  no  marked  capUlary  injection.  There  may  be  a  few  white  or  yellowish 
patches,  where  the  epithelium  is  found  compressed,  cloudy,  and  fatty. 
The  lumina  of  the  tubes  may,  in  places,  be  blocked  with  granular  matter 
or  well-formed  casts,  and  there  may  be  a  few  hemorrhagic  foci,  the  changes 
starting  from  the  pyramids. 

If  death  takes  place  later,  after  reaction  has  set  in,  the  kindey  is  en- 
larged. In  the  cortex  are  seen  grayish-white  and  yellow  patches,  alter- 
nating with  normal-hued  portions.  In  these  altered  places  the  tubes  are 
opaque  with  granular  and  fatty  debris.     Hemorrhagic  infarcts  may  also 


78  IXFECriOUS  DISEASES 

be  found  in  the  cortical  substance.  The  Malpighian  capsules,  with  their 
included  glomerular  capillaries  are  intact. 

The  heart  is  normal  in  size,  but  its  walls  flaccid.  The  right  caviti&s  are 
commonly  filled  with  dark,  liquid  blood;  the  left  cavities,  empty. 

In  many  instances  the  lungs  also  present  an  appearance  more  or  less 
characteristic,  being  shrunken  and  small,  lying  back  in  the  thorax,  as 
though  collapsed.  Like  the  other  tissues,  they  are  empty  of  blood  except 
in  their  dependent  portions,  which  are  the  seat  of  hypostasis.  They  have 
been  compared  by  Parkes  to  fetal  lungs.  Sutton  found  the  two  organs 
to  weigh  but  20  ounces  (600  gm.,)  as  compared  with  45  ounces  (1350  gm.), 
when  death  occurred  after  reaction  had  been  established — that  is,  after 
the  blood  had  again  occupied  the  pulmonary  artery  and  its  branches. 
Collapse  may  be  interfered  with  by  adhesions,  in  which  event  it  is  only 
partial. 

Such  appearances  could,  of  course,  occur  in  death  from  hemorrhage 
and,  after  all,  the  only  distinctive  condition  is  the  presence  of  the  rice- 
water  fluid  in  the  stomach  and  intestine,  or  in  both,  containing  the 
"comma"  bacillus  and  desquamated  epithelium.  The  latter,  to  which  the 
earlier  descriptions  attached  great  importance,  is  now  generally  regarded 
as  postmortem  in  origin.  The  flakes  thus  produced  are  also  what  the  older 
authors  described  as  patches  of  lymph. 

Symptoms. — After  a  period  of  incubation  ranging  from  36  to  56  hours, 
rarely  five  days,  the  symptoms  of  cholera  commonly  present  themselves 
gradually  enough  to  permit  of  arrangement  into  three  distinct  groups  or 
stages : 

1.  The  stage  of  preliminary  diarrhea. 

2.  The  stage  of  collapse. 

3.  The  stage  of  reaction. 

The  stages  are  by  no  means  always  recognizable,  and  the  severity  of 
the  symptoms  varies  greatly,  such  variations  being  reasonably  ascribed 
to  the  varying  quantities  or  virulence  of  the  specific  poison.  Mildness  in 
a  given  case  is  no  guarantee  against  virulence  in  another  caused  by  it. 

1.  The  stage  of  preliminary  diarrhea  is  characterized  by  moderate  diar- 
rhea, which  is  characteristically  painless,  but  may  be  associated  with 
colicky  pains.  The  stools  are  yellow  or  yellowish  throughout  this  stage, 
and  are  alkaline  in  reaction.  Nausea  and  vomiting  are  not  usual  in  it, 
and  the  patient  may  feel  but  slightly  indisposed.  There  is  generally  a 
feeling  of  restless  discomfort  and  depression,  to  which  headache  may  con- 
tribute. The  temperature  remains  normal.  The  first  stage  may  last  for 
a  week  or  longer,  or  a  few  hours  only,  or  it  may  be  entirely  absent. 

2.  In  the  stage  of  collapse  the  diarrhea  has  become  profuse.  The  dis- 
charges have  lost  their  yellowish  color  and  resemble  thin  gruel  or  rice-water. 
The  fluid  gushes  out  with  great  profuseness  and  apparent  force.  There 
may  be  griping  or  tenesmus,  but  more  characteristic  are  the  very  painful 
muscular  cramps,  which  usually  begin  in  the  fingers  and  toes  and  extend 
thence  to  the  calves  of  the  legs  and  abdominal  walls.  Vomiting,  bilious 
at  first,  is  soon  added  to  the  diarrhea.  The  fluid  vomited  soon  assumes 
the  rice-water  character,  and  gushes  from  the  mouth  as  from  the  bowel, 
in  enormous  quantities. 


CHOLERA  79 

Extreme  weakness  and  exhaustion  are  by  this  time  present.  The  skin 
is  blanched  and  shrunken,  the  lusterless  eyes  are  sunken  and  bounded 
below  by  great  circles  of  blue.  The  nose  is  pinched,  the  lips  are  thin,  the 
cheeks  hollow,  and  the  countenance  pallid  to  bluish  grayness.  The  ex- 
tremities and  entire  body  become  clammy  and  cold,  the  superficial  tem- 
perature falls  5°  or  6°,  while  that  of  the  rectum  rises  to  103°  and  104°  F. 
(39°  and  40°  C).  There  is  intense  thirst,  the  mouth  is  dry,  speech  is  huskj-, 
whispering,  and  labored.  The  pulse  is  feeble,  frequent,  or  absent  at  the 
wrist,  and  the  patient  appears  to  be  dying.  Even  the  heart-beat  and 
sounds  are  almost  gone,  but  the  breathing  continues.  Through  all  this, 
conciousness  may  be  maintained  to  the  end  or  coma  may  supervene.  Death 
commonlj''  occurs  in  this  stage. 

On  account  of  the  scantiness  of  blood  certain  secretions  cease  and  there 
is  neither  urine  nor  saliva,  while  power  to  perspire  and  even  the  lacteal 
secretion  in  nursing  women,  remain. 

A  closer  examination  of  the  rice-water  vomited  matters  and  bowel 
discharges  reveals  flakes  of  epithelium,  mucus,  and  granular  debris,  and, 
with  sufficientl}'  high  powers  and  suitable  preparation,  the  cholera  bacillus 
together  with  numerous  other  bacteria.  Occasionally  a  little  blood  is 
present.  The  fluid  is  albuminous  and  contains  the  salts  of  the  blood, 
among  which  sodium  chlorid  is  conspicuous.  Sometimes,  however,  there 
may  be  no  vomiting  or  purging,  whence  the  term  cholera  sicca.  In  these 
cases,  however,  the  stomach  and  bowels  are  commonly  found  containing 
the  characteristic  fluid  after  death. 

This  second  stage  is  generally  of  shorter  duration,  commonly  a  few- 
hours  onlj',  but  it  may  be  prolonged  to  12  or  24.  The  disease  is  sometimes 
ushered  in  wdth  the  symptoms  of  this  stage.  It  has  been  ascribed  to  the 
action  of  a  toxin  produced  bj^  the  baciUi,  which,  when  absorbed,  produces 
the  systemic  effects  of  this  stage,  but  it  is  likely  that  the  flux  is  the  principal 
factor  in  its  production. 

3.  The  stage  of  reaction  is  characterized  by  the  return  of  warmth  and 
color,  the  latter  more  slowly,  and  the  re-establishment  of  secretions.  Espe- 
cially favorable  is  the  return  of  the  urinary  secretion.  Along  with  these 
changes  the  vomiting  and  piirging  occur  at  longer  intervals.  Such  im- 
provement is,  however,  often  delusive.  The  diarrhea  may  return,  the 
collapse  repeat  itself,  and  the  patient  die.  Or  there  may  supen.'ene  cholera 
typhoid,  a  state  characterized  b}^  a  frequent,  feeble  pulse,  ixy  tongue, 
delirium,  and  sometimes  an  erythematous  or  roseolar  eruption  on  the  ex- 
tremities. This  may  end  in  recovery.  Or  there  may  be  superadded 
symptoms  of  nephritis,  including  uremia,  coma,  and  death.  Or  there  ma}- 
be  inflammation,  diphtheritic  or  catarrhal,  of  the  bowels. 

Diagnosis. — In  the  matter  of  diagnosis  it  is  well  known  that,  so  far 
as  symptoms  are  concerned,  cases  of  acute  enteritis,  have  occurred  with 
symptoms  absolutely  identical  with  those  of  true  cholera,  including  the 
fatal  termination. 

There  is  one  very  important  etiological  difference  between  enteritis 
and  true  cholera,  which  is  also  of  great  diagnostic  value,  and  that  is 
that  almost  invariably  cholera  morbus  is  traceable  to  a  severe  and  irri- 
tating exciting  cause,  such  as  a  meal  of  indigestible  fruits  or  vegetables,  or 


80  INFECTIOUS  DISEASES 

imperfectly  cooked  or  decomposing  fish  or  shell-fish,  while  cholera  comes 
on  without  any  such  cause,  or  succeeds  trifling  derangements  of  digestion, 
which  in  other  than  cholera  seasons  pass  away  without  harmful  results. 
As  a  rule,  too,  the  symptoms  of  enteritis  are  much  more  severe  at 
first  than  those  of  true  cholera,  and  the  substances  first  vomited  are  un- 
digested articles  that  have  acted  as  exciting  causes,  succeeded  by  green, 
bilious  matter.  The  discharge  from  the  bowels  is  first  also  of  a  more  bilious 
character,  and  above  all,  the  mortality  is  much  less  serious;  indeed,  recovery 
is  the  rule.     Yet  these  differences  are  not  to  be  relied  upon. 

By  bacteriological  investigation  only  can  a  given  case  be  identified  with 
absolute  certainty.  The  agglutinative  reaction  is  a  ready  method.  It 
is  similar  to  the  Widal  test  for  typhoid  fever,  the  blood-serum  of  the  in- 
fected case  agglutinates  the  comma  bacillus.  Some  hours  are,  however, 
necessary  to  complete  such  a  bacteriological  diagnosis. 

As  to  the  microscopic  examination  of  the  dejecta,  which  is  more  feasible 
for  the  practitioner,  it  may  be  said  if  the  examination  reveals  a  preponder- 
ance of  curved  bacilli,  comma-shaped,  and  sometimes  joined  end  to  end,  so 
as  to  form  figures  somewhat  resembling  the  letter  S,  and  again  appearing 
in  long  threads,  we  may  feel  justified  in  considering  the  case  one  for  care- 
ful study  by  bacteriological  methods.  Although  there  are  found  in  the 
alimentary  tract  other  bacilli,  the  morphology  of  which  is  much  like  that 
of  the  cholera  bacillus,  they  are  not  numerous. 

How,  then,  shall  we  know  a  case  of  vomiting,  serous  diarrhea,  severe 
colicky  pain,  followed  by  collapse,  to  be  a  case  of  cholera?  Every  sus- 
pected case  should  at  once  have  an  agglutination  test  made,  and  the  stools 
should  be  examined  for  the  comma  bacillus.  In  this  country,  where  such 
a  thing  as  endemic  cholera  is  unknown,  it  goes  without  saying  that  any 
isolated  case,  even  if  fatal,  cannot  be  one  of  true  cholera  unless  there  be 
traceable  some  connection  with  an  acknowledged  focus  of  cholera  else- 
where. Second,  such  communication  must  have  taken  place  within  the 
period  of  incubation  required  for  the  development  of  the  case,  saj^  within 
six  days.  Of  course,  such  communication  need  not  be  a  personal  one.  It 
may  be  by  clothing,  merchandise,  and  possibly  letters. 

These  conditions  being  fulfilled,  the  patient  suffering  with  the  symp- 
toms of  cholera  must,  for  the  time  being,  be  regarded  as  a  case  of  the  true 
disease,  and  isolated  until  the  bacteriological  investigation  can  be  made, 
but  the  rapid  occurrence  of  similar  cases  increases  the  probability  of  its 
being  true  cholera,  and  finally  establishes  its  certainty. 

Symptoms  similar  to  those  of  cholera  arise  from  poisoning  by  corrosive 
sublimate,  tartar  emetic,  arsenic,  mushrooms,  and  ptomains  from  various 
sources,  but  their  symptoms  are  rarely  confounded  with  those  of  cholera. 

Prognosis. — The  prognosis,  always  grave,  varies  with  the  stage  of  the 
epidemic.  It  is  well  known  that  in  the  beginning  a  very  large  proportion 
of  cases  die,  fully  80  per  cent.,  but  as  the  epidemic  is  prolonged  the  ratio 
of  deaths  to  persons  attacked  grows  less,  the  mortality  falling  to  30  per 
cent,  or  less.  The  habits  and  morals  of  the  patient  have  an  important 
influence.  Intemperance  and  dissipation  diminish  greatly  the  powers  of 
resistance,  as  do  also  fatigue,  indigestion,  fright,  and  fear. 

Treatment. — The  treatment  of  cholera  is  very  appropriately  divided 


CHOLERA  81 

into  prophylactic  and  curative;  the  former,   when  properly  carried  out, 
being  more  effectual  than  the  latter. 

Prophylaxis. — It  consists  mainly  in  the  isolation  oj  the  patient  and  in 
certain  precautions  against  the  spread  of  infection  by  sterilizing  the  discharges. 
To  this  end: 

1.  The  vomited  matter  and  the  discharges  from  the  bowels  are  to  be 
gathered  in  carbolic  solution,  i  to  20,  or  chlorinated  lime,  i  to  10,  some  of 
which  should  be  in  the  vessels  before  it  is  used.  After  use,  more  should 
be  added.  The  matter  thus  collected  should  be  gently  stirred  and  allowed 
to  remain  20  minutes  before  being  poured  into  the  water-closet  hopper. 
When  the  excreta  can  be  thrown  into  a  pit,  or  even,  as  may  be  done  in  the 
country,  on  the  manure  pile,  milk  of  lime,  or  what  is  the  same  thing,  ordi- 
nary whitewash,  is  a  very  efficient  and  cheap  medium  with  which  to  disin- 
fect them. 

2.  After  vomiting,  the  mouth  of  the  patient  should  be  rinsed  with  a 
solution  of  hydronaphthol,  i  to  5000,  care  being  taken  that  none  is  swal- 
lowed. After  each  evacuation  from  the  bowels,  the  buttocks,  thighs,  and 
anus  should  be  washed  with  soap  and  water. 

3.  All  body  and  bed  linen  soiled  with  the  discharges  should  be  imme- 
diately moistened  with  carbolic  solution,  i  to  60,  and  removed  in  a  covered 
vessel  from  the  apartment,  placed  in  a  wash-boiler,  and  boUed  for  half  an 
hour  in  a  one  per  cent,  solution  of  washing  soda. 

4.  Napkins,  towels,  and  table  linen  should  be  placed  in  a  surdlar  vessel 
or  canvas  bag  for  removal  and  similarly  boiled. 

5.  All  dishes,  knives,  forks,  spoons,  etc.,  used  by  the  patient  should  be 
boiled  after  each  meal  in  a  one  per  cent,  solution  of  soda. 

6.  The  remains  of  meals  should  be  thrown  into  a  vessel  containing  milk 
of  lime  or  whitewash,  and  removed  at  the  end  of  the  day. 

7.  Door-knobs  are  liable  to  be  soiled  by  the  hands  of  one  carrying  out 
excreta,  and  should  be  carefully  washed  and  sterilized,  lest  they,  in  turn, 
communicate  the  infectious  material  to  another  person. 

8.  In  case  of  death,  the  body,  without  being  washed,  should  be  wrapped 
in  sheets  wet  in  a  solution  of  bichlorid  of  mercury,  i  to  1000,  and  allowed 
to  remain  until  removed  for  prompt  burial. 

Special  Directions  to  Nurses : 

1.  They  should,  under  no  circumstances,  take  their  meals  in  the  same 
apartment  with  the  patient,  and  before  leaving  the  room  the  hands  should 
be  cleansed  with  soap  and  bichlorid  solution,  and  such  portion  of  the  dress 
as  is  liable  to  be  soiled  should  be  changed.  The  hands  should  be  again 
rinsed  in  bichlorid  solution,  i  to  1000,  after  leaving  the  patient's  room. 
A  very  convenient  plan  is  to  wear  a  slip  or  "overall"  with  a  hood  to  cover 
the  hair,  which  can  be  easily  thrown  aside  before  leaving  the  room.  A 
canvas  slipper  or  overshoe,  readily  removed,  should  also  be  worn  in  the 
sick-room. 

2.  The  food  of  the  nurse  should  be  wholesome  and  plain,  freshly  cooked, 
•and  served  hot.  No  uncooked  vegetables  should  be  eaten.  Milk  should 
be  boiled  and,  if  desired,  cooled  before  using.  Cold  drinks  should  be 
taken  moderately,  if  at  all.     Coffee  and  tea  may  be  taken  hot. 


82  INFECTIOUS  DISEASES 

3.  Teeth  should  be  cleansed  after  each  meal,  as  the  mouth  aiTords  a 
peculiarly  favorable  nidus  for  decomposing  matters  and  a  favorable  nidus 
for  the  multiplication  of  pathogenic  fungi.  A  daily  bath  in  warm  water, 
with  the  use  of  soap,  should  be  taken  by  each  nurse. 

4.  Care  should  be  observed  to  keep  the  body  from  being  chilled  by 
drafts  or  other  cool  exposures,  and  to  this  end  woolen  underclothing  should 
be  worn. 

5.  All  nurses  should  wear  rubber  gloves  and  a  gowns. 

6.  Courage  and  cheerfulness  are  amply  justified,  because  it  is  really 
almost  impossible  to  take  cholera  if  the  above  precautions  are  carried  out. 

During  an  epidemic  the  public  must  be  warned  to  boil  all  drinking  water 
and  all  milk.     To  seek  relief  for  the  most  trifling  diarrhea. 

It  early  appeared  that  a  certain  degree  of  immunity  from  cholera  is 
secured  by  a  first  attack.  This  was  also  the  conclusion  of  a  collective 
investigation  directed  by  the  Academy  of  Medicine  of  Paris  in  1884,  and 
by  Edward  O.  Shakespeare  from  information  collected  by  him  during  his 
residence  in  Spain  in  1885.  From  this  standpoint  Ferran  and  others 
sought  to  secure  immunity  by  vaccination  with  protective  virus.  Ferran 
injected  subcutaneously  into  each  arm  of  the  subject,  i  c.c.  of  a  pure 
culture  in  bouillon  of  the  comma  bacillus,  during  the  epidemic  of  1885,  in 
Spain.  Notwithstanding  the  discouraging  results  of  Ferran's  method 
that  of  Haffkine,  which  proved  successfid,  is  essentially  the  same. 

The  vaccination  of  human  beings  is  done  in  two  stages.  In  the  first  .05 
to  .1  gram  of  a  24  hour  agar  tube  of  an  attenuated  culture,  suspended  in 
bouillion  is  injected  under  the  skin.  Three  to  eight  days  later  the  same 
amount  of  vrulent  or  fixed  virus  is  inoculated.  Only'  a  slight  local  reaction 
is  said  to  follow  the  injection  of  the  attenuated  culture,  which  modifies  the 
reaction  of  the  second.  When  thus  injected  the  microbes  die  and  disappear, 
setting  free  a  substance  which  acts  upon  the  organism  and  confers  immu- 
nity on  it.  The  same  result  follows  the  injection  of  their  dead  bodies  only. 
Thus  he  was  enabled  to  prepare  vaccine,  preserv^ed  in  weak  solutions  of  car- 
bolic acid,  which  remains  efficacious  for  six  months,  and  may  be  used  by  per- 
sons without  bacteriological  training. 

According  to  Haffkine^  70,000  inoculations  against  cholera  were  made 
in  India  on  42,179  persons,  without  a  single  accident  which  could  be  ascribed 
to  the  inoculations,  and  he  regards  the  results  as  eminently  satisfactory  in 
cases  where  the  vaccination  is  properly  carried  out. 

Notwithstanding  the  claims  of  Haffkine  it  is  held  by  others  that  the 
discomforts  and  more  serious  results  which  ensue  are  a  drawback  to  its 
use. 

The  Treatment  of  the  Attack. — Before  any  general  plan  is  followed  the 
intestinal  tract  must  be  freed  by  castor  oil  or  calomel.  The  indications  in 
the  management  of  cholera,  apart  from  isolation  of  the  patient  and  the 
sterilization  of  the  discharges,  are,  in  the  first  stage,  to  combat  the  multi- 
plication of  bacilli  and  neutralize  their  toxic  influence.  In  the  second 
stage,  to  relieve  the  cramp  and  pain  and  check  the  flux. 

I. — The  former  is  to  be  attained  by  the  judicious  use  of  opiates  and 


*  See  a  lecture  by  W.  W,  Haffkine  on  "Vaccination  against  Cholera*'  in  "Baumgarten's  Jahresbericht." 
vol.  xi,  189s.  p.  411. 


CHOLERA  83 

acids  on  the  one  hand  or  opiates  and  antiseptics  on  the  other.  Any  of  the 
mineral  acids,  such  as  hydrochloric,  nitromuriatic,  and  sulphuric  acids  in 
doses  of  lo  to  15  minims  (0.66  to  i  c.c.)  of  the  dilute  acid  with  as  much 
tincture  of  opiiun  or  a  corresponding  dose  of  paregoric  or  deodorized  tincture 
of  opium  properly  diluted,  may  be  given  every  two  hours.  Or  a  lemonade 
of  tartaric  or  citric  or  lactic  acid,  2.5  drams  to  i  quart  of  water  (9.5  gm.  to 
a  liter),  may  be  used  in  conjunction  with  the  opiate.  In  addition,  the 
rectum  may  be  washed  out  by  the  warm  solution  of  tannic  acid  in  water 
or  camomile  tea. 

Instead  of  the  acid  solutions,  antiseptics  may  be  given  for  the  same 
purpose.  Of  these,  salol  is  a  favorite,  and  may  be  given  in  doses  of  10  to 
15  grains  (0.66  to  i  gm.)  every  two  or  three  hours,  and  it  may  be  combined 
with  subnitrate  of  bismuth  in  large  doses,  with  wine  of  opium  or  deodorized 
tincture. 

The  greater  or  less  usefulness  of  calomel  in  cholera,  as  attested  by 
experience  in  so  many  epidemics,  beginning  in  1885,  may  be  ascribed  to 
its  antiseptic  qualities,  although  it  is  probably  as  efficient  in  controlling 
vomiting  as  any  other  drug.  The  plan  pursued  at  the  New  Hamburg 
Hospital  and  at  the  Moabit  Hospital  in  Berlin  was  to  give  an  initial  dose  of 
4  to  7  grains  (0.3  to  0.5  gm.),  after  which  1/3  to  3/4  grain  (0.02  to  0.05 
gm.)  was  given  every  two  hotirs  through  the  first  and  second  stages.  A 
portion  of  the  calomel  becomes  changed  in  the  intestine  to  corrosive  sub- 
limate; and  as  corrosive-sublimate  solutions  have  a  fungus-destroying  ac- 
tion, in  a  strength  of  i  to  30,000,  it  is  reasonable  to  suppose  that  the  bacilli 
in  the  intestine  are  directly  killed  by  the  calomel. 

II. — The  indications  in  the  second  stage  are  to  relieve  the  painful  cramp, 
to  continue  to  try  to  check  the  discharges,  and  to  compensate  for  the  loss 
of  liquid  by  the  vomiting  and  piu-ging. 

For  the  relief  of  cramps  morphin  hypodermically  is  to  be  preferred, 
because  of  the  promprness  of  its  effect  and  because  absorption  from  the 
gastro-intestinal  mucous  membrane  is  much  hindered,  if  not  altogether  pre- 
vented, in  true  cholera,  while  the  vomiting  is  a  fiu-ther  obstacle  to  the 
administration  of  medicine  by  the  mouth.  Full  doses  should  be  given,  1/6 
to  1/4  grain  (o.oi  to  0.016  gm.),  which  may  be  repeated,  if  necessary.  If 
circumstances  compel  the  administration  of  anodynes  by  the  mouth,  chloro- 
dyne  is  one  of  the  best,  and  is  well  administered  in  brandy  or  whiskey. 
Such  administration,  too,  fulfills  any  indication  for  opium  to  control  the 
bowels.  Some  difference  of  opinion  exists  as  to  the  propriety  of  checking 
,  the  discharges  in  this  stage,  the  chief  reason  assigned  being  that  the  bacilli, 
whose  presence  is  directly  or  indirectly  the  cause  of  the  flux,  are  thus  re- 
tained. But  such  objection  is  offset  by  the  fact  that  the  flux  itself  is  the 
greater  source  of  danger  and  that,  if  it  can  be  controlled,  the  bacilli  in  the 
bowels  are  comparatively  harmless.  Unfortunately,  in  the  la,ter  stages, 
when  the  flux  is  established,  nothing  avails  to  control  it,  and  the  opiate 
may  as  well  be  limited  to  that  hypodermically  administered  for  the  relief 
of  pain.  We  quite  agree  with  those  who  hold  that,  notwithstanding  the 
opposition  to  it,  opium  will  retain  its  place  among  the  chief  weapons 
against  the  disease. 

The  effect  of  the  copious  discharge  is  to  produce  the  intense  exhaus- 


84  INFECTIOUS  DISEASES 

tion  referred  to  under  symptomatology,  and  it  is  imperative  to  counteract 
this,  if  possible,  by  stimulants  freely  administered.  Champagne,  brandy, 
and  ammonia,  combined  with  ice  and  carbonated  waters,  are  suitable.  If 
not  retained  by  the  stomach,  whiskey,  ether,  and  the  aromatic  spirit  of 
ammonia  may  be  given  hypodermically  in  30  minim  (2  c.c.)  doses  fre- 
quently repeated.  The  hope  of  benefit  from  these  remedies  is  justified,  if 
reaction  once  sets  in. 

More  serious  still  is  the  drainage  of  liquid  from  the  tissues,  and  the 
most  serious  consequences  ensue  from  the  resulting  stagnation  in  the  blood. 
To  restore  the  water  is,  therefore,  of  the  greatest  importance.  Intraveneous 
injections  of  normal  salt  solution  are  of  the  greatest  value.  More  easy  in 
private  practice  are  hypodermic  injections  of  hot  saline  solutions  or  hypo- 
dermoclysis,  also  enemas  or  enteroclysis  of  similar  fluids,  slightly  astringent. 
They  were  practised  successfully  by  Cantani  in  Italy  in  1892,  and  have  been 
continued  with  various  results  in  Europe,  and  in  a  more  limited  manner,  with 
with  satisfactory  results,  at  Swinburne  Island  in  New  York  Harbor.  The 
benefit  derived  from  the  use  of  this  measure  under  other  circumstances — 
as,  for  example,  succeeding  large  hemorrhages  and  uremia — together  with 
the  facility  with  which  it  can  be  carried  out,  commend  it  strongly.  A 
heaping  teaspoonful  of  common  salt  to  a  pint  of  sterilized  water  furnishes  with 
sufficient  accuracy  the  proportion  desired. 

Whenever  the  discharges  have  been  so  copious  as  to  make  it  reasonable 
that  the  vessels  are  becoming  drained,  hypodermoclj'sis  is  indicated,  and  maj^ 
be  repeated  every  two,  four,  or  six  hours  as  required. 

Enteroclysis  is  made  with  a  one  or  two  per  cent,  solution  of  tannic 
acid  at  a  temperature  of  113°  F.  (45°  C).  For  an  adult  2  quarts  (2  liters) 
may  be  administered;  for  an  adolescent,  i  quart  (i  liter).  It  is  intro- 
duced slowly,  by  a  fountain  syringe,  through  a  rectal  tube  with  lateral 
outlets  but  closed  at  the  end.  The  tube  is  inserted  gently  by  a  com- 
bined rotary  and  pushing  motion  to  the  depth  of  ten  inches,  when  the 
fluid  is  allowed  to  enter  very  slowly,  consuming  not  less  than  ten  minutes. 
The  patient  should,  of  course,  be  encouraged  to  retain  the  fluid,  and  may  be 
aided  by  pressure  on  the  anus  with  a  napkin.  Enteroclysis  is  useful  in  any 
moderateh^  severe  case  of  cholera,  and  may  be  given  night  and  morning, 
more  frequently  in  severe  cases. 

It  is  in  the  algid  stage  that  this  treatment  is  especially  useful,  but 
other  means  must  be  taken  to  keep  up  the  warmth  of  the  body.  To  this 
end  the  patient  is  immersed  in  the  hot  bath  at  a  temperature  of  38°  to  42°  C. 
(100°  to  107°  F.).  In  favorable  response  the  warmth  of  the  body  returns, 
the  pulse  is  fidler  and  stronger,  the  respiration  deeper.  Hot-water  bottles, 
hot-water  bags,  and  hot  bricks  may  be  applied  alongside  the  body. 

III. — In  the  third  stage,  that  of  reaction,  indicated  by  the  return  of 
warmth,  piolse,  and  heart-beat,  and  especially  the  establishment  of  the 
urinary  secretion,  restorative  measures  are  continued  with  the  addition  of 
judicious  nutriment,  preferably  in  the  shape  of  peptonized  foods,  especially 
peptonized  milk.  Great  care  must  be  exercised  lest  diarrhea  be  induced  by 
too  liberal  feeding.  Convalescence  is  necessarily  very  slow  in  serious  cases, 
and  relapses  are  prone  to  occur. 


DYSENTERY  85 

DYSENTERY. 

Synonym. — Bloody  flux. 

Definition. — The  term  dysentery,  derived  from  the  Greek  words  Sys  dif- 
ficult and  Ei/rtpov  bowel  is  applied  to  inflammations  of  the  large  intestine, 
sometimes  extending  into  the  small  bowel,  which  are  iniectuous  in  character. 
The  condition  can  be  best  considered  under  two  heads  which  represent  va- 
rieties or  different  forms  of  the  disease.  These  are:  ist,  bacillary,  and 
2d,  amebic  dysentery. 

Bacillary  Dysentery. 

Definition. — An  acute  infectious  disease  due  to  the  inplantation  of  some 
strain  of  the  bacillus  dysenteric^.  It  is  characterized  by  sudden  onset,  fever, 
abdominal  pain,  sharp  and  cramp-like,  frequent  stools  at  first  large  and  loose, 
soon  small  containing  blood  and  mucus  accompanied  by  much  tenesmus. 

Etiology. — Beginning  with  the  researches  of  Shiga  in  Japan,  in  1898, 
which  were  followed  by  the  investigations  of  Flexner  and  Barker  carried  out 
in  Manila,  in  1900,  and  afterward  by  Flexner  in  this  country,  and  Kruse 
and  others  in  Germany,  the  evidence  has  grown  in  favor  of  the  B.  dysen- 
teric as  being  the  specific  cause  of  this  variety  of  dysentery. 

The  bacillus  dysenteries  of  which  there  are  several  varieties,  is  a  well- 
characterized  micro-organism  belonging  to  the  colon  typhoid  group  of 
bacilli,  which  can  be  distinguished  by  its  cultural  and  other  characteristics. 
In  morphology  it  differs  only  slightly  from  the  typhoid  bacillus,  with  which 
it  has  certain  cultural  properties  in  common.  It  is  highly  toxic,  the  poison- 
ous character  being  due  to  an  endotoxin.  Vedder  and  Duval,  late  of  the 
University  of  Pennsylvania  have  demonstrated  the  presence  of  this  bacillus 
in  sporadic  cases  in  Philadelphia  and  in  epidemics  in  other  portions  of 
Pennsylvania.  Hunt^  has  recently  reported  several  epidemics  of  dysentery 
from  which  he  recovered  bacilli  of  one  or  the  other  of  three  groups  of  dysen- 
teric bacilli.  The  organism  is  pathogenic  for  a  wide  series  of  laboratory 
animals,  and  when  injected  into  the  intestine  of  cats,  or  fed  to  them  after 
alkalinization  of  the  gastric  juice,  it  is  capable  of  setting  up  an  inflammation 
of  the  gut  from  which  the  bacillus  may  be  recovered.  Ingested  by  man  it 
rapidly  sets  up  a  severe  colitis.  There  are  two  instances  on  record  of  its 
actions  on  man:  The  first,  reported  by  Flexner,  in  which  a  small  quantity 
of  a  culture  was  accidently  aspirated  into  the  mouth  by  one  of  his  assistants, 
the  intestinal  symptoms  appearing  with  forty-eight  hours;  the  second, 
reported  by  Strong,  in  which  a  Filipino  prisoner  voluntarily  swallowed  a 
portion  of  a  culture  of  the  baciUus,  in  which  case  the  symptoms  quickly 
developed  and  were  of  marked  severity,  the  bacillus  being  recovered  from 
the  stools.     The  man  finally  recovered. 

Morbid  Anatomy. — The  anatomical  features  of  bacillary  dysentery 
vary  with  the  form  and  duration  of  the  disease.  The  lesions  vary  from  a 
mere  hyperemia  of  the  mucous  membrane  of  both  ileum  and  colon  to  de- 
structive ulceration  of  the  mucous  membrane  more  particularly  of  the  colon, 
there  may  be  a  grayish  pseudo-membrane  which  is  easily  scaled  off  covering 

»  "Jour.  Amer.  Med.  Assoc,"  September  21,  1912. 


86  INFECTIOUS  DISEASES 

the  entire  mucous  membrane  or  there  may  be  deep  localized  ulceration. 
Occasionally  the  whole  mucous  membrane  is  much  thickened.  As  the 
condition  progresses  in  severity  the  intervening  mucosa  is  covered  with 
pseudo-membrane.  The  entire  mucosa  is  injected,  swollen,  and  covered 
with  blood-stained  mucus,  beneath  which  bleeding  points  inay  be  discerned. 
Upon  microscopical  examination  the  pseudo-membrane  is  found  to  consist 
of  a  fibrinous  and  cellular  exudation  which  lies  upon  the  surface  and  pene- 
trates into  the  substance,  for  a  variable  distance,  of  the  mucosa.  The 
glands  of  Liberkiihn  undergo  necrosis  and  become  invaded  by  pseudo- 
membrane.  Large  numbers  of  micro-organisms  are  present  in  the  dead 
tissue,  and  the  blood-vessels  of  the  mucosa  are  extensively  occluded  by 
thrombi. 

A  demarcating  inflammation  takes  place  at  the  limits  of  the  living  and 
necrotic  tissue,  causing  separation  of  the  latter,  which  upon  exfoliation  leaves 
behind  defects  which  constitute  the  acute  dysenteric  ulcers.  The  disease 
may  come  to  an  end  at  this  stage  or  an  earlier  one,  and  the  integrity  of  the 
mucosa  be  restored,  or  the  necrosis  may  extend  more  deeph'  and  involve 
the  death  depth  of  the  mucosa  and  be  associated  with  marked  inflammatory 
changes  in  the  submucous  and  muscular  tunics.  In  these  instances  ulcera- 
tion may  extend  through  the  mucosa  and  invade  the  submucosa,  and  even 
penetrate  more  deeply,  and  in  the  subsequent  process  of  repair  new  tissue 
develops  in  the  submucosa  which  leads  to  the  permanent  thickening  of  the 
intestinal  wall. 

It  is  the  form  of  dysentery  which  tends  to  pass  into  the  chronic  disease, 
the  ulceration  is  deep  and  persistent,  and  much  new  tissue  develops  in  the 
submucosa,  in  the  mucosa,  and  even  in  the  muscular  coat.  O^'ing  to  the 
persistence  of  the  ulceration  and  possibly  to  the  interaction  of  secondary 
micro-organisms,  including  the  pyogenic  cocci,  always  present  in  the  in- 
testinal canal  of  man,  the  ulceration  extends  not  only  more  deeply,  but  tends 
also  to  heal  slowly  and  imperfecth%  whence  arise  the  sj-mptoms  character- 
izing chronic  ulcerative  dysentery.  That  the  specific  organism  persists 
throughout  long  periods,  where  these  pathological  conditions  are  present,  is 
shown  by  the  acute  exacerbations  of  the  disease  and  by  the  association  of 
the  chronic  ulcerative  with  fresh  pseudo-membranous  inflammation  met,  not 
infrequently,  at  autopsy.  It  is  during  the  exacerbation  that  the  specific 
bacillus  is  to  be  sought  in  the  dejecta  and  the  blood  reaction  looked  for. 

The  new  formation  of  connective  tissue  tliroughout  the  coats  of  the  gut 
may  be  so  extensive  as  to  bring  about,  after  its  contracture,  serious  deform- 
ity and  narrowing  of  the  lumen.  Inflammation  sometimes  extends  to  the 
peritoneal  coat,  whence  adhesions  to  the  neighboring  parts  take  place.  Only 
rarely  does  ulceration  proceed  so  rapidly,  or  fail  to  be  attended  by  connective 
tissue  formation,  as  to  perforate  the  peritoneal  coat. 

Symptoms. — The  symptoms  of  bacillary  dysenterj'  vary  greatly  in  in- 
tensity. Those  cases  due  to  the  Shiga  group  of  bacilli  have  the  most  severe 
symptoms.  To.  this  class  belongs  the  bacillary  type  of  tropical  dysentery. 
The/ewr  is  high,  the  pain  is  great,  the  tormina  and  tenesmus  are  severe,  the 
stools  are  bloodjs  and  the  adynamia  is  profound.  Delirium  is  often  present, 
and  the  tongue  ma}^  be  dry.  The  abdomen  is  tender  and  swollen,  and 
typhoid  fever  ma}-  be  simulated. 


DYSENTERY  87 

Those  cases  due  to  the  other  two  groups  of  baciUi  have  much  milder 
symptoms.  There  is  sudden  abdominal  pain,  fever,  reaching  103°  or  some- 
times over,  but  usually  101°  to  102°,  tenesmus,  frequent  stools  every  hour  to 
every  half  hour.  The  stools  containing  blood  and  mucus.  There  is  much 
prostration  and  emaciation,  there  is  frequency  vomiting.  This  latter  group 
of  cases  belong  to  those  formerly  designated  catarrhal  dysentery. 

Complications  and  Sequelae. — The  complications  in  this  form  of  dys- 
entery are  more  numerous.  Abscess  of  the  liver  is  rare,  and  is  ascribed 
to  thrombotic  extension  from  the  seat  of  inflammation  along  the  vessels 
of  the  portal  system  into  the  liver,  or  to  emboli  carried  from  the  primary 
focus  to  the  liver.  Perforation  of  the  bowel  is  not  a  very  rare  complica- 
tion, having  been  found  by  Woodward,  in  a  studj^  of  the  statistics  of  the 
late  Civil  War  in  America,  11  times  in  108  autopsies.  This  accident  is 
followed  by  a  peritonitis,  which  is  usually  fatal,  the  local  symptoms  of  which 
vary  with  its  exact  seat.  If  in  the  neighborhood  of  the  cecum,  peritj^phlitis 
ensues;  if  lower  down  in  the  rectum,  a  proctitis.  A  peritonitis  may  also 
arise  by  extension  of  the  inflammation  from  the  mucous  lining  of  the  bowel. 

The  same  opportunities  enabled  Woodward  to  show  the  undoubted 
association  of  malaria  with  dysentery,  though  it  is  likely  that  the  "chills" 
referred  to  in  older  reports  were  sometimes  septic  and  due  to  the  dysenten,-. 
The  same  is  true  of  the  joint  swelling  described  bj^  the  older  authors,  among 
whom  was  Sydenham.  They  may  be  a  part  of  pyemic  processes.  Paraly- 
sis, commonly  paraplegia,  as  a  sequel,  is  attested  by  Woodward  and  Weir 
Mitchell.  Pleurisy,  pericarditis,  endocarditis,  and  Bright's  disease  are 
among  sequelse  reported. 

Diagnosis. — The  condition  must  be  distinguished  from  a  simple  ileo- 
colitis due  to  improper  food,  or  drink. 

Bacteriological  Diagnosis. — Diagnosis  of  this  form  of  dj-senters^  can  be 
established  in  two  waj-s:  First,  by  recovery  of  the  specific  organism  from 
the  stools;  second,  by  obtaining  the  agglutination  reaction  with  the  blood 
of  the  patient  and  the  specific  baciUi  in  a  manner  similar  to  that  of  the 
Widal  test  in  typhoid  fever. 

In  the  acute  disease  the  specific  bacilli  are  abundant,  and  can  be  sepa- 
rated without  great  difficulty  from  the  dejecta. 

The  agglutination  test  with  the  blood  of  persons  iU  of  bacUlary  dysen- 
tery is  easily  obtained.  For  this  purpose  cultures,  24  hours  old,  upon 
agar-agar,  are  employed,  from  which  suspensions  are  made  in  bouillon. 
In  using  the  blood,  it  is  preferable  to  employ  the  wet  method  by  which 
the  blood  is  obtained  in  capillary  tubes,  from  which  the  serum  can  be  col- 
lected. After  proper  dilution  of  the  serum  the  tests  are  carried  out  in  the 
usual  manner.  Positive  reactions  may  be  obtained  in  dilutions  varying 
from  1/20  to  i/iooo  in  a  period  of  from  one-half  to  one  hour,  and  as  eariy 
as  from  the  third  to  the  fourth  day  of  illness.  This  method  is  applicable 
to  the  study  of  all  cases  of  dj^sentery,  as  weU  as  the  entero-colitides  of 
children. 

Prognosis. — The  prognosis  depends  upon  the  locality  and  the  type  of 
infecting  organism.  In  the  tropics  the  mortality  is  high  and  a  high  mor- 
tality accompanies  the  infection  of  the  Shiga  type  wherever  it  occixrs.  In 
temperate  climates  the  mortality  is  very  low  especially  where  the  infecting 


88  INFECTIOUS  DISEASES 

organism  is  one  of  the  less  virulent  types.  Most  cases  perish,  death  being 
preceded  by  extreme  adynamia  and  other  symptoms  of  the  typhoid  state, 
including  dry  tongue,  stupor,  emaciation,  and  the  cadaveric  countenance. 
Consciousness  is  sometimes  painfully  persistent  to  the  end. 

Amebic  Dysentery  {Amwbiasis). 
Synonyms. — Amebic  Enteritis;  Tropical  Dysentery. 

Definition. — An  vilcerative  inflammation  of  the  large  intestine  due  to 
amceba  coli.  This  form  has  sometimes  been  termed  tropical  dysentery. 
One  hundred  and  nineteen  cases  were  treated  in  the  Johns  Hopkins  Hos- 
pital, Baltimore,  Md.,  from  the  date  of  its  opening,  Maj'  15,  1889  to 
1902,  a  period  of  nearly  13  years.' 

Etiology. — The  amceha  coli  or  dysenterice  is  now  the  acknowledged 
cause  of  this  form  of  dysentery. 

The  amebas  are  found  in  the  dejecta,  in  the  intestinal  ulcers,  and  in  sec- 
ondary liver  abscesses  complicating  the  disease.  The  organism  varies  from 
15  to  20  microns  in  diameter  and  is  actively  motile  when  examined  in  the 
living  state.  It  consists  of  two  portions,  an  outer  ectosarc  and  an  inner 
endosarc.  Its  movements  are  brought  about  through  the  propulsion  of 
the  former,  after  which  the  granular  inner  substance  flows  into  the  pseudo- 
podia.  The  ameba  is  phagocytic,  taking  up  foreign  substances  from  the 
intestine,  etc.,  and  especially  englobing  the  red  corpuscles.  At  present  two 
varieties  of  amebas  are  distinguished  as  occurring  in  the  stools :  the  first  non- 
pathogenic— amoeba  coli  mitis — and  the  second  pathogenic — amoeba  coli. 
The  former  has  been  found  repeatedly  in  healthy  stools,  and  it  does  not  ex- 
hibit phagocytic  properties  for  red  corpuscles.  In  this  country  amebic 
dysentery  has  been  found  to  occur  as  a  sporadic  disease,  especially  in  the 
Southern  States,  but  also  in  Pennsylvania,  New  York,  and  the  New  England 
States.     In  the  latter  three  it  is  probably  imported. 

Morbid  Anatomy. — The  intestinal  lesions  are  usually  Hmited  to  the' 
large  intestine;  rarely  they  are  found  in  the  ileum.  The  characteristic 
lesion  is  tdceration,  involving  the  mucosa  and  submucosa.  In  early  ulcers  a 
small  defect  only  is  found  in  the  mucosa;  more  rarely  the  muscular  coat  is  in- 
vaded, and  rarest  of  all  the  peritoneal  coat.  In  the  course  of  the  ulceration 
the  submucosa  becomes  infiltrated  with  a  grayish  gelatinous  material,  the  ex- 
foliation of  which  gives  rise  to  the  tdcer.  In  this  material  there  are  a  few 
pus  cells,  but  it  consists  chiefly  of  necrotic  material.  Amebje  may  be  dis- 
covered in  the  necrotic  tissue,  as  well  as  in  the  adjacent  portions  of  the  mu- 
cosa and  submucosa.  In  the  immediate  neighborhood  of  the  ulcer  prolif- 
eration of  the  connective  tissue  takes  place  which,  in  favorable  cases,  may 
completely  restore  the  defect,  and  in  chronic  cases  brings  about  permanent 
changes  in  the  gut  similar  to  those  described  in  chronic  bacillary  dysentery. 
Pseudo-membrane  is  never  present  in  uncomplicated  cases,  but  instances  of 
combined  amebic  and  bacillar}^  dysentery,  in  which  pseudo-membrane  has 
been  present,  have  been  described. 

Sjrmptoms. — The  symptoms  of  amebic  dysentery  are  similar  to  those 

'See  Thomas  B.  Fatcher's  paper  "A  Study  of  the  Cases  of  Amebic  Dysentery,"  occurring  at  the 
Johns  Hopkins  Hospital.     "Jour.  Amer.  Medical  Assoc,"  Aug.  22,  1903. 


AMEBIC  DYSENTERY  89 

of  bacillary  dysentery,  but  much  more  irregular  and  prolonged.  The  onset 
is  usually  less  sudden,  but  may  be  equally  so.  The  stools  are  less  numer- 
ous, and  are  apt  to  be  more  liquid  and  more  copious.  They  abound  in  the 
amcebce  colt.  The  straining  at  stool  is  less  severe  and  persistent,  while 
there  may  be  several  days  of  relief,  to  be  followed  by  the  usual  train  of 
symptoms.  The  fever  may  be  severe  or  mild.  Intestinal  hemorrhage 
should  be  mentioned  as  an  occasional  symptom  of  amebic  dysentery. 
This  symptom  rarely  has  resulted  fatally  being  caused  usually  by  extensive 
ulcerative  gangrenous  processes  which  prevail  in  this  disease.  The  subject 
has  been  exhaustively  studied  by  Richard  P.  Strong,  Director  of  the  Bio- 
logical Laboratory  at  A'lanila,  P.  I.  (Journal  of  American  Medicine, 
January  27,  1906.) 

Complications. — The  most  common  and  serious  complication  is  abscess 
of  the  liver,  which  is  now  believed  to  be  due  to  the  wandering  amosba  dysen- 
terica,  which  reaches  the  liver  through  the  blood-vessels.  The  abscess  may 
be  single  or  multiple.  In  the  former  case  it  may  be  of  large  size,  involving 
fully  half  of  the  bulk  of  the  liver.  The  multiple  abscesses  are  smaller  in 
size  and  superficial.  The  abscess  walls  are  peculiar,  being  ragged  from  the 
presence  of  necrotic  projections.  Only  occasionally,  in  the  older  abscesses, 
are  there  firm,  smooth,  fibrous  walls.  Next  to  the  innermost  necrotic  zone 
is  a  zone  of  cellular  infiltration  encroaching  upon  and  destroying  the  liver- 
cells,  and  external  to  this  again  a  zone  of  intense  hyperemia.  The  contents 
of  the  abscess  are  not  pure  pus.  In  fact,  the  paucity  of  the  pus-cells  here  is 
as  significant  as  in  the  inflammatory  infiltration  of  the  mucosa,  indicating 
a  similarity  in  the  etiology.  The  pyoid  material  consists  rather  of  fatty 
and  granular  debris  and  the  amebae,  which  are  also  found  in  the  walls  of  the 
abscess.  These  abscesses  sometimes  break  into  the  lungs,  carrjdng  the 
amebas  with  them,  which,  under  these  circumstances,  may  be  found  in  the 
expectoration. 

In  addition  to  the  abscesses  described  there  are  found  also  in  the  liver 
in  amebic  dysentery  patches  of  circumscribed  necrosis,  scattered  through 
the  liver  as  the  result  of  the  action  of  the  amebas. 

Diagnosis. — The  diagnosis  is  rendered  easy  bj^  the  recognition  of  the 
amceba  coli  in  the  stools,  which  should  be  examined  b)^  the  microscope  in 
every  case  of  dysentery  as  directed  under  microscopical  diagnosis. 

Microscopical  Diagnosis. — Detection  of  the  specific  amebs  in  the  stools, 
or  of  secondary  liver  abscesses,  confirms  the  diagnosis  of  the  disease.  Great 
care  should  be  exercised  to  obtain  fresh  material  for  microscopical  exam- 
nation,  and  bits  of  mucus,  rather  than  fecal  material,  should  be  chosen 
for  study.  The  mucus  or  pus  is  slightly  pressed  out,  but  not  too  firmly, 
under  a  cover-glass,  and  the  slide  slightly,  but  carefully,  warmed  up  to 
body  heat,  before  examination.  Inasmuch  as  desquamated  epithelial  cells 
sometimes  take  on  a  round  form  and  stimulate  amebas,  it  is  desirable  that  a 
definite  movement  be  detected  before  passing  upon  the  nature  of  the  sus- 
pected cells.  Living  amebffi,  especially  those  enclosing  red  corpuscles, 
are  taken  to  indicate  the  nature  of  the  pathological  condition  of  the  intestine. 

Prognosis. — The  prognosis  is  more  serious  than  that  in  the  bacillary 
variet}'.  The  course  of  the  disease  is  always  prolonged,  and  a  fatal  issue 
is  much  more  frequent.     It  would  seem  that  the  patient  must  outlive  the 


90  INFECTIOUS  DISEASES 

organism  before  he  can  recover,  and  even  then  recovery  is  delayed  by  the 
cxhatisted  condition  into  which  he  has  fallen.  When  the  termination  is 
most  favorable,  cases  of  amebic  dysentery  last  from  6  to  1 2  weeks. 

Treatment  of  Dysentery. — The  first  measure  of  treatment  of  mild  or 
sporadic  cases  of  dysentery  duly  recognized  should  always  be  a  purgative. 
No  aperient  is  better  than  castor  oil.  An  ounce  of  oil  (30  c.c.)  is  the 
proper  dose  for  an  adult.  The  saline  treatment,  especially  when  there  is 
high  fever  and  no  marked  adynamia,  is  also  efficient,  working  a  rapid  cure 
in  many  cases.  Two  dr&ms  (8  gm.)  of  sulphate  of  magnesium,  or  1/2 
ounce  (16  gm.)  of  Rochelle  salts  dissolved  in  water,  should  be  given  every 
hour  until  copious  watery  purgation  results.  The  patient  should  always  be 
required  to  use  a  bedpan. 

After  free  purgation,  an  opiate  may  be  given.  Plain  opium  in  doses  of 
I  grain  (0.066  gm.)  every  three  hours,  or  1/2  grain  (0.033  &"!■)  of  the 
extract,  is  the  favorite.  Bismuth  subnitrate  in  10  to  30  grain  (0.66  to  2 
gm.)  doses,  one  of.  the  astringents,  tannic  acid  in  2  to  5  grain  (0.132 
to  0.33  gm.)  doses,  or  the  acetate  of  lead,  i  to  2  grain  (0.066  to  0.132 
gm.);  or  maybe  salol  in  5  to  10  grains  (0.3  to  0.6  gm.)  maj^  be  given. 
Very  comforting  in  quieting  rectal  irritation  is  an  opium  suppository  con- 
taining I  to  2  grains  (0.066  gm.  to  0.132.  gm)  of  opium,  or  1/2  to  a  grain 
(0.033  gni-  to  0.066  gm.)  of  the  extract. 

High  enemata  of  normal  salt  solution  introduced  very  slowly  will 
frequently  give  more  relief  than  any  other  measure.  The  solution  should 
be  luke  warm,  from  one  pint  to  one  quart  may  be  used.  If  the  funnel  is 
held  not  more  than  15  to  18  inches  above  the  anus  the  whole  amount  may 
be  introduced  taking  about  one-quarter  to  one-half  an  hour. 

It  goes  without  saying  that  the  food  should  be  liquid  and  of  the  blandest 
kind:  boiled  milk,  better  still  peptonized,  light  animal  broths,  and  beef- 
juice,  not  beef-teas,  are  the  type.  Barley  or  rice  may  be  added  to  such 
broths,  and  should  be  thoroughly  cooked. 

Severe  Epidemic  Forms. — The  first  consideration  in  the  treatment  of 
bacillary  dysentery  is  a  bland  and  nonirritating,  hut  nourishing,  diet,  one 
that  leaves  as  little  residue  as  possible.  The  peptonized  foods,  such  as  pep- 
tonized milk,  malted  milk  and  beef-preparations,  in  addition  to  beef-juice 
and  somatose,  are  the  types.  To  these,  stimulants  should  be  freely  added. 
Opiates  are  needed  to  relieve  the  pain,  and  their  hypodermic  use  is  some- 
times especially  efficient  for  this  purpose.  When  the  necrotic  membrane 
is  removed,  an  extensive  ulcerated  surface  remains  to  be  healed.  Such 
healing  is  favored  bj^  the  restrained  peristalsis  that  opium  produces.  The 
same  purpose  may  be  served  by  the  use  of  ipecacuanha.  Directions  for  its 
administration  are  given  below. 

On  the  other  hand,  it  is  uncertain  whether  soluble  remedies  intended 
for  the  direct  healing  of  the  ulcers  ever  reach  these  surfaces  in  an  active 
state,  when  administered  by  the  mouth.  Nitrate  of  silver,  when  admin- 
istered, does  sometimes,  however,  reach  the  lower  bowel.  Bismuth,  being 
largely  insoluble  when  administered  in  large  doses,  30  to  60  grains  (2  to 
4  gm.)  every  two  or  three  hours,  undoubtedly  reaches  the  bowel,  and 
may  produce  some  healing  effect. 

Amebic  Dysentery. — The  same  indication  as  to  diet  exists  in  the  amebic 


DYSENTERY  91 

as  in  the  other  forms  of  dysentery.  It  is  in  this  form,  as  well  as  in  the 
bacillary  type  of  severe  grade  of  which  only  isolated  cases  are  met  in  tem- 
perate climates,  that  the  ipecacuanha  treatment  of  the  East  Indian  physicians 
has  been  so  successful.  It  is  claimed  to  act  as  a  muscular  sedative  and 
secretory  stimulant ;  by  its  effect  the  former  allays  the  exaggerated  peris- 
taltic activity  so  characteristic  of  the  disease,  by  the  latter  it  augments 
the  secretion  of  mucus  as  well  as  stimulates  the  activity  of  the  liver-cells 
in  bile  formation — a  function  which  in  dysentery  is  in  abeyance.  Great 
stress  is  laid  on  the  mode  of  administration.  It  is  best  given  in  pills 
coated  with  salol  or  keratin,  so  that  it  reaches  the  intestines  undissolved. 
The  stomach  should  be  empty  when  the  pill  is  given,  at  bed  time.  One 
dose  is  given  each  night,  the  first  60  to  90  grains  (4  to  6  grams),  which  is 
reduced  about  5  grains  each  night  until  the  dose  is  down  to  10  grains  (6/10 
of  a  gram).  Milk  should  form  the  staple  food.  Later,  farinaceous  foods 
and  soups  may  be  carefully  given,  but  no  solids  should  be  permitted  for  a 
long  time. 

Warm  injections  of  quinin,  i  to  5000,  i  to  2500,  and  i  to  1000,  have 
been  employed  at  the  Johns  Hopkins  Hospital  with  good  results,  the  amebse 
being  rapidly  destroyed  by  them.  Perhaps  ipecacuanha  acts'  similarly. 
For  the  relief  of  pain  opiates  must  also  be  administered,  preferably  by  the 
rectum  in  suppository  or  small  starch- water  enemas;  or  morphin  may  be 
given  hypodermically  if  the  stomach  be  sensitive.  Appendicostomy  has 
been  lately  practriced  in  chronic  forms.  The  appendix  is  stitched  to  the 
belly  wall,  is  kept  open  and  the  gut  flushed  through  this  opening. 

Serum  Therapy. — The  immunizing  protective  effect  of  vaccines  against 
the  dysentery  bacillus  and  the  protective  and  curative  effect  of  the  anti- 
dysenteric  sera  demand  allusion.  Curative  serum  was  first  employed  by 
Shiga  in  1898  in  the  treatment  of  65  cases  in  the  hospitals  in  Tokio  and  by 
Rosenthal  and  Kruse.  Shiga  also  practised  vaccination  to  some  extent  in 
Japan,  making  a  prophylactic  vaccine  out  of  dead  dysentery  bacilli.  The 
availability  of  sera  received  fresh  support  from  experimental  studies  by 
Simon  Flexner  and  Frederick  P.  Gay.^ 

Dysentery  vaccines  were  made  of  dead  cultures  as  described  in  Gay's 
paper.  Guinea-pigs  which  received  one  or  more  subcutaneous  injections 
of  subminimal  lethal  doses  showed  a  marked  protection  against  multiple 
intraperitoneal  lethal  doses  of  the  living  organism.  It  is  interesting  to  note 
that  while  protection  afforded  by  a  given  vaccine  against  its  own  strain 
of  bacillus  dysenterise  was  absolute,  within  limits,  it  was  found  that  under 
similar  conditions  such  protection  may  not  be  secured  against  other  strains, 
suggesting  the  advisability  of  combining  several  strains  of  bacilli  after  their 
cultivation  in  the  preparation  of  vaccines. 

Antidysenteric  curative  serum  was  obtained  from  the  horse  after  im- 
munization. It  was  found  to  possess  agglutinative  properties  for  bacillus 
dysentricB.  This  serum  also  had  protective  as  well  as  curative  properties 
against  multiple  fatal  intraperitoneal  doses  in  guinea-pigs.  Gay  concludes 
that  this  protective  power  may  be  regarded  as  proven  beyond  peradventure. 

While  a  very  considerable  reduction  of  the  mortality  of  dysentery  has 

*  "Vaccination  ^nd  Serum  Therapy  against  the  Bacillus  of  Dysentery.  An  Experimental  Study." 
By  Frederick  P.  Gay,  "  University  of  Pennsylvania  Medical  Bulletin,"  November,  1902. 


92  INFECTIOUS  DISEASES 

appeared  to  result  in  Japan  and  Russia,  from  32  to  12,  9  and  even  four  per 
cent.,  the  results  thus  far  obtained  in  this  country  have  not  been  suffi- 
cient to  justify  any  conclusions  as  to  the  efficiency  of  sera  although  they 
show  it  to  be  harmless  even  in  the  case  of  little  children. 

Chronic  Dysentery. 

Any  one  of  the  forms  of  dysentery  described  may  become  chronic,  but 
bacillary  dysentery  is  the  more  usual  form. 

Morbid  Anatomy. — All  the  lesions  described  as  occurring  in  the  dif- 
ferent varieties  of  dysentery  may  be  present.  The  most  common  is  ulcera- 
tion, which  is  variously  extensive  and  exhibits  also  efforts  at  healing.  On 
the  other  hand,  cases  of  chronic  dysentery  are  met  with  in  which  there  are 
no  ulcers  whatever.  The  coats  of  the  bowel  are  thickened,  especially  the 
submucosa  and  the  muscularis,  while  patches  of  black  and  slate-gray  dis- 
coloration are  scattered  through  it,  the  resuit  of  blood  extravasation  and 
disintegration.  Puckering,  pseudopolyposis,  and  cystic  degeneration  may 
be  present  as  described  under  Morbid  Anatomy  of  bacillary  dysentery. 

Treatment. — The  patient  should  be  put  to  bed  on  a  diet  easy  of  assimi- 
lation and  furnishing  a  minimum  of  waste.  Its  quantity  should  be  just 
what  is  needed  and  no  more.  From  what  has  been  said  it  may  be  inferred 
that  we  have  little  confidence  in  methods  of  treatment,  the  object  of  which 
is  to  get  remedies  to  the  diseased  bowel  by  way  of  the  mouth.  Bismuth  in 
large  doses,  iodoform,  and  even  nitrate  of  silver  may,  however,  be  tried  for  the 
purpose.  One-half  to  i  dram  (2  to  4  gm.)  of  bismuth  should  be  given  at  a 
dose,  so  that  from  12  to  15  drams  (48  to  60  gm.)  are  administered  in  the 
course  of  a  day.     Iodoform  may  be  given  as  above  directed. 

The  topical  treatment  of  chronic  dysentery  by  way  of  the  rectum  is  that 
on  which  most  reliance  is  placed  at  the  present  day.  Its  object  is  to  get 
remedies  to  the  diseased  part.  To  this  end  they  are  dissolved  and  their 
solutions  are  introduced  into  the  lower  bowel.  Nitrate  of  silver  is  the  favor- 
ite remedy,  but  alum,  sulphate  of  zinc,  sulphate  of  copper,  and  acetate  of 
lead  are  also  used  in  the  same  doses.  Twenty  to  30  grains  (1.3  to  2  gm.) 
are  dissolved  in  a  pint  (1/2  liter)  of  water,  and  from  3  to  6  pints  (1.5  to  3 
liters)  are  injected  at  one  time  through  a  long  tube  gently  introduced  well 
up  into  the  bowel,  but  at  the  onset  weaker  solutions  and  smaller  quantities 
are  injected.  The  patient  shovdd  be  placed  on  his  back  \vith  the  hips  ele- 
vated by  a  pillow,  so  that  there  may  be  the  cooperation  of  gravity.  The 
treatment  is  sometimes  painful.  More  may  be  expected  from  the  irriga- 
tion of  the  colon  by  lilce  solutions,  through  an  appendiceal  fistula. 

THE  PLAGUE.  1 

Synonyms. — The  Bubonic  Plague;  Oriental  Plague;  Black  Death;  Black 
Plague;  Pestis  Hominis. 

Definition. — The  plague  is  a  febrile  infectious  disease,  characterized  by  a 
tendency  to  buboes  or  carbuncles,  in  addition  to  the  usual  phenomena  of 
the  typhoid  state. 

'For  an  admirable  series  of  papers  on  the  Plague  see  "British  Med.  Jour.,"  October  27,  1900;  also, 
"Bubonic  Plague."  by  Simon  Flexner,  "University  of  Pennsylvania  Medical  Bulletin,"  November,  1902. 


THE  PLAGUE  93 

Etiology. — The  epidemic  of    1894  gave  the  opportunity  of  isolating 

the  specific  germ  bacillus  pesiis  of  plague  which  was  discovered  by 
Kitasato  and  later  by  Yersin.  It  is  a  short  rod  with  rounded  ends, 
and  resembles  the  bacillus  of  chicken  cholera.  It  is  found  in  the  blood, 
glands,  and  other  viscera,  and  in  no  other  disease  excepting  the  plague. 
It  is  comparatively  easily  isolated  from  the  blood  and  it  becomes  an 
important  aid  to  diagnosis  in  those  cases  where  the  rapidit}'  of  the  dis- 
ease does  not  permit  the  development  of  other  distinctive  symptoms. 
Obtained  in  pure  cultures,  it  can  produce  in  inoculated  animals  the 
same  effects  as  in  human  beings.  Filth  is  a  potent  predisposing  cause, 
as  the  description  of  Aoyoma,  who  was  a  member  of  Kitasato's  expedition 
and  himself  fell  a  victim,  vividly  portrayed.  The  rat  and  the  ground 
squirrel  are  the  means  of  transmission  from  house  to  house,  while  man  in 
his  travels  is  the  agent  of  transmission  through  long  distances.  The  rat  is 
the  subject  of  plague.  The  fleas  which  infect  its  body  become  infected, 
they  in  turn  bite  an  uninfected  individual  thus  transmitting  the  disease. 

Plague  is  a  disease  of  hot  countries  and  of  hot  seasons,  but  it  may  break 
out  in  midwinter.  The  disease  is  kept  alive  by  plague  in  rats  and  sporadic 
cases  in  man.  It  attacks  all  ages  and  classes,  but  the  poor,  who  live  in 
crowded  quarters  and  amid  unfavorable  hygienic  surroundings,  are  its 
favorite  victims.  -  Small  animals,  such  as  monkeys,  squirrels,  rats,  and 
mice  die  in  great  numbers  during  epidemics,  and  seem,  indeed,  to  be 
the  first  victims.  In  this  respect  it  is  similar  to  anthrax  and  tetanus. 
Persons  who  live  in  upper  stories  are  less  frequently  attacked  than  those  who 
live  on  the  ground  floor.  The  boating  population  of  China,  which  lives 
mostly  on  the  water,  is  comparatively  exempt.  Body  linen,  bed  clothing, 
carpets,  rags,  and  baggage  are  frequent  media  of  communication. 

On  the  other  hand,  virulent  as  is  the  plague,  its  contagium  appears  to 
be  more  controllable  than  that  of  such  diseases  as  smallpox  and  scarlet  fever, 
as  evidenced  by  the  fact  that  with  ordinary  cleanly  precautions  few  physi- 
cians, nurses,  or  others  attendant  on  the  sick  acquire  the  disease,  and  even 
those  employed  to  guard  and  disinfect  houses  commonly  escape.  In  the 
epidemic  in  Canton,  during  which  upward  of  30,000  Chinese  died,  not  one 
of  300  American  and  English  residents  was  affected.  It  is  of  the  greatest 
importance  to  know  that  a  considerable  interval  may  exist  between  the 
importation  of  an  infection  and  the  outbreak  of  an  epidemic. 

Morbid  Anatomy. — There  is  no  morbid  anatomy  to  the  plague  beyond 
the  buboes  and  internal  suppurating  processes,  which  seem  to  be  essential 
symptoms,  the  cutaneous  and  other  hemorrhages,  and  the  various  tissue 
alterations  that  attend  high  fevers  generally.  The  liver  and  kidneys  are 
congested  and  the  spleen  is  enlarged  to  two  or  three  times  its  normal  size. 

Varieties  of  the  Disease. — Four  principal  forms  are  easily  separated: 
(i)  Pestis  minor,  abortive  or  larval  form,  which  commonly  appears  before 
the  outbreak  of  an  epidemic.  It  is  also  the  form  which  is  endemic.  It  is 
characterized  by  moderate  swelling  of  the  lymphatics,  little  fever  or  other 
constitutional  disturbance,  and  usually  terminates  favorably  at  the  end  of 
about  two  weeks.  (2)  The  bubonic  form  is  the  more  common  severe  epi- 
demic form —  the  malignant  adenitis  of  James  Cantlie.  Until  recently  all 
plague  was  called  "bubonic,"  but  it  is  now  known  that  only  about  70  per 


94  INFECTIOUS  DISEASES 

cent,  of  cases  are  accompanied  by  glandular  enlargement.  (3)  The  septi- 
cemic form,  also  known  as  toxic,  fulminant,  or  siderans,  a  severe  form,  in 
which  death  may  occur  in  twenty-four  hours  with  associated  hemorrhages, 
but  in  which  glandular  enlargement  is  slight;  the  time  between  the  onset  and 
the  fatal  termination  being  too  short  to  allow  its  development.  Prostration 
is  extreme.  (4)  The  pneumonic  form,  in  which  no  buboes  appear  on  the 
surface,  but  the  force  of  the  disease  is  spent  on  the  lungs,  the  sputum 
swarming  with  bacilli.     The  processes  in  the  latter  organs  are  septicemic. 

Symptoms. — Of  the  bubonic  or  ordinary  form. — A  period  of  incubation 
of  from  two  to  seven  days  usually  precedes  the  appearance  of  the  intense 
weakness  which  is  one  of  the  earliest  characteristic  symptoms  of  the  plague. 
A  second  period  or  period  of  prodrome  maj'  follow  the  incubation,  though 
it  is  not  common.  It  is  short,  from  a  few  hours  to  a  couple  of  days,  and 
includes  headache,  prostration,  marked  nausea,  vomiting,  vertigo,  and 
rarely  lumbar  pain.  A  chill  is  not  usual,  but  there  may  be  chilliness,  after 
which  the  usual  fever  of  the  infectious  diseases  sets  in  with  great  severity 
and  with  its  accompaniments,  among  which  severe  headache,  backache, 
delirium,  and  the  typhoid  state  are  conspicuous.  The  temperature  rises 
rapidly  to  102°  and  104°  F.  (39°  and  40°  C.)  and  even  higher.  The  pulse 
ranges  from  90  to  120,  of  fair  volume,  often  dicrotic.  Before  the  fever  sets 
in  great  weakness  is  manifest.  The  patient  reels  like  a  drunkard,  with 
weakness  and  vertigo.  He  breathes  hurriedly  and  is  anxious,  restless,  and 
depressed.  The  features  are  drawn  and  haggard.  Petechiae,  vibices — 
the  plague-spots  of  the  Bible — albuminuria,  hematuria,  and  even  hema- 
temesis  may  be  included.     Slight  enlargement  of  the  spleen  is  present. 

Pre-eminently  characteristic  is  the  bubo  or  suppurating  gland.  It 
appears  on  the  second  or  third  day,  if  the  patient  live  to  it.  It  occurs  in 
order  of  frequency  in  the  glands  of  the  groin,  the  armpit,  the  neck,  or  in  the 
popliteal  region.  It  commonly  reaches  the  size  of  a  walnut  or  egg,  when  it 
ruptures,  if  not  opened  with  the  lance.  It  may,  however,  subside  mthout 
discharging.  Suppuration  is  a  desirable  termination.  It  is  painful  and 
tender,  as  buboes  commonly  are.  Coincident  with  the  appearance  of  the 
bubo  the  fever  subsides,  a  profuse  sweat  breaks  out,  and  the  pulse  falls  to 
90  or  100.  In  addition  to  the  bubo,  carbuncles  may  also  be  present  in  the 
lower  extremities,  the  buttocks,  or  in  the  neck.  In  some  epidemics  hemor- 
rhages are  common,  and  even  the  buboes  may  contain  blood. 

In  the  pneumonic  form  there  are  the  usual  symptoms  of .  pneumonia, 
chill,  high  fever,  severe  pain  in  the  side,  dyspnea,  cough,  rusty  sputum,  and 
physical  signs  of  consolidation,'  and  marked  prostration.  Bacilli  may  be 
found  in  the  sputum;  and  this  form  is  infecti^•e  through  the  sputum. 

In  the  septicemic  form  the  patient  is  stricken  by  a  virulent  poison  and 
the  prostration  is  extreme.  The  glands  are  enlarged,  but  there  are  no 
buboes.  The  enlargement  is  slight  and  may  only  be  detected  at  necropsy, 
but  it  is  general.  Hemorrhages  from  the  nose,  bowel,  and  kidney  are  most 
frequent  in  this  form.  Apyrexia  is  not  uncommon,  fever  reaction  being 
impossible  because  of  the  extreme  depressing  influence  of  the  disease. 
The  delirium  is  of  the  typhoid  type. 

Diagnosis. — In  its  fever,  its  intense  prostration,  its  petechise  and  vibices 

1  For  reports,  see  "Sajous"  Annual.'*  vol.  v.,  rpoo,  article  "Plague." 


THE  PLAGUE  95 

of  the  early  stages  the  plague  resembles  typhus.  No  other  fever  is  charac- 
terized by  such  intense  prostration.  The  bubo  and  the  carbuncle  seem  to  be 
the  distinctive  signs,  although  they  are  said  to  be  sometimes  absent  in  the 
milder  cases  of  a  declining  epidemic,  as  well  as  in  the  intense  pestis  siderans. 
The  bacillus  may  be  isolated  from  the  blood  in  suitable  cultures  and  should 
be  thus  sought  in  doubtful  cases.  The  diazo  reaction  of  the  urine  is  usually 
absent. 

Prognosis. — The  plague  is  said  to  be  the  most  fatal  of  all  diseases,  70 
to  90  per  cent,  perishing,  districts  and  towns  being  half  depopulated,  while 
whole  families  have  been  annihilated.  Death  occurs  from  the  second  to  the 
fourth  day,  and  if  recovery  take  place  it  is  delayed  by  the  slowly  healing 
buboes  and  carbuncles.     These  may,  however,  heal  rapidly. 

Treatment. — Prophylaxis  is  the  most  important  part  of  the  treatment, 
all  rats  must  be  exterminated — no  rat,  no  plague.  Cleanly  habits  which 
insure  absence  of  the  infected  flea  from  the  body  are  necessar\-.  Free 
stimulation,  nutritious  food,  as  in  the  most  adynamic  forms  of  typhus  and 
typhoid  fevers  together  is-ith  cool  baths  to  combat  the  fever,  are  the  measures 
indicated.  Antiseptic  treatment  of  the  buboes  and  abscesses  should  be 
practised,  and  raax  shorten  the  duration  of  these  plagues  of  the  skin  as 
compared  with  the  older  treatment.  Morphin  should  be  given  to  produce 
sleep  and  relieve  pain.  Kitasato's  general  directions,  so  often  quoted,  can 
hardl}'  be  improved.     They  are  as  follows : 

"The  disease  prevails  under  faulty  hygienic  conditions;  it  is,  therefore, 
urged  that  general  hygienic  conditions  be  carried  out.  Proper  receptacles 
for  sewage  should  be  pro^aded,  a  pure  water  supply  afforded,  and  streams 
cleansed;  all  persons  sick  of  the  disease  isolated;  the  furniture  of  the  sick- 
room washed  with  a  two  per  cent,  carbolic  solution  in  milk  of  lime;  old 
clothes  and  bedding  are  to  be  steamed  at  212°  F.  (100°  C.)  for  at  least  one 
hovir,  or  exposed  for  a  few  hours  to  sunlight.  If  feasible,  all  infected  articles 
should  be  biimed.  The  evacuations  of  the  sick  are  to  be  mixed  with  milk 
of  lime,  and  those  who  die  of  the  disease  are  to  be  buried  at  a  depth  of 
three  meters  (about  12  feet)  or,  preferably,  cremated.  After  recovery- 
the  patient  is  to  be  kept  in  isolation  at  least  one  month.  All  contact 
with  the  sick  is  to  be  avoided,  and  great  care  exercised  with  reference 
to  food  and  drink."  Instead  of  carbolic  acid  and  milk  of  lime  for  the 
disinfection  of  buildings,  Haffkine  suggests  sulphuric  acid  in  the  proportion 
of  I  to  200  of  water. 

Serum  Therapy. — Preventive  inoculation  was  introduced  by  Yersin, 
Calmette,  and  BorreU  conjointlj-  in  1895.  Dead  cultures  of  plague  bacilli 
were  injected  subcutaneously  into  rabbits  and  guinea-pigs  and  found  to 
convey  a  certain  degree  of  immunity  against  plague.  Haffkine  extended 
this  method  of  preventive  inoculation  to  man.  The  dead  bacilli,  suspended 
in  bouillon,  were  injected  subcutaneously,  first  in  lower  animals,  notably 
monkeys,  with  the  result  of  protecting  them  against  subsequent  inoculation 
with  virulent  plague  bacilli;  then  upon  human  beings  in  India  and  China. 
Haffkine's  vaccine,  or  prophylactic,  is  a  solution  of  toxic  substances  produced 
during  the  growth  of  plague  bacilli,  and  should  not  be  spoken  of  as  a  serum 
as  no  animals  are  used  in  its  preparation. 

The  results  of  these  inoculations  are  more  definitelv  stated  in  the  fol- 


96  IXFECTIOUS  DISEASES 

lomng  conclusions  reached  by  the  Indian  Commission:  "(i)  Inoculation 
sensibly  diminishes  the  incidence  of  plague  attacks  on  the  inoculated  popu- 
lation, but  the  protection  which  it  affords  against  attacks  is  not  absolute;  (2) 
Inoculation  diminishes  the  death-rate  among  the  inoculated  population. 
This  is  due  not  only  to  the  fact  that  the  rate  of  attack  is  diminished,  but 
also  to  the  fact  that  the  fatality  of  the  attacks  is  diminished;  (3)  Inoculation 
does  not  appear  to  confer  any  great  degree  of  protection  within  the  first  few 
days  after  it  has  been  performed;  (4)  Inoculation  confers  a  protection 
which  certainly  lasts  for  some  considerable  number  of  weeks.  It  is  pos- 
sible that  the  protection  lasts  for  a  number  of  months.  The  maximum 
duration  of  protection  can  only  be  determined  by  further  observation; 
(s)  The  varying  strengths  of  the  vaccine  employed  have  apparently  had  a 
great  effect  upon  the  results  which  have  been  obtained  from  inoculation. 
There  seems  to  be  a  definite  quantity  of  vaccinating  material  which  gives  the 
maximum  amount  of  protection ;  and  provided  that  this  quantum  can  be  in- 
jected in  one  dose,  and  provided  also  that  the  protection  turns  out  to  be  a 
lasting  one,  reinoculation  might  with  advantage  be  dispensed  with."' 
Colonel  Bauner,  Director  of  the  Plague  Laboratory  and  successor  of  Haffkine, 
devised  a  number  of  methods  by  which  the  vaccine  could  be  produced  in  a 
purer  state,  uncontaminated  by  other  bacteria  which  had  been  productive 
of  serious  complications. 

As  contrasted  -wdth  preventive  treatment  Yersin's  antipest  serum^  and 
Lustig's  serum  are  intended  for  curative  purposes,  after  the  manner  of  diph- 
theritic antitoxin.  Yersin's  is  not  only  curative  but  antitoxic  and  may  be 
employed  at  any  stage.  It  is  prepared  by  injecting  the  horse,  first,  with 
dead  and  then  with  living  plague  cultures.  The  serum,  to  insure  sterility,  is 
heated  to  140°  F.  (60°  C.)  before  being  sent  out.  Lustig's  senmi  is  pre- 
pared from  the  horse  after  injection  with  a  substance  derived  from  bacilli  bj^ 
treatment  with  alkali  and  precipitation  bj'  hydrochloric  acid. 

Small  animals  have  been  rescued  from  infection  by  plague  germs  by 
Yersin's  serum,  but  in  human  beings  the  results  have  been  less  conclusive, 
Arnold'  claiming  that  it  reduced  the  mortaHty  of  cases  70  to  90  per  cent., 
while  Cremow*  denies  any  therapeutic  value.  Calmette  and  Salimbini" 
claim  to  have  shown  from  their  observations  and  experiments  during  the 
plague  epidemic  in  Oporto,  Portugal,  that  much  larger  doses  of  the  antipest 
serum  may  be  used,  and  are  sometimes  demanded,  than  have  heretofore 
been  deemed  sufficient.  The  use  of  a  preliminary  immunizing  dose  of 
antipest  serum,  followed  by  an  injection  of  a  dose  of  Haffkine's  prophy- 
lactic, removed  the  element  of  danger  and  conferred  an  immunity  of  prob- 
ably longer  duration  than  would  be  produced  by  the  exhibition  of  the  serum 
alone. 

Notwithstanding  the  seeming  inconclusiveness  of  these  observations, 
the  Indian  Commission  reports  that  "though  the  method  of  serum  therapy 
as  applied  to  plague  has  not  been  crowned  with  a  therapeutic  success  in 
any  way  comparable  to  that  obtained  in  the  treatment  of  diphtheria,  never- 


>See  Simon  Flexner's  paper  on  "Bubonic  Plague,  its  Nature.  Mode  of  Spread,  and  Clinical  Mani- 
festations."    "University  of  Pennsylvania  Med.  Bulletin,"  November,  190s. 

•  "Sajous'  Annual."  vol.  v.,  p.  491. 
^  "Med.  News,"  January  I.  1898. 

*  "London  Lancet."  May  6,  1899. 

'  Calmette  and  Salimbini."  Philadelphia  .Medical  Journal."  Feb.  10,  1900. 


MEASLES  97 

theless,  the  method  of  serum  therapy  is  in  plague,  as  in  other  infectious 
diseases,  the  only  one  which  holds  forth  the  prospect  of  success." 

Walter  Wyman,  Supervising  Surgeon-General  United  States  Marine 
Hospital  service,  has  directed  that  between  i6o  and  200  c.c.  of  antipest 
serum  should  be  given  during  the  first  48  hours  of  the  disease.  In  severe 
cases,  20  to  40  c.c.  of  this  amount  should  be  injected  into  a  vein.  In 
immunizing  with  Yersin's  serum  inject  5  to  10  c.c.  every  15  days.  In  case 
the  Haffkine  prophylactic  cannot  be  administered  on  account  of  exposure  to 
the  disease,  the  mixed  plan  of  immunization  may  be  used.  This  consists 
of  giving  5  to  10  c.c.  of  antipest  serum,  and,  three  days  later,  i  c.c.  of  the 
Haffkine  prophylactic' 

MEASLES. 
Synonyms. — Rubeola;  Morbilli. 

Definition. — Measles  is  an  acute,  highly  contagious  disease,  character- 
ized especially  by  a  mottled  eruption  and  naso-bronchial  catarrh. 

Etiology. — Measles  is  in  all  probability  due  to  a  micro-organism,  which, 
however,  has  not  as  yet  been  isolated.  Anderson  has  shown  experimentally 
that  the  disease  may  be  transmitted  to  monkeys  by  injecting  the  blood, 
the  expectoration,  and  nasal  and  conjunctival  mucus  of  cases  of  measles, 
and  that  it  cannot  be  transmitted  by  injecting  the  desquamating  skin. 
Whatever  the  infecting  agent  may  be,  it  is  very  unerring,  since  the  disease 
is  more  unfailingly  communicated  to  those  unprotected  by  previous  attacks 
than  is  scarlet  fever.  The  contagium  has  been  transmitted  by  the  inocula- 
tion of  morbillous  blood  and  nasal  mucus,  and  it  is  most  active  when  the 
breath  is  its  medium.  It  is  communjcable  by  a  third  party  and  by  fomites; 
though  more  active  and  unfailing  than  the  contagium  of  scarlet  fever,  it 
is  less  so  than  that  of  smallpox.  It  is  not,  however,  so  tenacious  as  these. 
Measles  is  a  disease  of  childhood,  but  adults  often  get  it,  and  that  very 
severely.  No  age  is  exempt.  Repeated  attacks  are  possible,  but  as  other 
eruptive  affections  resemble  it  and  diagnosis  is  often  careless,  some  of  the 
repeated  attacks  may  be  thus  explained.  It  is  milder  and  rarer  in  suck- 
lings under  six  months.  Further,  the  studies  of  Carr,  Mayo  and  Edw. 
Graham  go  to  show  that  the  new-born  are  very  slightly  susceptible.  Six 
months  would  appear  to  be  the  age  at  which  susceptibility  begins,  although 
Bartsch  reports  a  case  of  intrauterine  infection.  Finally  the  age  during 
which  the  disease  is  more  commonly  contracted  is  from  one  to  five  years. 

Morbid  Anatomy. — There  is  no  essential  morbid  anatomy  of  measles 
beyond  the  nasal  and  bronchial  catarrh,  and  the  signs  of  these  generally 
disappear  with  death.  When  death  occurs  it  is  usually  the  result  of  com- 
plications, and  the  morbid  anatomy  of  such  is  present.  The  most  frequent 
complication  is  bronchopneumonia.  There  may  be  lobar  pneumonia,  and 
among  the  morbid  phenomena  are  to  be  included  sometimes  those  of  collapse 
of  the  lung.  In  rare  instances  of  hemorrhagic  or  "black"  measles  there  is 
the  usual  discoloration  of  hemorrhagic  extravasation.  Rarely  also  the 
morbid  states  of  intestinal  catarrh  are  found. 


'Philadelphia  Medical  Journal,"  February  lo,  1900, 


98 


INFECTIOUS  DISEASES 


Symptoms. — The  period  of  incubation  of  measles  varies,  but  is  com- 
monly between  seven  and  14  days.  Rarely  it  is  a  day  or  two  longer.  A 
prodrome,  if  present,  in  measles  is  of  short  duration.  It  may  be  manifested 
by  sneezing,  fretfulness,  chilliness,  and  feverishness;  or,  if  the  child  is  old 
enough  to  express  itself,  by  headache.  Then  comes,  on  the  first  day,  the 
initial  or  prodromal  fever,  a  peculiarity  of  which  is  a  remission  on  the  third 
day.  This  is  shown  by  the  appended  cut  from  Eichhorst.  But  very  early, 
and  even  almost  suddenly,  coryza,  with  red  and  watery  eyes,  and  photo- 
phobia present  themselves,  closely  followed  by  troublesome  cough  and  cor- 
responding feverishness  reaching  103°  and  104°  F.  (39.4°  and  40°  C). 
Much  less  frequently  than  in  scarlet  fever  is  there  vomiting,  and  the  tongue 
is  apt  to  be  furred.  The  cough  is  sometimes  croupy.  Convulsions  very 
rarely  usher  in  the  disease.  In  the  very  beginning  Koplik's  spots  are 
present. 


Fig.  is. — Temperature  Chart  of  Measles. — {Eichhorst.) 


On  the  fourth  day  from  the  onset  the  eruption  makes  its  appearance. 
With  the  eruption  the  fever  usually  increases  for  24  to  48  hours.  It 
appears  first  in  the  face  in  the  form  of  papules  and  blotches,  which  coalesce 
more  or  less  imperfectly,  leaving  sometimes  islands  of  white  skin  between 
them.  Sometimes  after  coalescence  the  eruption  quite  resembles  that  of 
scarlet  fever.  Under  any  circumstances  the  boundary  between  the  erup- 
tion and  the  sound  skin  is  uneven  and  crescentic.  The  eruption  is  somewhat 
raised  above  the  surface,  and  the  whole  effect  is  to  make  the  face  appear 
swollen.  This  elevation  of  surface  at  times  becomes  distinctly  papular  and 
even  shot-like,  resembling  closely  the  papular  stage  of  smallpox.  In  fact, 
this  appearance  has  quite  often  lead  to  a  diagnosis  of  smallpox,  which  12 
hours  later  had  to  be  withdrawn.  From  the  face  the  eruption  spreads  to 
the  neck,  thorax,  abdomen,  and  extremities.     It  is  bright  red,  as  a  nile 


The  Pathognomonic  Sign  of  JIeaslics  (^Kopuk's  Spots). 

Fig.  I. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  show- 
ing the  isolated  rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  nor- 
mally colored  mucous  membrane. 

Fig.  2. — Shows  the  partially  diftuse  eruption  on  the  mucous  membrane  of  the  checks 
and  lips  ;  patches  of  pale  pink  interspersed  among  rose-red  patches,  the  latter 
showing  numerous  pale  bluish-white  spots. 

Fig.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  tlie  measles 
spots  completely  coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish- 
white  specks.  The  exanthema  on  the  skin  is  at  this  time  generally  fully  de- 
veloped. 

Fig.  4. — Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  mem- 
brane normal  in  hue.  Mmnie  yellow  poiii/s  are  surrounded  by  a  red  area.  Al- 
ways discrete. 

— {^From  ^'■Medical  -Wr^'j.**) 


MEASLES  99 

disappears  on  pressure.  Sometimes,  however,  even  in  mild  cases,  there 
are  petechise,  and  in  malignant  cases  the  extravasations  are  extensive.  At 
the  same  time,  the  mouth  and  fauces  are  bright  red  in  color  and  the  rash 
is  present  in  these  positions.  Not  infrequently  there  is  diarrhea,  as  though 
the  eruption  extended  throughout  the  entire  mucous  tract  as  well  as  over 
the  skin.  At  the  maximum  of  the  eruption  there  may  be  slight  swelling 
of  the  cervical  lymphatic  glands.  At  the  end  of  two  or  three  days  after  its 
appearance  the  rash  fades  gradually,  first  from  the  situations  in  which  it 
appeared  earliest,  and  a  fine,  branny  desquamation  occurs,  easily  over- 
looked. The  fading  takes  place  in  the  order  of  invasion.  The  typical 
rash  may  be  accompanied  by  sudamina. 

In  1896  Henry  Koplik'  called  attention  to  a  sign  that  has  been  found 
of  real  value  in  the  diagnosis  of  measles.  It  is  the  appearance,  on  the  first 
day  of  invasion,  on  the  buccal  and  labial  mucous  membrane,  of  a  scattered 
eruption  of  minute  bluish-white  specks  each  surrounded  by  a  bright  red 
areola.  They  have  been  found  45  times  in  52  cases  and  31  times  in  32  cases. 
They  may  appear  four  days  before  the  characteristic  rash,  and  rarely 
before  the  fever.  The  spots  somewhat  resemble  those  of  thrush,  from 
which  they  are  distinguished  by  their  roundish  shape  and  their  color,  as 
contrasted  with  the  more  yellomish  center  of  those  of  thrush  and  by  the  fact 
that  scrapings  do  not  show  the  oidium  albicans.  While  thoroughly  discrete 
in  the  beginning,  later  in  the  disease  the  spots  may  coalesce,  and  the  char- 
acters of  a  discrete  eruption  or  spotting  disappear,  producing  an  intense 
general  redness,  "which  is  simply  dusted  over  with  myriads  of  these  bluish- 
white  specks."  They  cannot  be  wiped  off,  but  the  whitish  portion  can  be 
removed  by  forceps  without  causing  pain  or  bleeding.  They  consist  of 
thick  layers  of  epithelium  in  a  state  of  partial  fatty  degeneration.  The}' 
require  a  good  light  for  their  demonstration.     (See  plate  opposite.) 

The  other  symptoms  described  continue  until  the  eruption  begins  to 
fade —  that  is,  on  the  fifth  or  sixth  day,  when  they  abate.  The  cough, 
often  hangs  on  quite  stubbornly,  especially  in  tuberculous  children,  and 
sometimes  even  persists  as  the  catarrhal  symptom  of  a  tuberculosis,  the 
development  of  which  seems  peculiarly  favored  by  the  disease.  Hence,  the 
cough  of  measles  should  never  be  slighted,  and  early  exposure  to  cold  and 
dampness  should  be  guarded  against. 

It  has  already  been  intimated  that  a  malignant  form  of  measles  some- 
times occurs,  called  also  "black"  measles,  which  is  very  serious — often, 
indeed,  fatal.  It  is  generally  epidemic,  occurs  in  institutions  and  camps, 
and  its  presence  is  characterized  by  subcutaneous  extravasations  of  blood 
and  hemorrhages  from  the  mucous  membranes.  Hoarseness  is  especially 
found  in  black  measles,  as  contrasted  with  black  smallpox. 

Complications  and  Sequelae. — These  furnish  most  that  is  serious  in 
the  disease,  and  of  them  the  most  frequent  and  dangerous  is  broncho- 
pneumonia, the  bronchitis  creeping  into  the  smaller  air-tubes.  The 
occurrence  of  this  form  of  pnetunonia  seems  to  be  favored  by  bad 
hygiene.  Collapse  of  the  lung  is  also  prone  to  occur,  caused  by  an  ac- 
cidental valve-like  plug  of  secretion.  Bronchopneumonia  is  recognized 
by  the  persistent  and  aggravated  cough,  the  continued  high  temperature, 

^  "Archives  of  Pasdiatrics,"  December,  1896,  and  "Medical  Record,"  April  9,  1898, 


lOU  INFECTIOUS  DISEASES 

and  physical  signs  of  a  circumscribed  pneumonia.  More  rarely  lobar 
pneumonia  supervenes  and  is  recognized  even  more  easily.  In  view  of  these 
possible  complications,  frequent  physical  examinations  of  the  chest  should 
be  made. 

Among  the  complications  may  be  mentioned  laryngitis,  catarrh  of  the 
middle  ear  leading  to  suppuration  and  perforation  of  the  drum,  and  chronic 
or  intractable  ophthalmic  trouble.  Ulcerative  and  even  gangrenous  stoma- 
titis or  cancrum  oris  are  met  under  unfavorable  hygienic  conditions;  also 
ulcerative  vulvitis. 

Nephritis,  although  not  often  a  complication  of  measles,  does,  however 
occur.  Tuberculosis  has  long  been  recognized  as  a  sequel  of  measles,  yet  it 
is  not  a  very  frequent  one.  Any  of  the  varieties  of  pulmonary  tuberculosis 
may  be  present.  Even  nervous  lesions  are  reported,  such  as  hemiplegia, 
paraplegia,  neuritis,  and  myelitis.' 

Diagnosis. — Measles  is  easy  of  diagnosis;  but  the  physician  must  not 
be  too  precipitate.  Allusion  has  already  been  made  to  the  possibility  of 
mistaking  it  for  smallpox,  on  account  of  the  similarity  of  the  eruption  in  the 
early  stage,  an  error  which  a  few  hours'  delay  wotdd  have  averted.  Koplik's 
spots  should  be  helpful  here,  as  they  appear  at  least  twenty-four  hours 
before  the  skin  eruption.  From  scarlet  j ever  there  is  sometimes  difRcvdty, 
as  there  is  occasionally  slight  sore  throat  and  the  eruption  may  be  diffuse, 
while  the  difficulty  is  increased  if  there  be  glandular  swelling  in  measles; 
but  the  catarrhal  symptoms  of  measles  are  essential  to  it.  The  time  of 
appearance  of  the  rash  is  much  later  in  men.  In  measles  there  is  no  leu- 
cocytosis.  In  scarlet  fever  there  is  leucocytosis.  The  mildest  cases  are 
probably  those  that  give  most  trouble.  The  distinction  between  measles 
and  rubella  is  sometimes  more  difficult,  but  this  wUl  be  considered  when 
treating  of  rubella. 

Typhus  fever  and  measles  have  been  confounded,  and  it  must  be  admitted 
that  in  the  asthenic  variety  of  measles  the  eruption  may  resemble  that  of 
typhus  fever.  It  will  be  remembered  that  the  eruption  of  typhus  is  de- 
scribed as  "rubeoloid."  Confusion  is  further  favored  by  the  fact  that  the 
eruption  occurs  at  about  the  same  time  in  each  disease. 

Prognosis. — The  vast  majority  of  eases  of  measles  get  well,  yet  measles 
is  not  the  slight  disease  it  is  often  considered.  In  epidemics  of  the  malignant 
form,  in  hospitals,  camps,  and  foundling  asylums,  that  death  occurs  as  a 
direct  result  of  the  disease.  In  these  the  mortality  is  sometimes  very  high. 
Epidemics  among  the  aborigines  in  North  and  South  America,  in  the  Maur- 
itius and  Feejee  Islands,  and  in  the  Confederate  Army  in  the  War  of  the 
Rebellion  in  America  were  of  signal  fatality.  Other  deaths  are  due  to 
complications,  especially  pneumonia.  Out  of  24  fatal  cases  collected  by 
Pott,  21  died  of  bronchopneumonia  and  pneumonia,  and  three  of  croup. 

Treatment. — After  surrounding  the  patient  by  a  uniformly  warm  tem- 
perature, best  secured  in  bed,  in  a  well  ventilated  room,  the  treatment  of 
measles  is  mainly  that  of  the  fever  and  the  cough.  The  former  is  sufficienth- 
treated  by  the  simple  diaphoretics  and  febrifuges,  such  as  citrate  of  potash 
and  sweet  spirit  of  niter,  or  tincture  of  aconite.     The  latter  is  efficient  and 

*  See  a  paper  hy  Imogene  Bassette  entitled  "The  Paralyses  in  Children  which  occur  during  and  after 
Infectious  Diseases,"  "Jour.  Nerv.  and  Ment.  Dig.,"  voL  xix.,  1902. 


RUBELLA  JOl 

tasteless.  The  coal-tar  derivatives,  acetanilid,  antipyrin,  thermol,  and 
phenacetin  may  be  used. 

The  cough  calls  for  positive  anodyne  measures,  of  which,  for  children, 
paregoric  is  the  best  because  the  safest.  Laudanum  or  deodorized  tincture 
of  opium  may  be  used  in  smaller  doses,  but  not  morphin.  It  is  best  to  pre- 
scribe the  opiate  separately  in  order  that  the  dose  may  be  decreased  or  in- 
creased at  will.  It  is  comparatively  rare  that  cool  sponging  is  needed  to 
reduce  the  temperature,  but  cold  water  drinking  should  be  allowed  ad  libitum. 
A  case  of  measles  under  our  care  received  the  cold  tub-bath  treatment 
under  the  impression  that  it  was  typhoid  fever.  The  rash  came  out  bril- 
liantly at  the  proper  time  and  the  case  did  splendidly.  Complications  should 
be  treated  as  they  arise.  Stimulants  and  tonics  are  necessary  in  the  ady- 
namic form.  When  the  cough  is  prolonged,  cod-liver  oil  is  a  valuable  remedy. 
Watchfulness  during  convalescence  is  more  important  than  is  supposed  by 
many,  and  carelessness  and  indifference  are  sometimes  responsible  for  un- 
fortunate results. 

It  occasionally  happens  that  the  eruption  is  "suppressed,"  or  its  appear- 
ance may  be  delayed.  Under  these  circumstances  the  hot  pack  is  ver\^ 
effectual.  The  child  is  wrapped  in  flannel  wrung  out  in  hot  water  and  then 
enveloped  in  a  mackintosh.  Copious  perspiration  soon  sets  in,  the  eruption 
appears,  and  general  reaction  begins. 

RUBELLA. 

Synonyms. — Rotheln;  Rubeola;^  German  Measles;  Rubeola  notha;  Epidemic 
Roseola;  False  Measles;  Hybrid  Measles;  Hybrid  Scarlet  Fever. 

Definition. — Rubella  is  a  mild,  acute,  contagious  disease,  characterized 
by  a  punctiform  rash  that  fuses  into  patches  less  plainly  crescentic  than  those 
of  measles.  There  is  often  slight  sore  throat,  more  rarely  mild  catarrhal 
symptoms,  and  trifling  fever.  Many  so-called  second  attacks  of  measles 
and  scarlet  fever  are  attacks  of  rubella. 

Etiology. — The  relation  of  the  disease  seems  rather  closer  to  measles 
than  scarlet  .fever,  and  may  be  said  to  bear  to  the  former  the  same  relation 
as  varicella  to  variola.  Though  contagious,  it  is  much  less  so  than  measles  or 
scarlet  fever.  It  affects  children  chiefly,  very  rarely  adults,  sucklings  less 
frequently  than  school  children,  because  the  latter  are  more  exposed  to  con- 
tagion. Isolated  cases  occur,  but  it  is  apt  to  prove  in  large  cities  epidemic. 
Such  epidemics  are  sometimes  widespread.  No  special  bacillus  has  as  yet 
been  isolated. 

Symptoms. — After  a  period  of  incubation  ranging  from  two  to  three  weeks, 
the  disease  sets  in,  as  a  rule,  with  no  distinctive  prodromal  symptoms 
prior  to  the  eruption.  There  may  be  chilliness,  moderate  muscular  pain, 
mild  catarrh,  and  slight  fever,  with  temperature  barely  reaching  ioo°  F. 
(37.8°  C),  for  a  day  or  two  previous  to  the  eruption.  Rarely  these  pro- 
dromal symptoms  may  be  prolonged  to  two,  three  or  even  four  days. 

More  frequently,  an  indistinct  macular  eruption  of  a  pale  rose  color  is 
the  first  symptom  noted.     The  papules  are  not  elevated,  and  vary  in  size 

J  It  is  unfortunate  that  the  Germans  have  selected  for  their  technical  term  for  this  affection  the  word 
Rubeola^  which  is  the  word  used  in  English  for  measles. 


102  INFECTIOUS  DISEASES 

from  a  pinhead  to  a  split  pea,  the  sfnaller  being  more  numerous,  much 
smaller  than  the  papules  of  measles.  They  may,  however,  fuse  and  form 
large,  irregular  patches,  with  little  or  no  disposition  to  form  small  crescent- 
shaped  groups  like  those  of  measles.  The  rash  may  appear  as  late  as  the 
second  dajs  rarely  on  the  third,  after  the  indistinct  symptoms  of  invasion 
mentioned. 

Two  types  of  the  spread  of  the  eruption  are  possible.  In  the  one  it 
appears  almost  simultaneously  all  over  the  body,  reaching  its  maximum  by 
the  second  A&y,  after  which  it  rapidly  fades.  In  the  second  mode  of  invasion 
the  rash  appears  first  on  the  face,  and  extends  rapidly  thence  all  over  the 
body,  reaching  the  hands  and  feet  last,  and  beginning  to  fade  on  the  face  and 
trunk  before  attaining  its  maximum  on  the  extremities,  or  even  before  it 
appears  there  at  all.  Thus  it  has  a  wave-like  course,  reaching  its  maximtmn 
in  twenty-four  hours,  when  it  begins  to  decline  rapidly.  It  is,  therefore,  of 
shorter  duration  than  the  eruption  either  of  measles  or  of  scarlet  fever.  It 
may  terminate  in  a  brannj^  desquamation,  less  evident  even  than  that  of 
measles. 

The  most  constant  symptom  after  the  eruption  is  the  sore  throat.  It 
varies  in  severity,  but  is  for  the  most  part  mild,  never  becoming  ulcerative. 
It  is  really,  perhaps,  the  eruption  in  the  throat.  Somewhat  less  constant 
than  the  sore  throat,  though  varying  somewhat  in  different  epidemics,  is 
swelling  oj  the  lymphatic  glands  of  the  neck,  especially  the  superficial  cervi- 
cal, postcervical,  and  postauricular  glands.  This  swelling  is  present  dur- 
ing the  eruptive  stage  and  maj'  occur  even  earlier.  Its  possible,  though 
rarer,  occurrence  in  measles  and  scarlet  fever  also  is  to  be  remembered. 

The  remaining  symptoms  of  rubella  are  not  marked  nor  distinctive. 
There  is  little  or  no  constitutional  disturbance,  and,  as  already  mentioned, 
rarely  any  fever  above  ioo°  F.  (37.8°  C),  although  102°  F.  (38.9°  C.)  and 
even  103°  F.  (39.4°  C.)  have  been  noted.  There  may  be  slight  catarrh, 
watering  of  the  eyes,  and  running  at  the  nose,  all  much  less  marked  than  in 
measles.  There  are  no  complications,  as  a  rule,  though  albuminuria, 
nephritis,  pneumonia,  colitis,  and  icterus  have  been  reported,  but  it  would 
seem  as  though  measles  or  scarlatina  must  have  been  mistaken  for  rubella  in 
these  cases. 

Diagnosis. — Such  are  the  symptoms  of  a  typical  case.  Unfortunately, 
there  are  man}'  deviations,  some  approximating  measles  and  some  scarlet 
fever,  differing  from  either  mainh-  in  mildness.  The  absence  of  decided 
catarrhal  symptoms,  the  earlier  appearance  of  the  eruption,  its  more  diffuse 
character,  and  the  swelling  of  the  lymphatic  glands  are  its  chief  differences 
from  measles.  The  careful  studies  of  J.  P.  C.  Griffith^  show  the  latter  of 
less  significance  than  has  been  usualh-  supposed.  The  course  of  the  erup- 
tion differs  also,  that  of  measles  lasting  longer.  The  absence  of  Kopiik's 
sign  must  hereafter  be  helpful  in  distinguishing  it  from  measles.  The  same 
mildness  and  absence  from  fever,  with  the  more  distinct  mottling,  distin- 
guish it  from  scarlet  fever.  In  rubella  the  symptoms  of  invasion  are  all  very 
much  milder  than  in  either  measles  or  scarlet  fever,  even  mild  cases  of  the 
latter.    Most  cases  of  supposed  second  attacks  of  measles  are  cases  of  rubella. 

'  '.'Differential   Diagnosis  of  Rubeola  and  Rubella,  with  Special  Reference  to  Enlargement  of  the 
Glands  of  tlie  Neck,"  "University  Med.  Magazine."  June,  1892. 


SCARLET  FEVER  103 

Prognosis. — The  prognosis  of  rubella  is  invariably  favorable. 
Treatment. — Very  little  if  any  is  required,  except  rest  in  bed.     A  simple 
febrifuge  with  potassium  citrate  may  be  useful. 


SCARLET  FEVER. 

Synonym. — Scarlatina. 

Definition. — Scarlet  fever  is  an  acute  contagious  disease,  especially 
characterized  by  sore  throat  and  a  diffuse  scarlet  eruption,  terminating  in 
more  or  less  membranous  desquamation. 

Etiology. — The  organism  that  causes  scarlet  fever  has  not  been  isolated. 
Streptococci  have  been  found  in  the  blood  by  many  observers.  Less 
frequently  staphylococcus  aureus  and  the  influenza  bacillus  but  the  consen- 
sus of  opinion  is  that  these  are  cases  of  secondary  infection  and  that  the 
special  bacillus  of  scarlet  fever  has  not  as  yet  been  isolated.  Such  second- 
ary infection  has  been  moreover  held  responsible  for  many  serious  compli- 
cations attended  with  supptrration. 

Whatever  the  agency,  it  is  the  most  tenacious  of  all  the  contagia,  retain- 
ing its  power  to  infect  for  at  least  a  year  after  the  occurrence  of  a  case.  It  is 
especially  difficult  to  dislodge  from  organized  substances,  such  as  bedding, 
clothing  or  straw,  letters  and  books,  and  the  disease  has  been  commimicated 
to  newcomers  even  after  an  infected  apartment  has  been  thoroughly  cleaned 
and  fumigated  with  sulphur.  Physicians  have  doubtless  conveyed  it, 
and  the  beard  and  hair  are  contagium-bearers  more  frequently  than  is  sup- 
posed. Hence,  physicians  in  attendance  should  cover  the  head  with  a  cap 
which  will  protect  both  the  scalp  and  beard,  and  nurses,  before  passing  from 
one  case  to  another,  should  disinfect  the  hair  as  well  as  the  rest  of  the  body. 

While  the  contagium  itself  has  never  been  isolated,  there  is  every  reason 
to  believe  that  the  bearers  are  the  exudate  from  the  eyes,  nose  and  throat, 
from  the  skin  at  the  time  of  the  appearance  of  the  exudate,  as  well  as  the 
exfoliated  epithelium.  The  virulence  of  these  exudates  often  lasts  long 
after  desquamation  ends.  Discharging  ears,  discharging  sinuses  are  fre- 
quently infective,  the  ease  with  which  the  scaly  particles  are  disseminated 
through  the  air  and  the  tenacity  with  which  they  adhere  to  textures  readily 
explain  the  communicability  of  scarlet  fever  and  the  difficulty  in  destroying 
its  cause.  On  the  other  hand,  until  the  eruption  makes  its  appearance  the 
disease  is  not  likely  to  be  spread.  Hence,  children  removed  from  association 
with  the  disease  promptly  after  its  discovery,  and  kept  apart,  generally 
escape  it. 

The  route  of  infection  is  mostly  the  respiratory  tract,  although  the 
alimentary  canal  may  also  convey  it.  In  confirmation  of  this  is  the  fact  that 
in  a  number  of  instances  milk  has  been  the  medium  of  infection.  Trask 
("Hygienic  Laboratory  Bulletin,"  No.  56)  cites  51  epidemics  of  scarlet 
fever  spread  through  milk.  The  infecting  cause  was  variously  a  lack  of 
care  at  the  place  of  milk  supply,  unsterilized  bottles,  or  a  nurse. 

The  disease  occurs  more  frequently  in  children,  because  a  single  attack, 
as  a  rule,  protects  against  a  second.  Infants,  however,  even  under  exposrure, 
are  less  liable  to  the  disease,  and  it  would  seem,  too,  that  adults  who  have 


104  INFECTIOUS  DISEASES 

escaped  exposure  during  childhood  are  less  liable.  The  primary  attack  is 
not  always  protective;  second  and  third  attacks  are  reported.  But  here, 
again,  careless  diagnosis  and  defective  memory  are  responsible  for  a  certain 
number.     The  disease  is  most  common  between  the  ages  of  four  and  seven. 

Holt  says  that  about  50  per  cent,  of  all  children  exposed  to  the  disease 
are  attacked.  Koplik  gives  the  same  figures  and  Carr  places  the  number  as 
high  as  56  per  cent. 

Morbid  Anatomy. — There  is  no  morbid  anatomy  peculiar  to  scarlet 
fever.  The  eruption  fades  after  death,  unless  there  happen  to  be  hemor- 
rhagic extravasation.  There  may  be  lesions  the  result  of  ulcerative  destruc- 
tion in  the  neighborhood  of  the  throat.  The  intensity  of  the  fever  sometimes 
produces  granular  fatty  change  in  muscles,  which  is  pronounced  in  the  case 
of  the  heart;  also  cloudy  swelling  in  the  cells  of  the  kidney  and  liver. 
Glandular  swellings  present  at  death  maintain  themselves  afterward.  The 
morbid  anatomy  of  the  complications  and  sequela£  is  appropriately  con- 
sidered under  the  diseases  constituting  them. 

Symptoms. — The  period  of  incubation  varies  greatly.  It  is  some- 
times as  short  as  24  hours,  and  again  as  long  as  12  days;  more  frequently, 
perhaps,  from  two  to  four  days.  At  the  end  of  this  time  there  is  usually  a 
very  short  prodrome,  sometimes  none  at  aU.  Vomiting,  occurring  either 
as  an  initial  symptom  or  a  couple  of  hours  later,  is  often  present;  more 
rarely  a  convulsion,  still  more  rarely  a  chill.  Sore  throat  is  early  complained 
of,  and  high  fever  is  conspicuous.  The  fever  is  early,  the  face  is  flushed,  and 
the  temperature  rapidly  rises  to  103°  F.  (39.4°  C),  105°  F.  (40.5°  C),  and 
even  108°  F.  (42.2°  C),  and  the  pulse  to  no,  120,  or  more. 

The  eruption  appears,  as  a  rule,  on  the  second  day,  and  it  generally 
happens  that,  if  it  is  not  present  at  the  physician's  first  visit,  it  is  sure  to  be 
found  at  his  second.  Its  striking  character  is  its  uniform  redness.  It  is 
like  a  diftuse,  broadly  spread  blush,  appearing  first  upon  the  neck  and 
chest,  and  extending  thence  rapidly  over  the  whole  body,  so  that  at  the  end 
of  the  third  day  it  has  completed  its  invasion.  The  appearance  of  a  child 
covered  with  a  frank  scarlet  fever  eruption  is  very  characteristic.  The 
cheeks  and  forehead  are  flushed  while  around  the  mouth  the  lips  are  white 
forming  a  marked  "anemic  ring"  in  the  midst  of  the  flushed  face.  It  has 
been  well  compared  vnXh.  that  of  a  boiled  lobster  in  its  bright  redness.  It 
is  further  characterized  by  the  readiness  with  which  it  disappears  on  pressure 
and  the  promptness  vnih.  which  it  returns  after  the  pressure  is  removed. 
It  is,  however,  no  sooner  complete  than  it  begins  to  fade,  and  does  so  with 
great  rapidity  in  the  order  of  invasion.  The  eruption  is  not,  however, 
always  thus  typical,  and  presents  every  degree  between  that  described  and 
that  which  is  barely  recognizable.  It  is  also  at  times  more  "patchy,"  but 
never  presents  the  crescentic  or  otherwise  irregular  edges  or  mottled  appear- 
ance of  the  eruption  of  measles.  In  the  lower  and  more  malignant  forms  the 
redness  is  of  a  darker  or  dusky  hue,  and  in  the  worst  of  these,  petechia  are 
present.  Vesicles  are  even  found  with  turbid  contents,  producing  scarlatina 
miliaris.  The  eruption  is  sometimes  entirely  absent  from  the  face.  The 
thorax  and  inner  surface  of  the  thighs  are  more  favorable  sites.  The  erup- 
tion, when  severe,  is  constantly  accompanied  by  an  itching  or  burning  more 
or  less  intense,  and  there  is  a  feeling  of  slight  roughness  at  times. 


SCARLET  FEVER  105 

The  tongue  is  red  at  the  edges  and  tip,  furred  at  the  center,  but  through 
the  fur  the  papillae  stand  out  in  distinct  points,  producing  an  appearance 
that  is  regarded  as  more  or  less  characteristic.  This  has  been  called  by 
some  the  strawberry  tongue.  But  further  examination  into  the  subject 
leads  us  to  adopt  the  view  that  the  strawberry  tongue  is  the  red  and  raw- 
looking  tongue  with  enlarged  papillae,  as  originally  held  by  the  late  Dr. 
Flint,'  who  wrote  as  follows:  "In  the  progress  of  the  disease  the  coating 
exfoliates,  leaving  the  surface  of  the  tongue  reddened;  and  the  papillae  being 
enlarged,  the  appearance  is  strikingly  like  that  of  a  ripe  strawberry-."  The 
term  raspberry  tongue  is  also  applied  to  this  condition.  The  rest  of  the 
mouth,  including  the  roof  and  the  palate  and  tonsils  is  bright  red,  as  though 
the  eruption  extended  to  it,  as  it  doubtless  does. 

With  the  abatement  of  the  eruption  comes  desquamation,  and  it  is  gen- 
erally proportionate  to  the  intensity  and  extent  of  the  former.  It  sets  in 
about  the  tenth  da3^  and  continues  in  bad  cases  for  two  or  three  weeks  and 
even  longer.  When  the  eruption  is  slight,  the  little  scales  are  scarcely 
noticeable,  and  the  closest  examination  is  necessary^  to  discover  them,  while, 
where  there  is  a  vivid  and  extensive  eruption,  the  amount  of  desquamation 
is  enormous.  Glove-like  casts  of  the  fingers,  including  the  nails,  are  some- 
times exfoliated,  and  the  bed  contains  each  day  numerous  flakes  of  epiderm 
that  have  come  off,  while  many  days  are  required  for  complete  separation  of 
the  dead  skin.  Great  care  should  be  taken  in  gathering  it  up,  for  it  is  still 
believed  that,  in  the  desquamation  resides  the  contagium.  On  the  other 
hand,  when  slight  it  should  be  carefully  sought  for,  as  it  has  great  diag- 
nostic value.  At  the  same  time  it  should  not  be  regarded  as  something 
peculiar  and  confined  to  scarlet  fever,  for  every^  dermatitis  is  followed  by 
desquamation,  as  especially  exemplified  in  the  exfoliation  that  follows  an 
attack  of  erysipelas  on  the  face  or  irritation  by  iodin  or  mustard. 

The  urine  from  uncomplicated  scarlet  fever  is  like  that  of  fever  cases 
generally — scanty,  high-colored,  and  precipitatiag  uric  acid  and  urates  on 
cooling.     The  chlorids  are  diminished  during  active  fever. 

The  blood  in  scarlet  fever  exhibits  a  sudden  hj'perleukocytosis,  iS,ooo 
to  40,000  white  cells  per  cubic  millimeter,  falling  gradually  to  the  normal  in 
from  three  to  six  weeks.     There  is  also  a  moderate  secondary'  anemia. 

The  duration  of  simple  uncomplicated  scarlet  fever  ranges  from  three  to 
fourteen  days,  according  to  the  degree  of  severity.  Its  decline  is,  however, 
usuall}"  gradual  as  compared  ■nith  the  suddenness  of  onset. 

Such  is  the  general  picture  of  scarlet  fever  in  its  simple,  uncomplicated 
form,  so  characteristic  that  early  in  its  histor\^  it  received  the  name  scarla- 
tina simplex;  owing  to  further  combinations  of  symptoms,  there  have  been 
added  three  other  varieties:  the  anginose  form,  or  scarlatina  anginosa;  the 
malignant  form,  or  scarlatina  maligna,  and  the  hemorrhagic  form. 

In  the  anginose  variety  the  throat  symptoms  are  conspicuous  and  severe. 
In  no  well-developed  case  is  there  an  absence  of  throat  redness.  On  the 
other  hand,  there  may  be  intense  soreness  with  swelling  of  the  fauces  and 
tonsils,  giving  rise  to  extreme  dysphagia.  The  neck  may  be  so  swollen  as 
to  fill  up  the  depression  beneath  the  jaw.     There  maj^  be  a  false  membrane 


*  For  paper  containing  the  views  of  various  authors  on  this  subject  see  "  The  Strawberry  Tongu 
Scarlet  Fever,"  by  M.  H.  Fussell,  "University  Med.  Magazine,"  Philadelphia,  May.  1897. 


106 


7iVF£C  TIG  US  DISEA  SES 


SCARLET  FEVER  107 

involving  the  fauces,  the  posterior  pharynx,  the  nasal  cavities,  the  trachea, 
and  the  bronchi.  The  throat  may  present  all  the  features  of  a  severe  diph- 
theria. Abscess  and  destructive  ulceration  may  result,  which  may  proceed 
even  to  perforation  of  the  carotid  artery,  and  rapid  death  ensue  therefrom. 
The  inflammation  almost  certainly  ascends  the  Eustachian  tubes,  producing 
severe  ear  symptoms.  The  false  membrane  is  usually  the  result  of  the 
intensity  of  the  inflammatory  process,  due  to  the  specific  cause  of  the  disease 
or  to  a  streptococcic  infection  and  not  to  that  of  diphtheria,  but  there  may 
be  true  diphtheritic  membrane  containing  the  Loeffler  bacillus.  This  can  be 
decided  only  by  the  microscope.  Especially  is  this  true  of  the  cases  in  hos- 
■  pitals  for  infectious  diseases.  The  streptococcus  pyogenes  is  perhaps  the 
most  frequent  cause  of  the  throat  inflammation.  It  has  been  fotmd  also  in 
the  skin,  the  blood,  and  the  glandidar  organs  in  fatal  cases.  Scarlet  fever 
has,  indeed,  been  called  a  streptococcus  infection.  Follicular  tonsillitis  may 
also  be  one  of  the  forms  of  sore  throat. 

In  the  malignant  variet}^  there  is  an  overwhelming  intensity  of  the  cause 
which  may  result  in  almost  immediate  prostration  and  death  of  the  patient, 
giving  no  time  for  the  development  of  the  usual  symptoms,  or  these  may  be 
so  feebly  manifested  that  they  present  no  distinctness.  When  the  disease  is 
not  immediately  fatal,  there  is  intense  adynamia,  the  heart  and  pulse  sharing 
it.  The  breath  is  rapid;  the  capillary  circulation  is  feeble;  the  skin  dusky ; 
the  eruption  is  imperfectly  developed;  the  temperature  is  very  high,  reaching 
105°  to  108°  F.  (40.5°  to  42.2°  C);  there  is  delirium,  which  may  pass  over 
into  coma,  and  convulsions  may  occur.     The  pulse  ranges  from  120  to  150. 

In  the  hemorrhagic  form  there  are  more  or  less  extensive  hemorrhagic 
ejftravasation,  epistaxis,  and  hematuria.  It  attacks,  for  the  most  part,  the 
feeble  and  badly  nourished,  and,  like  the  previous  variety,  is  almost  invari- 
ably fatal. 

Epidemics  of  scarlet  fever  vary  greatl}'  in  severity.  In  some  all  the 
cases  appear  to  be  mild,  in  others  all  are  of  extreme  severity.  Families  of 
children  may  be  exterminated.  Again,  a  mild  case  may  give  rise  to  one  of 
the  most  intense  forms. 

Complications. — Acute  nephritis  is  the  most  frequent  complication  of 
scarlet  fever.  It  makes  its  appearance  usually  after  desquamation  is  more 
or  less  complete — in  the  second,  third,  or  fourth  week.  A  slight  albumi- 
nuria, which  is  common  at  the  height  of  the  fever,  is  not  to  be  confounded 
with  that  of  nephritis,  and  probably  does  not  predispose  to  it,  although  the 
cells  lining  the  tubules  are  at  this  stage  in  a  state  of  cloudy  swelling.  The 
rationale  of  its  production  is  not  precisely  understood.  It  is  probably  the 
direct  result  of  the  toxic  power  of  the  infecting  agent  upon  the  kidney 
substance.  The  fact  that  the  complication  is  usually  more  severe  the 
earlier  it  appears  and  the  more  severe  the  case  would  go  to  show  that  the 
specific  toxin  is  the  cause.  It  is  true,  too,  that  with  the  skin  functionally 
dead  the  complemental  work  thrown  upon  the  kidney  increases  its  suscepti- 
bility to  the  ordinary  causes  of  nephritis,  of  which  cold  is  one.  It  is  to  be 
remembered  also  that  other  diseases  in  which  the  skin  is  seriously  affected 
predispose  to  nephritis.     This  is  pre-eminently  true  of  biirns  and  scalds. 

However  it  may  be  brought  about,  the  result  is  generally  a  typical 
example  of  parenchymatous  or  tubal  nephritis,  although  instances  of  acute 


108  INFECTIOUS  DISEASES 

interstitial  inflammation  are  also  found.  Every  grade  of  severity  is  met, 
but  early  recognition  increases  our  power  to  control  this  severity.  The 
majority  of  cases  thus  recognized  get  well,  recovery  takes  place  after  sup 
pression  of  urine  has  lasted  for  a  week.  The  clinical  picture  is  that  of  actue 
nephritis  otherwise  caused,  and  its  consideration  may  be  deferred  until  that 
disease  is  studied.  This  complication  was  former]}^  often  over-looked,  but 
in  modem  times  cases  are  more  closely  watched  for  it.  The  possibility  of 
Bright's  disease  without  albuminuria  must  be  borne  in  mind. 

Adenitis  producing  a  moderate  degree  of  glandular  enlargement  occurs 
in  almost  aU  cases  of  scarlet  fever,  but  in  severe  cases  it  becomes  a  painful 
and  grave  complication.  A  majority  of  cases  subside,  but  some  go  on  to 
extensive  and  destructive  suppuration,  of  which  we  have  known  ulceration 
through  the  carotid  artery  a  consequence. 

Arthritis  ensues  in  a  certain  number  of  cases,  and  closely  resembles  that 
of  acute  rheumatism.  The  term  Scarlatinal  rheimiatism  is  not  justified  any 
more  than  is  the  term  gonorrheal  rheumatism.  Each  is  the  result  of  the 
specific  cause  of  the  disease,  and  not  of  the  cause  of  rhetmiatism.  It  occurs 
usually  at  defervescence,  and  recovery  is  almost  invariable.  Suppuration  in 
the  joint  has,  however,  occtirred. 

Otitis  is  one  of  the  most  serious  and  permanently  harmful  of  the  com- 
plications. It  is  commonly  considered  the  result  of  an  extension  of  inflam- 
mation from  the  throat  through  the  Eustachian  tube  to  the  middle  ear,  and 
is  associated  with  the  streptococcus.  It  has  occured  after  recovery  was 
supposed  to  have  taken  place.  On  the  other  hand,  it  sometimes  hap- 
pens quite  early  in  the  disease.  Suppuration  and  perforation  of  the 
membrane  of  the  tympanum  are  common,  and  more  rare  is  destructive 
suppuration  of  the  mastoid  cells.  As  a  consequence  of  one  or  both  of  these, 
it  almost  always  leaves  impaired  hearing  or  total  deafness.  The  facial 
nerve  may  become  involved  in  the  disease  of  the  labyrinth,  producing  facial 
palsy,  while  thrombosis  of  the  lateral  sinuses  may  be  another  result  of  the 
same  condition.     Meningitis  and  death  may  be  later  consequences. 

Meningitis  may  arise  independently  of  otitis;  in  fact,  scarlet  fever  is 
the  most  frequent  cause  of  meningitis,  after  cerebrospinal  fever,  tubercu- 
losis, and  syphilis. 

Various  other  nervous  affections  develop  as  rare  complications.  Among 
these  may  be  mentioned  chorea,  convulsions  followed  by  hemiplegia,  and 
ascending  spinal  paralyses  with  wasting  limbs. 

Of  thoracic  complications  endocarditis  and  pericarditis  not  infrequently 
develop  during  the  course  and  during  convalescence  from  scarlet  fever. 
Endocarditis  is  not  always  discovered,  and  a  few  unexplained  chronic 
valvular  defects  may  have  originated  in  this  way  and  thus  be  accounted 
for.  Pericarditis  is  less  likely  to  be  overlooked.  Pleurisy  may  also  occur, 
and  more  rarely  pneumoriia. 

Diagnosis. — The  diagnosis  of  scarlet  fever  is  easy  if  the  symptoms  are 
well  developed,  but  it  is  the  mtld  cases  that  escape  detection.  In  the  absence 
of  the  eruption  in  a  distinctive  form,  it  is  sometimes  impossible  to  aver  the 
presence  of  the  disease.  Two  new  diagnostic  signs  of  scarlet  fever  have 
been  recently  suggested,  first  by  Umber  (see  Medizinische  Klinic,  Februarj- 
25,  19 1 2).     This  is  a  urinary  action  brought  about  by  the  addition  of  two 


SCARLET  FEVER  109 

drops  of  a  preparation  made  by  tritrating  in-a  mortar  30  grams  of  concen- 
trated hydrochloric  acid,  and  2  grams  of  paradimethylamidobenzaldehyde 
and  diluted  with  70  c.c.  of  water.  This  will  bring  about  a  red  coloration, 
sometimes  in  the  cold  urine,  sometimes  in  urine  boiling. 

Another  sign  discovered  in  1911  by  Dohle  (Centrablett  f.  bact.,  Novem- 
ber 23,  1911)  there  were  certain  inclusion  bodies  found  in  the  polymorpho- 
nuclear-leucocytes  of  scarlet  fever.  These  inclusions  by  further  examina- 
tion have  been  proved  to  be  due  to  streptococcic  infection,  and  may  be  of 
value  in  differentiating  the  various  skin  eruptions.  If  there  be  a  doubt  as 
to  the  eruption,  close  watching  will  sometimes  discover  signs  of  desquama- 
tion in  the  shape  of  scales  beneath  the  underclothing  or  in  the  stockings. 
In  the  absence  of  this  the  question  must  occasionally  remain  forever  unset- 
tled. At  others  the  unfortunate  development  of  a  nephritis  sets  the  matter 
at  rest.  If  there  has  been  exposure  to  the  contagion,  it  is  best  to  regard 
every  case  of  sore  throat  as  a  possible  case  of  scarlet  fever,  and  treat  it 
accordingly.  While  the  throat  affection  of  diphtheria  closeh'  resembles  at 
times  that  of  scarlet  fever,  where  this  sj-mptom  is  at  all  conspicuous  in 
scarlet  fever  the  eruption  is  not  generally  wanting,  or  is,  at  least,  present 
to  such  extent  to  permit  recognition  of  the  disease.  The  fact  that  the  one 
or  the  other  of  the  two  diseases  is  prevailing  ma}^  settle  the  question.  It 
must  be  admitted,  too,  that  the  two  affections  may  succeed  each  other,  and 
even,  perhaps,  coexist  both  events  being,  however,  exceedingly  rare.  The 
diagnosis  of  diphtheria  is  rendered  certain  by  obtaining  a  successful  culture 
of  the  IClebs-Loeffler  bacillus.  The  facilities  furnished  at  the  present  daj- 
by  the  municipal  laboratories  to  this  end  make  it  easy  to  obtain  this  test. 

The  coryza  and  cough  in  measles  characterize  the  stage  of  invasion, 
while  the  eruption  occurs  later  than  in  scarlet  fever.  When  it  does  come 
it  is  very  different,  being  at  first,  at  least,  in  patches  bounded  by  irregular 
and  crescentic  outlines,  more  uneven  and  elevated,  and  is  conspicuous  in  the 
face,  where  the  scarlet  fever  eruption  is  faintest.  The  time  of  the  appear- 
ance of  the  rash  is  important.  This  is  early  in  scarlet  fever.  The  absence 
of  sore  throat  is  distinctive  of  measles,  though  its  occasional  presence  in 
mild  degree  must  be  admitted  in  the  latter  disease.  Leucoc5-tosis  is  present 
in  scarlet  fever  and  absent  in  measles. 

Rotheln,  or  rubella,  has  an  eruption  more  like  that  of  scarlet  fever  than 
is  the  typical  measles  eruption,  but  it  is  not  usually  followed  by  desquama- 
tion. There  are  no  uncomfortable  throat  symptoms,  and  the  constitutional 
disturbance  is  much  less.  It  is  also  of  much  shorter  duration.  It  is  pos- 
sible, too,  that  these  affections  may  succeed  each  other,  as  is  true  of  real 
measles  and  scarlatina. 

Acute  exfoliating  dermatitis  resembles  scarlet  fever  during  the  eruption, 
but  the  exfoliation  in  the  former  is  not  like  that  of  scarlet  fever.  As  in 
erysipelas,  it  has  more  the  appearance  of  scales  and  crusts  before  it  is  thrown 
off,  and  there  is  more  apt  to  be  a  moist  surface  left  behind,  followed  b}'  a 
second  exfoliation.  There  are  no  throat  symptoms,  and  the  tongue  char- 
acteristic of  scarlet  fever  is  wanting.  The  eruption  caused  by  belladonna, 
both  on  the  skin  and  throat,  resembles  that  of  scarlet  fever,  but  it  is  of  short 
duration  and  without  constitutional  symptoms. 

Prognosis. — The  prognosis  of  scarlet  fever  varies  greatly  in  different 


110  INFECTIOUS  DISEASES 

epidemics.  There  are  epidemics  of  great  severity,  in  which  the  mortality  is 
large,  and  certain  fvdminating  cases  are  beyond  treatment.  Yet  most 
physicians  of  large  experience  in  surveying  their  work  will  recall  that  the  per- 
centage of  deaths  in  their  scarlet  fever  cases  has  not  been  large,  and  that  it 
has  been  greatest  among  the  very  young.  The  percentage  of  deaths  is  put 
down  at  from  five  to  ten  per  cent,  in  mild  epidemics,  and  ?.o  to  30  per  cent,  in 
severe  ones.  The  mortality  is  greater  in  hospitals  than  in  private  practice. 
In  the  fulminating  cases  death  takes  place  before  a  chance  for  treatment  is 
offered;  but  in  the  next  grade  of  cases,  characterized  by  high  temperature 
and  severe  throat  symptoms,  a  survival  of  five  or  six  days  generally  means 
recovery,  unless  the  supervening  complications  carry  off  the  patient. 
Among  these,  nephritis  and  adenitis  passing  over  to  abscess  are  conspicuous, 
but  even  of  those  so  afiflicted  a  majority  recover. 

Treatment. — After  isolation  and  protection  in  bed  against  changes  of 
temperature,  the  treatment  of  scarlet  fever  is,  in  the  main,  a  sj'mptomatic 
one,  associated  with  a  vigilant  nursing  that  will  guard  against  complications. 
The  patient  should  be  isolated,  if  possible  at  the  top  of  the  house,  and  all 
communication  with  those  of  the  family  who  have  not  had  the  disease  inter- 
dicted. The  temperature  of  the  room  should  be  uniform,  while  effective 
ventilation  should  be  secured.  The  diet  should  be  liquid  as  long  as  the  fever 
persists,  and  the  best  of  all  liquids  is  milk,  though  light  broths  are  allowed 
as  is  also  an  abundance  of  water. 

If  the  fever  is  high,  say  above  103°  F.  (39.4°  C),  cool  sponging  may  be 
resorted  to,  but  it  is  to  be  remembered  that  high  temperatiore  in  this  disease 
is  usually  of  short  duration  and  not  likely,  therefore,  to  produce  the  mischief 
it  may  cause  in  long-continued  febrile  diseases  like  typhoid  fever.  Very 
high  temperatiu-e,  such  as  105°  F.  (40.5°  C),  with  meningeal  symptoms,  may 
require  the  tub-bath  or  cold  pack,  but  the  temperature  of  the  tub-bath 
should  not  be  so  low  as  that  used  in  typhoid  fever.  It  is  safer  to  put  a 
patient  in  a  bath  at  90°  F.  (32.2°  C.)  and  gradually  reduce  the  temperature. 
The  warm  bath  allays  the  itching  of  the  skin,  but  this  is  as  well  accomplished 
by  inunction  with  cold  cream  or  sweet  oil,  and  this  unguent  is  important  for 
another  purpose  as  soon  as  desquamation  takes  place,  to  keep  the  scales 
from  flying  about  and  spreading  the  contagium.  An  ice-cap  may  be  applied 
to  the  head  if  the  temperature  be  high,  and  especially  if  there  are  head 
symptoms.  While  cool  applications  are  allowable  during  fever,  they  are 
positively  contra-indicated  in  its  absence,  as  they  may  act  in  the  develop- 
ment of  complications  of  nephritis  and  otitis. 

Fever  is  best  controlled  by  these  measures,  but  it  is  desirable  to  give 
medicines  which  tend  to  the  same  purpose,  especially  if  they  dispose  to 
diuresis  as  well.  Hence,  the  officinal  solution  of  citrate  of  potassium  or  of 
the  acetate  of  ammonium  combined  with  the  spirit  of  nitric  ether,  or  a 
couple  of  drops  of  aconite  with  a  little  flavoring  syrup,  is  useful.  Consti- 
pation should  be  guarded  against. 

The  throat  symptoms  require  to  be  treated  according  to  the  degree  of 
their  severity.  Iron  and  potassium  chlorate  may  be  added  to  the  above 
mixture.  If  more  active  local  measures  are  needed,  the  throat  may  be 
sprayed  frequently  wdth  a  saturated  solution  of  boric  acid  or  a  normal  salt 
solution.     Irritating  applications   should  never  be  applied.     The  first  is 


SCARLET  FEVER  U\ 

the  best.  Great  care  must  be  taken  not  to  exhaust  the  child  by  spraying. 
Much  harm  may  be  done  by  holding  a  strviggling  child  and  applying  a  spray. 
Cold  water  applications,  and  ice  to  the  exterior  of  the  throat,  are  very  com- 
forting to  the  patient.  Very  efficient  and  soothing  is  a  bandage  for  the 
throat  with  pockets  opposite  to  the  tonsils,  into  which  pieces  of  ice  are  placed 
and  the  whole  covered  with  a  dry  towel ;  or  little  india-rubber  ice-bags  ma}- 
be  similarly  used.  In  adynamic  cases  stimulants  and  restorative  treatment 
in  general  are  indicated.  Due  regard  should  be  had  to  the  tendency  of 
the  disease  in  severe  forms  to  produce  degeneration  of  muscle  and  the  liability 
of  the  heart  to  share  in  this. 

The  proper  treatment  of  the  throat  tends  to  save  the  ear,  but  should  the 
middle  ear  become  involved,  the  membrane  should  be  watched  daily,  and  if 
the  tension  be  extreme,  perforation  practised,  even  more  than  once,  if 
needed.  Too  little  attention  has  been  paid  to  this  complication,  and  if 
circumstances  permit,  an  aural  surgeon  should  be  called  in. 

The  prophylaxis  against  nephritis  should  be  most  careful.  Whatever 
may  be  the  immediate  cause  of  the  renal  involvement,  it  is  certain  that  cold 
often  becomes  its  exciting  cause.  Hence,  the  patient  should  be  scrupulously 
guarded  against  drafts,  and,  tedious  as  it  may  sometimes  seem  to  mother 
and  child,  "six  weeks  in  the  room"  is  a  precaution  which  will  avert  many 
a  case  of  nephritis. 

The  treatment  of  complicating  nephritis  is  the  treatment  of  that  affec- 
tion under  other  circumstances,  and  the  reader  is  referred  to  the  appropriate 
section  on  it. 

Serum  Treatment. — An  important  addition  to  the  treatment  of  scarlet 
fever  has  been  made  by  Paul  Moser'  who  suggested  the  use  of  antistrepto- 
coccic serum,  not  with  a  view  to  combating  the  disease  itself,  but  the 
complications  which  are  the  result,  not  of  the  scarlatinous,  but  of  the  strep- 
tococcic infection.  G.  A.  Charlton,^  of  Montreal,  and  W.  R.  Hubbert,  of 
Detroit,  have  repeated  Moser's  treatment  with  gratifying  results.  Charlton 
says  that  he  employed  it  in  15  cases,  the  majority  of  which  wotdd,  in  his 
judgment,  under  ordinary  treatment,  have  terminated  fatall3^  or,  at  least, 
have  suffered  from  lingering  and  troublesome  complications.  There  were 
13  prompt  recoveries  and  two  deaths,  one  case  having  been  in  a  dying 
condition,  and  the  other  complicated  by  pneumonia  when  they  came  under 
treatment.  The  frequency  of  mixed  infection  is  shown  by  Moser's  statement 
that  in  99  cases  of  scarlet  fever  streptococci  were  obtained  from  blood  63 
times.  These  observations  have  been  amply  confirmed  by  other  bacteri- 
ologists.^ The  injections  should  be  made  early  in  the  disease.  Shick*  says 
the  use  during  seven  years  is  satisfactory.  Two  hundred  cubic  centimeters 
must  be  used  for  young  children,  100  c.c.  for  infants.  After  the  injection 
of  the  serum  a  rapid  subsidence  of  the  pyrexia  supervenes,  also  a  corre- 
sponding decrease  in  the  pulse  rate,  with  improvement  in  its  tension  and 
rhythm.  This  seemingly  harmless  treatment  demands  a  prompt  trial  for 
the  relief  of  the  dangers  of  this  serious  disease. 

1  "Ueber  die  Behandlung  des  Scharlachs  mit  einen  Scharlachsstreptococcen  serum,"  "Wiener  Idinische 
Wochenschrift,"  October  9,  1902. 

2  "Montreal  Medical  Journal,"  October,  1902. 

*  For  a  more  detailed  account  of  these  observations  see  "Die  Bakteriologie  des  Blutes  bei  Infektious- 
krankheiten,"  von  Dr.  Med.  Canon  Jena,  190S. 
^  Therap.  Monasthefte,  April,  1912. 


112  INFECTIOUS  DISEASES 

Prophylaxis  against  the  spread  of  the  disease  should  be  rigid  and  is  ac- 
complished by  the  same  measures  as  those  against  the  spread  of  diphtheria. 
(See  p.  122.) 

DIPHTHERIA. 

Synonyms. — Membranous  Croup;  Angina  maligna;  Angina  membranacea; 
Cynanche  contagiosa;  Diphtheria  faucium. 

Definition. — Diphtheria  is  an  acute,  contagious,  inflammatory  disease, 
caused  by  inoculation  with  tlie  Klebs-Loeffler  bacillus,  and  especially  char- 
acterized by  the  formation  of  false  membrane  and  by  secondary  constitu- 
tional infection.  It  may  attack  any  mucous  membrane,  and  even  the  skin, 
but,  as  usually  employed,  the  term  means  diphtheritic  inflammation  of  the 
oral,  faucial,  nasal,  laryngeal,  tracheal,  or  bronchial  mucous  membrane. 

Etiology. — The  specific  organism  which  by  common  consent  at  the 
present  day  is  the  cause  of  diphtheria  is  the  so-called  Klebs-Loeffler  bacillus, 
a  bacillus,  non-motile,  with  rounded  club-shaped  ends,  2.5  to  3  microns^  in 
length,  and  from  0.5  to  0.8  micron  in  thickness.  It  stains  readily  by 
Loeffler's  methylene  alkaline  blue  in  cover-glass  preparations  and  in  sec- 
tions. Its  cultures  in  blood-serum  are  small,  round,  grayish-white  colonies 
that  are  characteristic.  These,  with  the  clubbed  ends  of  the  bacillus  and 
clear  spaces  in  its  interior,  giving  it  an  appearance  as  if  broken,  suffice 
for  its  recognition.  It  grows  on  all  the  usual  culture-media,  but  ceases  to 
grow  at  a  temperature  below  68°  F.  (20°  C).  If  inoculation  cultures  are 
practised  on  the  lower  animals,  the  nature  of  the  virus  is  declared  by 
the  exudation,  the  bacilli,  the  swelling  of  adjacent  IjTnphatic  glands,  and 
the  invariably  fatal  results  of  such  inoculation.  The  bacillus  produces  in 
its  growth  a  potent  toxic  substance,  or  tox-albumin,  the  absorption  of  which 
from  the  seat  of  local  infection  causes  the  general  symptoms  of  the  disease, 
which  are  therefore  due  to  this  toxin  and  not  to  an  invasion  of  the  blood  by 
the  organism  producing  it.  The  toxin  is  an  albuminous  substance,  but  its 
composition  in  unknown.  When  injected  into  animals,  it  produces  paral- 
ysis, nephritis,  and  albuminuria.  Roux  and  Yersin  were  the  first  to  show, 
in  1888,  the  pathogenic  property  of  cultures  that  had  been  filtered  through 
porcelain. 

The  successful  implantation  of  the  bacillus  of  diphtheria  is,  depend- 
ent on  various  circumstances.  Certain  temporary  states  of  the  indi- 
■^adual  doubtless  favor  it,  while  others  retard  it.  While  general  weakness  or 
feeble  resisting  power  may  be  one  of  these  conditions  it  is  likely  also  that 
purely  local  states,  such  as  uncleanness  of  the  mouth,  teeth,  and  fauces,  as 
well  as  chronic  inflammatory  conditions,  may  act  as  predisposing  causes. 
Enlarged  tonsils  and  nasopharyngeal  catarrh  predispose.  It  has  been  shown 
that  there  are  difterent  degrees  of  virulence  in  the  contagious  organism  it- 
self. Diphtheria  bacilli  are  rarely  found  in  the  blood  especially  in  that  of 
the  heart,  in  very  severe  infections. 

The  bacillus  of  diphtheria  is  associated  with  other  pathogenic  bacteria , 
such  as  streptococcus  pyogenes  and  staphylococcus  albus  and  aureus,  micro- 
coccus lanceolatus,  and  bacilltis  coli  communis,  which  are  probably  responsi- 

i  i/iooo  millimeter,  or  1/25400  inch. 


DIPIirilERIA  113 

ble  for  suppurative  processes  often  associated,  as  well  as  for  certain  deep- 
seated  inflammatory  conditions  and  certain  forms  of  pseudo-diphtheria, 
which  often  complicate  the  disease  and  arc  sometimes  mistaken  for  it.  The 
streptococcus  is  probabl}^  the  most  active.  In  fact  secondary  streptococcus 
infection  is  often  more  dangerous  than  the  diphtheria  infection. 

It  was  formerly  believed  that  defective  drainage,  and  to  a  less  extent 
also  the  upturning  of  soil,  were  conditions  favoring  the  production  of  diph- 
theria, but  such  views  are  not  sustained  by  modern  studies.  The  contagion 
is  communicated,  as  a  rule,  through  the  air  and  not  by  fluids  ingested,  al- 
though epidemics  have  been  traced  to  milk,  in  which  the  bacillus  multiplies . 
In  the  vast  majority  of  instances  the  source  of  the  contagion  is  the  throat  or 
nose  of  another  individual  affected,  whence  the  infective  material  is  propelled 
by  acts  of  coughing  or  expectoration.  Hence  it  happens  that  the  physician 
and  nurse  are  not  infrequently  infected.  Perhaps  in  this  disease,  more  than 
any  other,  excepting  typhus,  are  doctors  and  nurses  the  victims  of  contagion. 
Much  may,  however,  be  done  to  secure  .protection  by  caution  during  such 
ministrations,  as  by  keeping  the  mouth  closed  and  carefully  cleansing  the 
hands  after  contact.  The  practice  of  wearing  a  gauze  mask  over  the  mouth 
when  examining  patients  is  a  further  protection  against  inoculation  of  the  ex- 
aminer. The  contagion  is  less  tenacious  than  that  of  scarlet  fever,  but 
is  highly  so,  having  been  found  to  live  on  blood-serum  for  155  days; 
dried  on  silk  threads,  172  days;  and  in  gelatin,  for  18  months.  It  has  been 
found  on  a  child's  toy  that  had  been  kept  in  a  dark  place  for  five  months  and 
in  the  hair  of  nurses.  It  resides  also  in  the  healthy  throats  of  immune  per- 
sons, in  simple  catarrhal  angina  without  membrane,  and  in  what  appears 
to  be  simple  lacunar  tonsillitis;  whence  it  is  plain  that  the  cause  is  difficult 
to  find  in  sporadic  cases. 

It  is  believed  by  some  that  diphtheria  affects  the  lower  animals,  espe- 
cially the  cat,  and  may  be  transmitted  from  them  to  children.  It  is  said, 
also,  that  such  an  affection  attacks  calves  and  heifers,  and  is  from  them  com- 
municable to  man. 

The  disease  is  much  more  common  in  children  than  in  adults,  though  no 
age  is  exempt.  It  is  rare  in  very  young  children,  and  more  girls  are  attacked 
than  boys.  Abraham  Jacobi,  whose  experience  has  been  very  large,  has 
seen  only  three  cases  in  the  newly  born.  Several  cases  in  children  about 
six  months  old  have  come  under  our  notice.  Epidemics  vary  in  severity, 
and  winter  is  the  season  in  which  the  disease  is  most  prevalent.  While 
crowding  in  cities  favors  it,  it  is  often  widespread  and  virulent  in  the 
country. 

Morbid  Anatomy. — The  morbid  anatomy  of  diphtheria  consists,  on 
the  one  hand,  in  the  presence  of  the  false  membrane  and  of  the  more  ordi- 
nary phenomena  of  inflammation,  most  of  which  latter  disappear  after  death; 
in  the  deep-seated  ulcerative  processes  that  sometimes  result;  and  in  the 
results  of  the  complications  and  sequelae  to  be  considered  later.  The  pa- 
ralyses do  not  fiu-nish  palpable  morbid  products. 

Under  morbid  anatomy  the  constitution  of  the  false  membrane  is  suit- 
ably considered.  At  its  first  appearance  it  is  yellowish-white,  but  later  may 
assume  a  grayish  hue.  Whether  superimposed  on  a  mucous  membrane  or 
set  into  it  as  in  a  frame,  depends  much  upon  the  character  of  the  epithelium 


114  I.XFKCTrOVS  DISEASES 

with  which  the  surface  is  normally  covered.  To  squamous  epithelium  the 
membrane  is  more  deeply  and  thoroughly  attached;  to  columnar  epithelium, 
such  as  hnes  the  larj-nx  or  bronchi,  it  is  more  loosely  adherent;  but  in  both 
situations  it  tends  to  become  looser  with  the  lapse  of  time. 

The  membrane  itself  is  to-day  considered  a  product  of  what  is  known 
as  coagulation-necrosis,  our  knowledge  of  which  is  based  on  the  studies  of 
Wagner,  Weigert,  and  especially  of  Oertel.  The  mechanism  of  its  produc- 
tion is  as  follows:  The  diphtheritic  poison,  probably  admixed  with  fibrin 
from  the  blood,  infiltrates  the  wandered-out  leukocytes  and  the  epithelial 
cells  of  the  part,  especially  the  more  superficial,  causing  first  their  death  and 
then  a  hyaline  transformation,  and  simultaneously  coagulation.  The  result- 
ant is  a  plate  of  necrotic  tissue  and  coagulated  fibrin.  Hence  the  word 
"coagulation-necrosis."  The  membrane  presents,  also,  a  laminated  struc- 
ture, probably  due  to  the  involvement  of  successive  layers  of  tissue  and 
wandering  cells.  If  forcibly  separated,  especially  when  recent,  it  is  apt 
to  leave  a  bleeding  surface,  on  which  new  membrane  is  generally  promptly 
deposited.  The  process  proceeds  from  without  inward,  and,  though  usually 
superficial,  may  extend  more  deeply,  invading  lymphatic  glands  and  adja- 
cent tissue,  producing  foci  of  necrosis,  which  may  be  extensive.  Blood-ves- 
sels may  also  be  invaded,  especially  capillaries.  Bacilli  are  everywhere 
present  in  the  necrotic  tissue,  but  they  do  not  directly  produce  the  mis- 
chief. It  is  caused  by  the  toxin  they  generate.  The  same  results  may  be 
produced  experimentally. 

Symptom.s. — The  period  of  incubation  varies  from  two  days  to  12, 
seldom  exceeding  one  week. 

According  to  what  may  be  the  primary  or  principal  seat  of  invasion  we 
may  speak  of  the  pharyngeal,  laryngeal,  and  nasal  forms  of  diphtheria. 

In  the  pharyngeal  variety,  fever  and  sore  throat  appear  simultaneously, 
sometimes  preceded  by  a  chill  or  chilliness.  Both  increase  rapidly.  There 
may  be  aching  or  a  sense  of  weariness.  More  rarely  a  convulsion  ushers  in 
the  attack.  At  times  at  the  beginning,  at  others  on  the  second  or  third  day, 
an  erythematous  eruption  more  or  less  extensive  appears  on  the  skin  and 
may  lead  to  the  diagnosis  of  scarlet  fever.  Usually,  as  soon  as  attention  is 
called  to  the  throat,  white  patches  are  fotmd  on  one  or  both  tonsils,  which 
spread  with  varying  rapiditj'.  It  is  this  spread  from  the  original  focus  by 
which  the  disease  is  especially  characterized  as  something  distinct  from  fol- 
licular tonsillitis.  Commonly,  the  extension  is  anterior,  over  the  anterior 
half-arches  to  the  uvula,  and  to  the  palate  or  up  into  the  nasal  passages,  or 
both.  With  the  invasion  of  the  uvula  and  palate,  commonly  reached  about 
the  foiuth  day,  the  diagnosis  becomes  certain.  Bacteriological  examination 
must  settle  the  diagnosis  before  this,  however.  More  serious  is  the  exten- 
sion backward  into  the  larj'nx,  producing  croup. 

The  temperature  rises  to  103°  or  104°  F.  (39.4°  or  40°  C),  but  is  not 
characterized  by  extreme  or  persistent  elevation.  The  pulse,  which  ranges 
from  120  to  140,  is  never  very  full  and  strong,  but  tends  early  to  smallness 
and  weakness.  Delirium  is  rarely  present.  Deglutition  becomes  more  and 
more  painful,  and  is  increased  by  external  glandular  swelling,  involving  the 
lymphatic  and  salivary  glands,  although  this  swelling  is  not  invariably 
present.     As  the  nasal  passages  become  involved,  breathing  becomes  more 


DIPHTHERIA  115 

and  more  obstructed,  until,  finally,  it  is  possible  through  the  mouth  only. 
The  Eustachian  tube,  middle  ear,  and  even  the  antra  may  be  invaded.  So, 
also,  there  may  be  diphtheritic  conjunctivitis,  and  even  keratitis,  and,  though 
rarely  indeed,  dermatitis.  Should  there  be,  however,  excoriations  or 
wounds,  these  may  be  invaded  by  the  diphtheritic  pseudo-membrane.  Such 
false  membrane  may,  however,  be  due  to  the  streptococcus,  which  requires 
a  bacteriological  examination  for  its  recognition. 

As  intimated  under  the  head  of  morbid  anatomy,  the  ulcerative  process 
may  extend  much  more  deeply,  producing  destruction  of  tissue  and  even 
gangrene,  resulting,  as  in  scarlet  fever,  in  a  fatal  erosion  of  blood-vessels. 
Usually,  the  membrane  gradually  disappears  from  the  fauces  as  convales- 
cence is  established,  or  is  coughed  up  if  deeper  in  the  respiratory  passages. 
At  times,  on  the  other  hand,  it  remains  on  the  tonsils  for  some  days  after 
aU  constitutional  disturbance  has  disappeared. 

If  the  inflammation  and  membrane  formation  extend  downward, 
laryngeal  cough  and  the  signs  of  laryngeal  obstruction  become  superadded 
— in  a  word,  the  symptoms  of  laryngeal  diphtheria  supervene.  Of  if  the 
process  begins  in  the  larynx — primary  laryngeal  diphtheria — we  have  croup 
at  the  outset,  which  differs  from  spasmodic  croup  in  being  less  sudden  in 
its  onset.  The  seriousness  of  the  disease  is  greatly  aggravated  bj^  the 
possibility  of  complete  obstruction  and  suffocation  unless  averted  by  opera- 
tive interference.  Not  the  larynx  alone,  but  the  trachea  and  bronchi  may 
be  invaded  by  false  membrane.  While  the  onset  is  slower  than  that  of 
pharyngeal  diphtheria,  the  course  is  more  rapid.  To  the  phenomena  of 
congestion  and  membrane  formation  with  resulting  obstructions  are  added 
those  of  spasm,  which  bring  on  at  intervals  the  alarming  paroxysms  that  add 
to  the  terrors  of  this  horrible  affection. 

Nasal  Diphtheria. — When  the  nares  are  invaded  by  the  membrane  in 
the  coturse  of  pharyngeal  diphtheria  the  child  frequently  becomes  seri- 
seriously  iU  because  of  the  greater  absorption  of  the  toxin  from  this  area. 
Membranous  rhinitis  while  it  gives  rise  to  few  symptoms  has  been  proven 
by  Albott  and  by  Park  to  be  a  true  diphtheria  of  low  virulence.  The  child 
is  not  sick,  the  nares  are  plugged  by  a  dense  membrane  but  this  condition 
can  give  rise  to  a  virulent  case  of  diphtheria  in  another  individual.  The 
membrane  contains  diphtheria  bacilli  of  varying  virulence. 

In  three  to  five  days  after  the  onset,  if  the  case  is  one  of  ordinary  sever- 
ity, the  phenomena  of  constitutional  infection  make  their  appearance  in  the 
shape  of  extreme  adynamia,  feebleness  of  pulse  and  heart-beat,  while  a  sense  of 
intense  weariness  is  complained  of.  From  this  time  a  new  period  of  danger 
begins,  the  danger  of  death  from  vaso-motor  paralysis.  At  times  in  diph- 
theria, as  in  scarlet  fever,  the  signs  of  constitutional  poisoning  appear  at 
the  outset,  and  the  patient  is  struck  down  as  by  a  blow,  but  this  is  less  com- 
mon than  in  scarlet  fever.  In  such  cases  the  temperature  may  not  rise, 
and  may  even  be  subnormal.  Constitutional  poisoning  is  not  so  prone  to 
take  place  in  primary  laryngeal  croup  as  in  secondary  croup.  This  lesser 
tendency  to  constitutional  poisoning  together  with  the  more  gradual  onset, 
the  spasm,  the  slighter  contagion,  the  shorter  duration,  and  more  serious 
mortality,  constitute  the  chief  clinical  features  of  the  laryngeal  variety. 

Complications    and    Sequelae. — The    most    frequent    complication    of 


116  INFECTIOUS  DISEASES 

diphtheria  is  nephritis,  which  pursues  a  course  somewhat  similar  to  the 
nephritis  of  scariet  fever,  but  is  less  frequently  accompanied  by  dropsy,  and 
generally  terminates  more  favorably.  On  the  other  hand,  albuminiiria  is 
present  in  almost  every  severe  case.  There  may  be  the  other  signs  of 
nephritis — viz.,  blood-casts,  epithelial  casts,  scanty  and  even  suppressed 
urine.  Capillary  bronchitis  and  bronchopneumonia  are  serious  complica- 
tions, especiallj'  if  the  result  of  insufflation  of  the  virulent  membrane. 
Endocarditis  and  arthritis  sometimes  occur. 

The  most  important  sequel  of  diphtheria  is  paralysis.  This  is  now  gen- 
erally regarded  as  the  result  of  a  toxic  neuritis.  It  may  come  on  as  early  as 
the  seventh  or  eighth  day,  or  as  late  as  the  second  and  third  week,  when  con- 
valescence is  apparently  established.  It  is  quite  as  likely  to  follow  mild  cases 
as  severe  ones.  It  may  even  follow  wound-diphtheria.  It  most  frequently 
affects  the  palate,  producing  nasal  speech  and  permitting  the  passage  of 
fluids  into  the  posterior  nares  and  through  the  nose.  There  is  simtoltaneous 
anesthesia  of  the  pharyngeal  mucous  membrane,  destroying  reflex  excita- 
bility. Next  in  frequency  of  involvement  are  the  muscles  of  deglutition; 
more  rarely,  the  eye  muscles,  especially  those  of  accommodation,  which  is 
thereby  rendered  defective.  There  may  be  also  ptosis  and  strabismus,  or 
paralyses  of  the  distribution  of  the  facial  nerve.  Still  more  rarely  the  nerves 
of  the  lower  extremities  are  involved,  producing  paralysis,  partial  recovery 
from  which  leaves  lameness  that  may  last  through  life.  Generally,  however, 
recovery  takes  place  in  the  order  of  involvement,  usually  in  two  or  three 
weeks.  Sometimes  there  is  a  general  multiple  neuritis  giving  rise  to  ataxic 
symptoms,  with  loss  of  the  tendon  reflexes,  but  no  involvement  of  sensation. 

The  most  serious  of  the  local  palsies  is  that  of  the  heart,  due  probably 
to  fatty  degeneration  of  the  heart  muscle  fibers,  though  a  degeneration  of 
the  nerves  may  take  place  in  some  cases.  In  this  there  may  be  bradycardia  and 
tachycardia  but  the  most  frequent  result  is  the  sudden  cessation  of  the  heart's 
action,  and  this  tragic  termination  may  take  place  during  convalescence. 
Indeed,  the  event  is  more  frequent  during  convalescence,  and  is  often  as  late 
as  the  sixth  or  seventh  week.  At  other  times  the  phenomena  of  heart 
failure  are  more  slow  in  their  development.  The  pulse  may  become  weak 
and  rapid,  or  more  rarely  become  slow,  while  the  extremities  become  cold, 
the  temperature  falls,  and  there  supervene  in  a  few  hours  all  the  signs  of 
collapse.  A  most  striking  instance  of  bradj'cardia  in  diphtheria  was  met 
by  Baumgarten,  wherein,  toward  the  close,  the  pulse  fell  to  25,  though  very 
regular.  It  must  be  remembered  that  the  sudden  failure  of  circulation  at  the 
height  of  an  attack  of  diphtheria  as  in  other  infectious  diseases  is  not  really 
due  to  cardiac  failure,  but  to  a  failure  in  the  peripheral  tone,  a  massing  of 
the  blood  in  the  splanchnic  area. 

Diagnosis. — The  onlj'  two  conditions  with  which  diphtheria  is  liable  to 
be  confounded  are,  first,  the  different  forms  of  sore  throat,  including  follic- 
ular tonsillitis,  and,  the  sore  throat  of  scarlet  fever.  The  difficulty  in 
deciding  between  the  former  condition  and  dipthheria  at  the  outset  is  some- 
times extremely  great,  and  time  or  the  bacteriological  investigation  may 
alone  settle  it,  therefore,  routine  examination  of  exudative  sore  throats 
should  always  be  made.  The  primarv'  fever,  constitutional  disturbance, 
and  d}-sphagia  are  often  equally  as  great  in  follicular  tonsillitis  due  to  strep- 


DIPHTHERIA  117 

tococcus  or  some  other  infecsion.  As  a  rule,  however,  the  follicular  exudate 
remains  limited  in  extent — it  does  not  spread,  and  in  the  second  or  third  24 
hours  is  apt  to  drop  out,  leaving  a  clean-cut  tdcer  that  heals  rapidly,  while 
the  constitutional  symptoms  disappear  with  equal  rapidity.  In  the  form  of 
follicular  tonsillitis  attended  by  multiple  white  spots  on  the  tonsils  the  local 
resemblance  to  diphtheria  is  even  greater,  but  the  white  spots  remain  isolated 
while  those  of  diphtheria  spread. 

Sometimes,  however,  the  mass  of  desquamated  epithelium,  fibrin,  and 
fungous  filaments,  which  make  up  the  contents  of  the  follicles  in  follicular 
angina  extend  outside  of  the  follicles  and  over  the  surface  of  the  tonsils. 
Then  it  becomes  more  difficult  to  decide.  It  does  not,  however,  pass  the 
boundary  of  the  tonsils.  The  follicular  fungi  are  said  to  stain  bluish-red 
with  an  iodopotassic  iodin  solution.  Further  certainty  is  secured  by  mak- 
ing cultures  from  the  membrane,  a  small  portion  being  removed  by  the 
sterilized  platinum  loop  or  cotton  swab,  and  planted  in  gelatinized  blood- 
serum.  In  diphtheria  in  the  course  of  24  hours  characteristic  colonies 
of  the  Klebs-Loeffler  bacillus  will  develop,  and  the  microscope  wiU  confirm 
the  diagnosis.  A  smear  of  the  exudate  may  be  made  and  microscopic 
examination  give  an  immediate  diagnosis.  This  can  and  should  be  done  by 
every  physician.  If  he  has  not  learned  the  use  of  the  microscope,  he  should 
at  once  do  so,  or  have  proper  clinical  facilities  to  have  it  done  for  him. 

From  scarlet  fever,  diphtheria  is  usually  easily  distinguished  by  the 
absence  of  eruption,  although  this  aid  is  wanting  in  those  few  cases  of  scarlet 
fever  in  which  there  is  no  eruption,  and  in  those  of  diphtheria  where  there 
is  an  erythematous  redness.  Under  these  circumstances  the  distinction 
becomes  more  difficult  if  the  throat  symptoms  be  similar,  as  they  sometimes 
are.  The  prevalence  of  an  epidemic  of  one  or  the  other  disease  aids  in  the 
decision.  Later  on,  the  desquamation  that  takes  place  in  scarlet  fever,  but 
not  in  diphtheria,  also  settles  the.question. 

Diagnosis  is  sometimes  delayed  or  the  disease  entirely  overlooked  by 
concealment  of  the  membrane  in  localities  not  easily  open  to  examination,  as 
in  the  nasal  chambers.  Hence,  in  all  obscure  cases  these  should  be  exam- 
ined. Indeed,  it  is  not  impossible  that  diphtheria  may  exist  without  mem- 
brane, as  evidenced  by  prompt  recovery  after  the  use  of  antitoxin  in  certain 
obscure  throat  cases  with  continued  adynamia  and  fever. 

The  larger  cities  in  the  United  States  now  offer,  through  their  health 
bureaus,  to  make  bacteriological  examinations  for  physicians  in  all  cases  of 
possible  diphtheria.  Outfits  are  left  at  stations.  They  consist  of  a  box 
containing  a  tube  of  blood-serum  and  another  containing  a  sterilized  swab. 

Prognosis. — The  introduction  of  the  serum  treatment  for  diphtheria, 
which  may  be  dated  April,  1893 ,  when  the  first  30  cases  treated  by  Behring's 
normal  serum  were  reported,  ^  marks  an  era  prior  and  subsequent  to  which 
the  prognosis  of  diphtheria  presents  very  different  aspects.  Even  prior  to 
1893,  while  the  prognosis  was  so  unfavorable  as  to  justify  a  wholesome  dread 
of  the  disease  the  world  over,  many  moderately  severe  and  most  mild  cases 
got  well.  Allowing  for  the  great  variation  in  the  percentage  of  fatal  cases 
in  different  epidemics,  and  especially  at  different  ages,  the  very  careful  and 

I  The  prior  trials  of  immune  serum  in  the  treatment  of  human  diphtheria,  made  in  v.  Bergmann's 
clinic  in  Berlin  in  1891,  and  by  Henoch  and  Huebner  in  Berlin  in  189: 
weak  serum  and  in  insufficient  doses. 


118  IXFECTIOUS  DISEASES 

reliable  studies  of  Professor  William  H.  Welch,'  of  Johns  Hopkins  Hospital, 
make  it  safe  to  put  such  mortality  at  a  minimum  of  40  per  cent.  Where 
the  larynx  was  involved,  it  amounted  to  almost  100  per  cent.  Of  the  remain- 
ing nonlaryngeal  cases  probably  one-third  died.  Since  the  introduction  of 
the  antitoxin  treatment  the  studies  of  the  same  observer  (Welch)  show  a 
reduction  in  mortality  of  between  50  and  60  per  cent.  As  near  as  it  may  be 
possible  to  put  in,  the  mortality  since  the  introduction  of  antitoxin  has  been 
from  8  to  25  per  cent.  This  improvement  affects  all  classes  of  cases, 
including  those  operated  on  as  well,  and  is  attested  from  many  sources. 
For  example,  in  the  report  of  collective  investigation  by  the  American 
Pediatric  Society  we  have  the  following:  "Formerly,  27  per  cent,  approxi- 
mately represented  the  recoveries,  while  now  27  per  cent,  represents  the  rate 
of  mortality"  also  "Formerly,  only  ten  per  cent,  of  laryngeal  cases  did  not 
require  operation,  while  now  with  antitoxin  treatment  1 7  per  cent,  do  require 
this  procedure."  Finally,  the  most  remarkable  results  are  shown  in 
the  "Bulletin  of  the  Department  of  Health,"  city  of  Chicago,  for  February, 
1899,  which  reports  that  out  of  4071  cases  of  bacterially  verified  diphtheria, 
3705  recovered  and  276  died,  giving  a  mortality  rate  of  but  6.77  per  cent. 
In  New  York  City  for  1899  there  were  8240  cases  reported  with  a  mortality 
of  1087,  or  13  per  cent.  The  sooner  the  antitoxin  is  given  in  the  disease, 
the  less  the  mortality.     Holt  quotes  the  following  statistics: 

During  13  months  ending  October,  1896,  1972  patients  were  treated 
with  antitoxin  at  the  Boston  City  Hospital,  and  of  this  number  post- 
diphtheritic paralysis  occurred  in  5.8"  per  cent.,  which  percentage  is  smaller 
than  that  of  cases  not  treated  with  antitoxin.  A  fair  ratio  of  the  causes  of 
death  in  2  5  fatal  cases  prior  to  the  use  of  antitoxin  was  given  in  a  paper  by 
William  P.  Munn-  as  follows:  from  septic  intoxication  eight,  laryngeal 
stenosis  seven,  cardiac  paralysis  six,  hemorrhage  from  the  bowels  one, 
nephritis  one,  unknovm  two;  total  25.  Thus  the  chief  causes  of  death  are 
adynamia,  laryngeal  obstruction,  heart  paralysis,  or  suffocation  from 
paralysis  of  deglutition;  more  rarely  nephritis  and  bronchopneumonia. 
Hemorrhage  from  an  eroded  blood-vessel  is  a  possible  cause  of  death. 
Morse  analyzed  366  deaths  occurring  in  1972  consecutive  cases  treated  since 
189s  in  the  Boston  City  Hospital,  and  found  the  mortality  only  18.5  per 
cent.  Sevent}^  of  these  cases  died  on  the  day  of  admission,  and  38  on  the 
following  day;  in  other  words,  100  were  moribund  on  admission.  The 
following  are  the  causes  of  death:  sepsis,  107;  bronchopneumonia,  91; 
cardiac  complications,  52;  exhaustion,  13;  tuberculosis,  one;  empyema,  one; 
typhoid  fever,  one;  moribund  when  admitted,  100;  total,  366. 

Under  the  use  of  antitoxin  the  average  duration  of  an  ordinary  case  may 
be  put  down  at  about  five  days  and  of  a  very  bad  case  ten  days.  It  is 
important  to  remember,  however,  that  actively  growing  bacilli  can  be 
cultivated  from  the  throat  of  cases  treated  early  with  antitoxin,  two  weeks 
after  the  membrane  has  disappeared. 

Treatment. — In  the  management  of  every  case  of  diphtheria  there  are 
two  principal  indications:  first,  to  combat  the  toxin  and  thereby  neutralize 


>  "The  Treatment  of  Diphtheria  by  Antitoxin."     Reprint  of  paper  read  before  the  Association  of 
American  Physicians,  May  31,  189s.  and  published  in  the  "Transactions"  for  that  year. 
'"Diphtheria:     A  clinical  Study."  "Medical  Nen-s."  Philadelphia,  March  25.  1893. 


DIPHTHERIA  119 

constitutional  infection;  second,  to  co-operate  with  this  object  by  suitable 
supporting  treatment. 

I.  To  combat  the  toxin  and  to  prevent  constitutional  infection.  This 
is  accomplished  (a)  by  serum  therapy,  that  is,  by  antitoxin;  {b)  by  local 
antiseptic  measures. 

(a)  Antitoxin. — The  treatment  of  diphtheria  by  antitoxin  is  based  on 
the  fact  that  animals  may  be  made  immune  to  diphtheria  by  the  injection 
of  diphtheria  toxin,  and  that  the  serum  from  such  animals  is  antitoxic  to 
the  toxin  of  diphtheria.  This  was  shown  by  Behring  in  1891,  after  some 
preliminar}'  experiments  had  been  made  b}'  Frankel  in  the  same  j^ear.  In 
1892  Behring  and  Wernicke  employed  this  method  successfully  in  immu- 
nizing sheep,  and  also  ascertained  the  second  important  fact  mentioned 
that  blood-serum  from  an  immune  animal  could  be  used  with  success  in 
arresting  diphtheritic  infection  in  susceptible  animals.  To  this  was  added 
the  further  important  fact  that  a  smaller  amount  of  serum  is  required  to 
produce  immunity  than  is  necessary  for  the  cure  of  an  anim-al  already  infected. 
If  the  injection  be  made  immediately  after  infection,  from  one  and  a  half  to 
twice  as  much  is  required;  eight  hours  after,  three  times  as  much,  and  24  to  36 
hours  after  infection  the  dose  required  is  eight  times  the  immunizing  dose. 

One  of  the  objections  to  the  serum  treatment  at  first  was  the  necessarily 
large  bulk  of  the  injection.  This  has,  however,  been  reduced  by  increasing 
the  strength  of  the  serum,  so  that  the  dose  now  injected  gives  no  more 
discomfort  than  a  hypodermic  injection  of  morphin.  Reliable  preparations 
are  now  made  in  this  country  by  various  weU-known  firms,  and  in  some 
cities  by  the  official  authorities  under  direction  of  the  citj^  board  of  health. 
The  manufacture  should  be  placed  under  governmental  control. 

Technique  of  the  Administration  of  Antitoxin. — Antitoxin  should  be 
administered  at  once  if  there  is  a  reasonable  probability  of  the  presence 
of  diphtheria,  without  waiting  for  the  bacteriological  diagnosis.  Antitoxin 
does  no  harm  where  the  disease  is  not  diphtheria,  and  delay  in  a  true  case 
may  be  fatal. 

Very  much  larger  doses  of  antitoxin  are  given  now  than  formerly. 
Thus  the  beginning  dose  was  1000  units  for  ordinary  pharyngeal  diphtheria. 
Now  3000  units  are  a  frequent  initial  dose,  and  even  more  is  given  in  bad 
cases,  7000  to  10,000.  In  laryngeal  diphtheria  at  least  5000  units  should 
be  given  at  the  first  dose.  The  "concentrated"  form  is  preferred  on 
account  of  its  small   bulk. 

A  large  hypodermic  syringe  is  used  for  the  administration.  The 
syringe  must  be  made  sterile  by  boiling  for  five  minutes  just  before  being 
used.  Always  test  the  syringe  with  water  before  filling  ■with  serum. 
After  the  administration  the  syringe  should  be  washed  out  with  clean  cold 
water.  At  the  present  day  the  serum  is  dispensed  in  proper  dose  in  a  glass 
syringe  with  a  needle  point  attached,  by  which  the  serum  is  injected,  thus 
avoiding  the  manipulation  necessary  of  transfer  from  bottle  or  tube  to 
syringe.  The  injection  is  given  in  the  back  just  below  the  scapula  or  in  the 
flank  or  buttock,  the  skin  being  cleaned  with  soap  and  water  followed  by 
alcohol.  If  the  smaller  bulk  be  used,  it  can  be  injected  quickly.  If  the 
larger  be  used,  inject  slowly  in  order  to  avoid  injury  to  the  underlying 


120  INFECTIOUS  DISEASES 

tissues  by  too  rapid  stretching.  Immediately  after  the  injection  there  is  an 
occasional  rise  of  temperature,  which  need  give  no  concern,  or  an  eruption 
may.  appear  which  is  equally  harmless. 

In  favorable  cases,  after  24  hours  have  passed,  the  temperature  will 
not  have  risen;  the  pulse  will  be  slower;  the  membrane  will  not  have  spread; 
the  mucous  membrane  at  the  edge  of  the  exudation  will  be  bright  red  in 
color.  There  will  be  a  feeling  of  diminished  discomfort  and  revival  of  spirits. 
These  are  favorable  signs,  and  a  second  dose  need  not  be  administered. 
A  second  dose  is  administered  after  12  hours  if  the  temperature  has  risen,  if 
the  membrane  is  spreading,  and  if  the  general  condition  of  the  patient  is 
not  so  good  as  at  the  previous  injection.  As  might  be  expected,  improve- 
ment is  more  rapid  in  mild  cases. 

W.  K.  Sutherlin  reports  a  case  of  diphtheria  in  which  498,000  units  of 
antitoxin  were  used'  in  a  protracted  case  with  relapses  between  Aug.  22  and 
Oct.  17.     On  the  7th,  8th  and  9th  of  October,  she  took  32,000  units  daily. 

For  Immunization. — For  producing  immunity  to  those  subject  to  infec- 
tion from  diphtheria,  immunizing  doses  should  be  administered.  These 
range  from  500  to  1000  units,  according  to  the  age  of  the  person  to  be  pro- 
tected. Infants  and  very  young  children  are  easilj'  protected  by  the  smaller 
dose.  Adults,  especially  those  in  attendance  upon  the  sick,  should  receive 
the  larger  dose.  Persons  who  have  been  exposed  and  probably  are  already 
infected  should  receive  500  units.  The  throat  irritation  so  common  in  those 
who  are  attending  diphtheria  is  said  to  have  yielded  promptly  to  a  dose  of 
500  units.  If  suspicious  symptoms  have  appeared,  not  less  than  1000  units 
should  be  given. 

Immunization  cannot  be  too  strongly  insisted  upon.  The  protection 
afforded  by  one  dose  will  last  for  at  least  three  or  four  weeks,  at  most  not 
more  than  eight  or  ten  weeks;  within  which  time,  -^^ith  proper  means  of 
disinfection,  the  source  of  infection  should  be  eliminated. 

Behring  and  others  declare  that  the  diphtheria  antitoxin  has  no  injuri- 
ous effect  upon  animals  in  the  largest  dose  in  which  it  has  been  employed, 
and  that,  aside  from  its  antitoxic  powers,  its  properties  are  entirely  negative, 
as  far  as  himian  beings  are  concerned.  This  is  essentially  true;  but  a  few 
cases  have  died  suddenly  as  the  result  of  the  injection  of  the  serum.  There- 
fore it  is  a  wise  precaution  to  inject  only  a  drop  or  two  at  first,  wait  ten  or 
fifteen  minutes  and  inject  the  rest  if  no  reaction  has  taken  place.  If  there 
is  any  sign  of  shock  no  more  should  be  injected.  The  few  fatal  cases  are 
probably  the  result  of  anaphylactic  shock. 

Serum  sickness  is  now  very  well  recognized.  It  is  an  anaphylactic 
phenomenon.  It  is  the  result  of  the  introduction  into  the  economy  of  a 
foreign  proteid.  Its  symptoms  var>^  in  severity  from  a  local  irritation  to 
severe  constitutional  symptoms.  In  from  six  to  twelve  hours  after  the 
injection  the  temperature  rises  and  severe  local  pain  at  the  site  of  injection 
accompanied  by  redness  and  edema  appear.  The  pain  is  frequently  so 
severe  that  the  patient  has  curled  up  on  his  side  refusing  to  be  moved. 
In  from  24  to  36  hours  the  soreness  disappears  ^^'ithout  treatment.  Occa- 
sionally there  are  severe  joint  pains  or  the  patient's  skin  may  be  covered 
with  an  urticarial  rash.     These  symptoms  may  appear  as  late  as  six  days 

I  "Medical  Record."  Shreveport.  Louisiana,  Jan..  ipos.  , 


DIPHTHERIA  121 

after  the  injection.  Cases  are  on  record  where  the  mucous  membrane  of 
the  respiratory  passages  have  been  covered  with  urticarial  rash. 

Local  treatment  should  be  confined  to  keeping  the  throat  clean  and  clear 
of  mucus.  To  this  end  a  spray  of  boric-acid  solution  or  normal  salt  solution 
should  be  used.  The  sprajr  should  be  used  through  the  nose  as  well  as 
through  the  mouth.  No  irritating  solution  should  be  used.  As  stated 
above  the  child  should  not  be  forced  to  have  the  spraying  done.  The  wash 
may  be  gently  applied  by  washing  out  the  nares  by  means  of  a  douche. 

II.  The  second  object  includes  measures  which  also  have  for  their 
purpose,  first,  checking  the  spread  of  the  membrane,  its  loosening  and  solu- 
tion, and,  second,  maintaining  the  strength  of  the  patient  against  the  de- 
pressing action  of  the  absorbed  toxin,  (a)  The  former  is  accomplished 
by  the  preparations  of  mercurJ^  Of  these,  the  bichlorid  of  mercur\'  in 
doses  of  1/48  grain  (0.0027  gm)  to  1/12  grain  (0.005  g™-)  for  ^^  adult,  in 
conjunction  with  tincture  of  the  chlorid  of  iron,  may  be  given  ever\"  two 
hours,  taken  freely  diluted.  The  former  dose  makes  1/4  grain  (0.0162  gm.) 
of  the  bichlorid  in  24  hours,  but  as  much  as  one-half  (0.03  2  gm.)  may  be  given 
in  that  period.  These  doses  are  given  to  adults,  and  they  need  not  be  much 
reduced  for  children.  There  need  be  little  fear  of  poisonous  effects  from 
the  bichlorid,  as  bowel  irritation,  pain,  and  loose  movements  give  warn- 
ing before  any  more  serious  consequences  supen^ene.  When  these  symp- 
toms appear,  the  bichlorid  should  be  discontinued  or  the  dose  decidedly 
diminished. 

(b)  Iron  is  also  useful  in  supporting  the  strength  of  the  patient.  Strych- 
nin in  1/60  grain  .001  dose  everj^  3  hours  and  caffein  2  grains  every  3  hours 
for  an  adult  are  the  most  useful  stimulants.  The  strychnin  can  be  used 
hypodermicaUy.  Stimulating,  nourishing,  and  easily  assimilated  food  is 
necessary.  MiLk  is  to  be  preferred  to  all  else,  fortified  with  whiskey  or 
brandy,  i  dram  to  2  drams  (4  to  8  c.c),  ever}^  two  hours,  being  required 
in  all  cases  of  severity,  and  proportional  doses  for  children.  The  milk  may, 
of  course,  be  alternated  with  nutritious  animal  broths.  In  extreme  cases  of 
difficult  deglutition  nutrient  enemas  may  be  useful,  but  nourishment  by 
the  stomach-tube,  if  possible,  is  more  efficient.  For  enemas,  peptonized 
milk  is  the  most  suitable.  To  this  brandy  or  whiskey  may  be  added,  if 
needed.  Rectal  alimentation  has  sometimes  to  be  discontinued  because 
the  enema  is  made  too  large  and  is  too  frequently  administered.  Once  in 
six  hours  is  often  enough,  and  4  ounces  at  a  time  are  as  much  as  the  rectum 
will  commonly  bear,  although  this  quantitj^  may  be  gradually  increased. 
Smaller  quantities  should  be  used  for  children. 

^  Treatment  Demanded  by  Special  Indication. — Where  laryngeal  obstruction 
is  imminent,  intubation  or  tracheotomy  should  be  performed.  Lives  have 
been  saved  by  both  of  these  operations.  Intubation  may  precede  trache- 
otomy, as  its  use  does  not  preclude  the  more  serious  operation  at  a  later  date, 
if  the  obstruction  increases. 

In  the  nasal  variety  of  diphtheria  special  means  must  be  employed  to 
disinfect  and  cleanse  the  nasal  passages.  The  solutions  recommended  to 
spray  the  throat  may  be  used  for  such  cleansing.  Gentle  injections  into 
the  nostril  may  be  more  efficient  than  the  spray,  precaution  being  taken 
to  keep  the  mouth  ooen.  bv  which  the  entrance  of  fluid  into  the  Eustachian 


122  IXFECriOVS  DISEASES 

tube  is  guarded  against.  The  injections  should  be  continued  until  the 
fluid  has  free  exit  either  by  the  other  nostril  or  through  the  mouth.  Jacobi 
recommends  that  when  about  to  bring  the  injection  to  a  close,  the  nasal 
cavities  should  be  pressed  together  for  an  instant  with  the  fingers,  as  in  this 
way  the  fluid  is  forced  backward  into  the  pharynx  and  swallowed  or  ejected 
through  the  mouth,  thus  washing  both  at  the  same  time. 

The  Treatment  of  Complications  and  Sequelae. — Complications  are 
treated  as  the  same  conditions  under  other  circumstances,  and  the  paralysis 
so  frequently  succeeding  upon  diphtheria,  alone  requires  special  allusion. 
The  prognosis  is,  on  the  whole,  good,  and  time,  under  favorable  circvmi- 
stances,  mainly  effects  the  cure,  and  during  this  the  most  important  measures 
are  those  that  save  the  patient  from  accident.  Thus  if  there  is  paralysis 
of  the  muscles  of  deglutition,  liquid  food  only  should  be  used,  and  it  may 
be  necessary  to  nourish  for  a  time  by  the  rectum  or  by  means  of  the  stomach- 
tube.  So,  too,  undue  exertion  should  be  avoided.  Electricitj^  and  tonics, 
especially  strychnin,  are  indicated.  The  former  is  applied  to  wasting 
muscles,  and  vaay  be  advantageously  associated  with  massage.  Strychnin 
should  be  given  in  full  doses,  ascending  gradually  to  1/20  grain  (0.003  g™-) 
three  and  four  times  a  day,  with  appropriate  reduction  for  children.  Iron 
and  quinin  should  also  be  given. 

The  electrical  treatment  for  paralysis  of  the  pharyngeal  muscles  is. 
applied  in  the  following  manner:  An  electrode  is  placed  at  the  back  of  the 
neck  and  a  very  small  electrode  is  touched  to  the  velum  palati,  and  a  rapidly 
interrupted  faradic  current  of  moderate  strength  applied.  Galvanism  may 
be  similarly  used.  A  specially  constructed  electrode  is  also  applied  to  the 
throat. 

Prophylaxis  Against  Diphtheria. — Most  important  are  the  precautions 
necessary  to  prevent  a  spread  of  the  disease.  To  this  end  the  patient 
should  be  isolated,  all  carpets  and  unnecessarj-  furniture  and  hangings 
should  be  removed  from  the  room,  and  all  utensils  used  in  treatment  should 
be  kept  apart  and  separate  for  the  patient's  own  use.  Spoons  should  be 
kept  in  carbolic  acid  solution,  or,  better,  thrown  into  water  kept  boiling. 
Tongue  depressors  should  be  made  of  wood  and  burned  immediately  after 
using.  All  bed  linen  and  clothing  removed  from  the  patient  should  be 
boiled,  being  immersed  in  water  before  removal  from  the  room.  Mat- 
tresses, pillows,  and  woolen  garments  too  good  to  be  destroyed  should  be 
exposed  to  superheated  steam  in  establishments  provided  for  the  purpose  in 
the  cities;  or  they  may  be  disinfected  at  the  same  time  with  the  apartment 
occupied  by  the  patient.  Thej'  should  be  opened  and  suspended  in  this 
apartment,  of  which  all  the  doors  and  windows  must  be  closed  tightly  and, 
the  room  fumigated  vnth  formaldehyd  gas,  of  two  to  four  per  cent,  volume 
strength,  for  not  less  than  1 2  hours.  Suitable  lamps  are  provided  for  this 
purpose.  If  formaldehyd  is  not  available,  sulphur  may  be  used.  The  sul- 
phur, in  the  amount  of  two  pounds  to  every  ten  square  feet  (2  kilos  to  every 
2.5  meters)  should  be  placed  in  iron  pans  and  these  supported  by  bricks  in 
washtubs  containing  a  little  water.  The  sulphur  is  then  ignited  by  glowing 
coals  or  by  burning  alcohol.  The  room  should  be  kept  closed  for  twentj'- 
four  hours.  After  this  fumigation  the  articles  of  clothing  should  be  hung 
out  in  the  open  air  for  several  hours,  and  the  doors  and  woodwork  washed 


FOLLICULAR  TONSILLITIS  123 

well  with  a  solution  of  corrosive  sublimate,  i  to  looo,  while  the  walls  should 
be  wiped  down  with  a  similar  solution. 

Finally,  physicians  and  nurses  in  attendance  on  the  patient  should 
wear  gowns  which  will  be  left  behind  on  leaving  the  room.  The  gown 
can  be  kept  in  a  tight  receptacle  containing  formaldehyde  between  visits. 
The  hands  shoiild  be  washed  before  leaving  the  room,  first  in  soap  and  water, 
and  finally  rinsed  in  corrosive  sublimate  solution,  i  to  looo. 

As  the  bacillus  has  been  found  to  midtiply  in  milk,  it  is  safer  to  use 
sterilized  milk  during  an  epidemic. 

The  convalescent  patient  should  also  be  kept  isolatedu  ntil  two  consecu- 
tive negative  cultures  are  obtained  from  the  throat.  On  leaving  the  sick 
room  they  must  be  given  first  a  hot  water  and  soap  bath,  then  washing  the 
body  of  the  patient  with  a  solution  of  bichlorid  of  mercury,  i  to  2000,  or 
two  per  cent,  solution  of  carbolic  acid,  or,  what  is  more  agreeable,  25  to  50 
per  cent,  alcohol.  This  shovild  be  done  two  or  three  days  in  succession. 
The  hair  should  be  cut  or  similarly  washed  with  these  solutions. 

FOLLICULAR  TONSILLITIS. 

Synonyms. — Angina  follicularis;  Lacunar  Tonsillitis. 

Definition. — An  infectious  disease  due  usually  to  a  streptococcus  or 
staphylococcus  and  characterized  by  swelling  of  the  tonsils  with  a  whitish- 
yellow  exudate  in  the  crypts,  or  extending  over  the  entire  tonsil. 

Symptoms. — The  patient  is  suddenly  seized  with  headache,  aching 
limbs,  sore  throat  and  high  fever.  The  tonsils  are  red  and  swollen.  In 
the  crypts  of  the  tonsil  is  a  j'ellowish  exudate  which  can  be  easily  removed 
by  a  swab.  Sometimes  the  exudate  covers  the  entire  tonsil.  Usually  the 
exudate  is  easily  removed  but  in  certain  cases  there  is  a  membranous  forma- 
tion which  leaves  a  bleeding  surface.  The  cervical  glands  are  sometimes 
swollen. 

Diagnosis. — It  is  extremely  important  to  differentiate  this  condition 
from  diphtheria  and  scarlet  fever.  From  diphtheria  the  diagnosis  is  onl}' 
certainly  made  by  means  of  examination  of  a  smear  or  of  a  culture.  The 
absence  of  Kleb's  Loeffler  bacillus  means  no  diphtheria.  From  scarlet  fever 
the  condition  may  be  separated  by  the  fact  that  the  throat  of  scarlet  fever 
is  more  uniformly  red,  the  redness  covering  the  whole  soft  palate  and 
pharynx  and  also  by  the  fact  that  a  skin  rash  appears  in  scarlet  fever  within 
the  first  24  hours.  The  exudate  in  scarlet  fever  is  not  confined  to  the  lacunje 
of  the  tonsils  and  is  apt  to  be  streaked  over  the  part.  Unquestionably  many 
cases  of  endocarditis  have  their  origin  in  acute  tonsillitis. 

The  disease  occurs  in  children  and  young  adults,  and  is  one  of  the 
affections  sometimes  mistaken  for  diphtheria.  It  is,  however,  something 
very  different.  It  is  a  much  less  serious  disease,  of  shorter  duration,  and 
patients  never  die  of  it.  It  is,  however,  probably  infectious  in  origin, 
caused  by  a  germ  other  th?n  the  diphtheritic,  perhaps  the  streptococcus 
or  staphylococcus.     There  is  often  very  decided  fever. 

Treatment. — The  treatment  of  this  form  of  tonsillitis  is  definite  and 
easily  carried  out.  In  the  first  place,  cold  should  be  applied  to  the  neck  by 
cloths  wrung  out  in  cold  water  or  by  ice,  wliich  is  conveniently  applied  in 


124  INFECTIOUS  DISEASES 

little  muslun  bags  made  to  fit  under  the  angle  of  the  jaw  and  held  in  place  by 
a  bandage.  Bicarbonate  of  soda  may  be  used  as  a  wash  or  the  throat 
should  be  sprayed  or  gargled  with  a  normal  salt  solution.  The  patient 
should  be  given  a  mixture  of  iron  and  bichloride  of  mercury.  Acetphene- 
tidin  (phenacetin)  and  phenol  salicylates  (salol)  will  relieve  the  joint-pains. 

VINCENT'S  ANGINA. 

Definition  and  Causes. — A  form  of  sore  throat  described  by  Professor 
Vincent,  of  Paris,  as  due  to  certain  spirilla  and  fusiform  bacilli.  It  occurs 
in  children  eight  to  ten  years  old,  or  at  about  the  time  of  the  second  dentition, 
and  in  adults  i8  to  20  years,  or  about  the  time  when  the  wisdom-teeth  arc 
appearing.  It  is  met  in  all  races  and  climates  and,  though  more  common  in 
alcoholics  and  tobacco  users,  is  found  also  in  those  who  are  not  cleanly  in 
the  care  of  their  mouths.  Bad  hygiene  favors  it  and  it  is  inocvdable.  The 
bacillus  is  bobbin-  or  cigar-shaped  and  associated  almost  always  with  the 
long  wiry  motile  spirilla.  The  bacilli  may  reach  10  to  12  microns  in  length 
and  a  micron  in  width.  They  do  not  stain  by  Gram's  method,  but  may  be 
colored  by  ordinary  stains,  especially  Wright's  stain,  thionin  or  Ziehl's 
solution.     The  spirilla  do  not  stain  as  well. 

Symptoms. — Clinically,  the  disease  occurs  in  two  forms:  One,  quite 
rare  (two  per  cent.)  resembles  closely  diphtheria,  and  the  exudate  contains 
bacilli  with  spirilla,  though  they  may  be  associated  mth  other  organisms,  as 
staphylococci  and  streptococci.  The  false  membrane  may  be  one  to  two 
centimeters  in  thickness,  and  be  made  up  of  an  almost  pure  culture  of  the 
organisms  described.  There  is  a  slight  fever,  the  submaxillary  glands  are  en- 
larged and  there  is  pharyngeal  pain.     The  illness  lasts  from  four  to  six  days. 

In  the  second  form  (98  per  cent,  of  cases)  there  is  a  "membranous 
ulceration"  containing  both  organisms  described.  The  onset  is  character- 
ized by  malaise,  lassitude,  pain  in  the  limbs,  headache  and  fever  to  102.2°  F. 
(39°  C).  Most  frequently  one  tonsil  only  is  involved.  The  breath  is 
fetid  and  there  may  be  salivation.  There  may  be  an  eruption  like  that  of 
scarlet  fever. 

The  pure  form  is  characterized  by  the  absence  of  the  Klebs-Loffler 
bacillus  of  diphtheria,  but  the  two  conditions  may  coexist.  It  is  also  dis- 
tinct from  syphilitic  stomatitis,  though  it  may  be  engrafted  on  it. 

Diagnosis. — The  disease  closely  resembles  certain  cases  of  diphtheria, 
therefore  a  culture  should  always  be  made  from  the  throat. 

Treatment. — It  is  said  to  be  easily  cured  by  painting  vnth.  iodin  twice  a 
day,  but  is  not  amenable  to  antitoxin. 

If  the  diphtheria  bacilli  as  well  as  the  spirilla  arc  present  in  the  throat, 
a  full  dose  of  antitoxin  must  be  given.  This  wll  cure  the  diphtheria  and 
\vill  not  interfere  fvath  the  Vincent's  angina. 

SMALLPOX. 
Synonym  . — 1  'ariola . 
Definition. — Smallpox  is  an  acute  contagious  disease  especially  char- 
acterized by  an  eruption  which  passes  through  the  successive  stages  of 
papule,  vesicle,  pustule,  desiccation,  and  desquamation. 


SMALLPOX  125 

Etiology. — The  contagium  of  smallpox,  probably  the  most  unfailing  of 
all  the  contagia  in  its  effect  upon  the  unprotected  victim,  is  not  certainly 
known  an  intracellular  parasitic  protozoon,  was  first  clearly  described  by 
Guarnieri  in  1892,  and  named  by  him  the  cytoryctes  variolcB.  The  studies 
of  Guarnieri  were  confirmed  by  Wasielewski  in  1901,  and  more  recently  in 
1903-03  by  the  exhaustive  work  of  Councilman,  Calkins,  Tyzzer  and  their 
colleagues,   but   these  observations   are  not  confirmed  by   all   observers. 

The  degree  of  mildness  or  severity  of  a  case  does  not  influence  that  of 
another  caused  by  it,  the  severest  cases  being  at  times  followed  by  the 
mildest,  and  vice  versa.  The  contagium  is  very  tenacious,  and  may  be 
dormant  for  months  in  clothing  or  furniture  hangings.  No  age  nor  sex 
nor  race  is  exempt,  but  the  number  of  cases  in  successive  decades  diminishes 
because  of  the  immunity  furnished  by  a  previous  attack.  The  fcstus  in 
utero  may  acquire  the  disease  from  the  mother,  and  the  child  may  be  borne 
with  the  eruption  on  it.  Certain  individuals  are  invulnerable  even  though 
unprotected  by  vaccination,  while  the  mortality  in  aboriginal  races  is  very 
great.     Many  alleged  immunes  respond  to  a  proper  vaccination. 

Some  difference  of  opinion  exists  as  to  the  period  at  which  smallpox 
is  contagious.  Welsh  and  Schamberg,  in  their  book  on  Contagious  Diseases, 
make  the  following  statement,  which  may  be  considered  as  embodying  the 
most  recent  views : 

"Smallpox  is  undoubtedly  infectious  in  all  stages  characterized  by 
symptoms.  It  is  alleged  by  some  that  the  disease  is  even  infectious  during 
the  period  of  incubation,  but  we  think  there  is  very  little  reason  to  believe 
that  such  is  the  case." 

' '  The  disease  is  least  infectious  during  the  initial  stage,  and  most  highly 
so  during  the  suppurative  and  early  period  of  the  desiccative  stages." 

Morbid  Anatomy. — The  essential  morbid  anatomj^  of  smallpox  is  that 
of  the  eruption  as  represented  by  its  various  stages  and  modifications,  in- 
cluding hemorrhagic  infiltration.  To  the  anatomy  of  the  eruption  is  added 
that  of  the  complications  that  may  occur. 

The  histology  of  the  pustule  shows  that  it  starts  from  a  single  point  in 
the  rete  mucosum,  close  to  the  true  skin,  whence  it  extends  in  all  directions 
to  a  varying  extent.  The  center  or  older  area  is  a  focus  of  coagulation 
necrosis,  and  about  it  the  reticular  spaces  are  filled  with  serum,  leukocytes, 
and  fibrin  filaments.  In  the  older  area,  too,  the  most  highly  developed  of 
the  cytoplasmic  inclusions  are  found  and  in  the  peripheral  area  the  smallest 
and  presumably  j^oungest  forms.  As  long  as  the  process  does  not  extend 
deeper,  healing  takes  place  without  a  scar.  In  the  more  severe  cases  the 
papillae  of  the  true  skin  are  invaded  to  various  depths  and  destroyed  by  the 
infiltration,  producing  a  loss  of  tissue  constituting  the  pit. 

Among  other  morbid  phenomena  may  be  mentioned  a  hardness  and 
firmness  of  the  spleen.  Cloudy  swelling  of  the  secreting  cells  of  the  liver  and 
kidney  occur,  as^  in  other  fevers  with  high  temperature.  True  nephritis  is 
rarely  present. 

Symptoms. — After  a.. period  of  incubation  of  from  seven  to  12  days, 
and  sometimes  longer,  the  victim  is  seized  with  violent  muscular  pain, 
especially  in  the  back.  Often  a  chill  or  chills  usher  in  the  disease,  and  in 
children  a  convulsion  may  be  the  initial  symptom.     Intense  headache  is  also 


126 


INFECTIOUS  DISEASES 


present.  Fever  sets  in  rapidly  and  the  temperature  reaches  103°  to  104° 
F.  (39.4°  to  40°  C.)  the  first  day.  The  pulse  is  rapid,  hard,  and  strong  at 
this  stage.  Delirium  may  be  present  and  is  sometimes  very  violent.  Vomit- 
ing and  diarrhea  are  sometimes  initial  symptoms  and  may  continue  later 
in  the  disease. 

About  the  second  day  the  initial  rashes  make  their  appearance.  These 
have  been  especially  studied  by  Theodore  Simon,'  Kuecht,'^  Scheby- 
Busch,'  and  William  Osier,''  although  they  are  mentioned  by  some  of  the 
older  authors,  including  Sydenham,  Wood,  Watson,  Niemeyer,  Trousseau, 
Marson,  Munrb,  and  others. 

They  include  a  diffuse  scarlatinous  rash  and  a  macular  or  measly  form, 
dark  red  in  color  and  occupying  a  variable  extent  of  svirface.  Either  may 
be  associated  with  petechial  ecchymoses.  Sometimes  they  are  general,  but 
as  a  rule  they  are  limited  to  the  abdomen,  the  inner  surface  of  the  thighs, 


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or  the  lacteral  region  of  the  thorax  and  axilla.  Among  Osier's  cases  was 
one  of  a  true  turticarial  prodrome.  While  it  is  to  be  remembered  that  the 
coexistence  of  smallpox  and  measles  and  of  smallpox  and  scarlet  fever  is 
possible,  it  is  more  than  likely  that  the  eruptions  on  which  the  diagnosis 
was  based  were  really  the  initial  rashes  of  uncomplicated  smallpox. 

On  the  third  day  of  the  disease,  the  distinctive  eruption  makes  its  appear- 
ance in  the  shape  of  small  red  spots,  first  on  the  forehead  and  wTists,  whence 
it  extends  rapidly  over  the  face  and  extremities,  becoming  quite  general 
in  the  first  24  hours.  At  this  time  the  temperature  rapidly  falls  to  again 
rise  at  the  stage  of  suppuration.  At  this  stage  the  eruption  is  not  unlike 
measles,  but  in  another  24  hotu-s  it  is  decidedly  different.  The  papules 
have  acquired  shot-like  hardness.  With  the  appearance  of  the  eruption 
the  fever  falls  and  the  patient  feels  comfortable.  On  the  fifth  or  sixth  day 
a  clear  or  slightly  turbid  serum  makes  its  appearance.  Coincident  with 
this  a  depression  is  seen  in  the  middle  of  each  vesicle.  It  is  umbilicated, 
and  this  umbilication  is  the  most  characteristic  feature  of  the  eruption. 
Frequently,  a  hair  follicle  passes  up  through  the  center  of  it.  Umbili- 
cation is  not  usually  present  in  the  papular  stage,  its  presence  is  not 
pathognomonic.     By  the  eighth  day  the  turbidity  has  increased  until  it  is 

'  "Das  Prod romal-E:ianthema  der  Pocken."     "Arch.  f.  Dermatol,  und  Syph.,"  Prag.,  Heft  iii..  1870, 
346;  1871,  Heft  ii..  242;  Heft  iii.,  309;  1872.  Heft  iv.,  541. 
'  "Arch.  f.  Dermatol,  und  Syph.,"  Heft  iii.,  1872,  372. 
'  "Arch.  f.  Dermatol,  und  Syph.."  Heft  iv.,  1872.  So5. 
*  "The  Initial  Rashes  of  Smallpox."  "Canada  Med.  and  Surg.  Jour.."  1875- 


SMALLPOX  127 

bright  yellow  and  the  umbilicus  has  disappeared.  The  pustule  is  complete. 
The  maturation  takes  place  in  the  same  order  as  the  eruption  appeared. 
With  the  appearance  of  suppuration  the  fever  again  returns,  known  as  the 
secondary  fever,  and  with  it  elevation  of  temperature  and  other  signs  of  fever. 
There  is  a  good  deal  of  pain  in  the  inflammed  parts  because  of  the  tension. 
On  the  -Loth  or  nth  day  the  pustules  become  dry,  and  by  the  14^/1  are  con- 
verted into  crusts,  which  drop  ofE,  leaving  in  mild  cases  a  simple  discolora- 
tion, in  severe  cases  a  more  or  less  deep  ulcer,  or,  if  cicatrization  be  complete, 
a  simple  pit.  The  eruption  may  be  found  on  the  tongue  and  buccal  mucous 
membrane  and  even  in  the  pharynx,  larynx,  and  esophagus,  and  pustules 
have  been  found  in  the  stomach  and  rectum.  In  the  trachea  and  bronchi 
there  may  be  ulcers;  also  on  the  cornea.  Sore  throat,  nausea, hoarseness, 
vomiting,  and  diarrhea  may  be  consequences.  With  the  drying  of  the 
eruption  the  fever  disappears. 

This  description  is  typical  of  the  course  of  the  eruption  in  the  simple 
discrete  variety.  It  may  be  variously  modified.  The  attack  maj^  be  so 
virulent  that  the  patient  dies  before  the  eruption  makes  its  appearance,  or  it 
may  be  arrested  at  any  stage.  Sometimes  blood  forms  the  contents  of  the 
pustule,  and  there  may  be  subcutaneous  infiltration  of  the  blood  in  addition. 
Along  with  this  there  may  be  hemorrhage  from  the  mucous  surfaces  of  the 
nose,  stomach,  or  bowels,  or  there  may  be  hematuria. 

The  pustules  may  be  so  close  to  each  other  that  they  join,  when  the 
case  is  confluent;  or  they  may  be  separate  and  distinct,  producing  the  discrete 
form.  The  variety  with  bloody  infiltration  is  called  hemorrhagic.  The 
diagnosis  as  to  whether  the  confluent  or  discrete  form  is  present  is 
generally  made  by  an  examination  of  the  face,  for  it  is  an  interesting  fact 
that  nowhere  are  the  pock-marks  more  abundant  than  upon  the  face. 

Sydenham  early  called  attention  to  the  fact  that  in  the  confluent  variety 
the  eruption  appears  earlier  (on  the  third  day),  and  its  early  appearance, 
according  to  him,  is  an  indication  that  the  case  will  be  one  of  that  variety. 
All  the  symptoms  are  much  more  severe.  There  is  not  the  abatement  of 
fever  described  as  occurring  on  the  appearance  of  the  eruption.  The  face, 
hands,  and  feet  present  an  almost  continuous  pus-vesicle,  which  often  bursts 
in  places,  and  the  pus  partly  drying,  there  results  a  picture  which  is  revolting. 
Such  pronounced  morbid  changes  must  produce  wide  systemic  exhaustion, 
as  is  manifested  on  the  tenth  or  nth  day  by  growing  weakness  of  the 
patient,  an  adynamia  that  frequently  terminates  in  death.  When  recovery 
takes  place,  the  secondary  fever  is  the  more  prolonged  the  more  widespread 
the  suppuration. 

The  hemorrhagic  variety  of  smallpox  is  still  more  severe.  Two  forms 
of  it  are  described:  One,  the  purpura  variolosa,  or  hemorrhagic  variola,  in 
which  the  hemorrhagic  symptoms  appear  early  in  the  shape  of  a  hemorrhagic 
rash  while  hemorrhage  takes  place  from  the  mucous  surfaces,  generally 
on  the  evening  of  the  second  or  third  day.  The  patient  dies  in  from  two  to 
six  days,  sometimes  before  the  eruption  makes  its  appearance.  In  the 
second  form,  variola  hemorrhagica  pustulosa,  the  case  progresses  at  first 
like  any  other,  and  it  is  not  until  the  vesicular  or  pustular  stage  that  blood 
makes  its  appearance  in  the  pocks. 

Varioloid. — A  third  variety  of  smallpox  is  varioloid,  which  is  variola 


128  IM'ECriOUS  DISEASES 

modified  by  vaccination  or  a  previous  attack  of  smallpox,  in  general, 
varioloid  is  smallpox  bereft  of  all  its  serious  features,  each  symptom  being 
milder.  The  initial  fever  is  less,  the  eruption  is  less  general  and  may  abort 
in  its  development,  the  secondary  fever  is  less  marked,  and  convalescence 
sets  in  earlier.  Yet  it  has  happened  that  both  classes  of  individuals  referred 
to,  those  having  had  smallpox  and  those  having  been  vaccinated,  have  had 
very  severe  attacks,  from  which,  indeed,  the  patients  have  perished.  Gen- 
erally, the  longer  the  interval  between  the  attack  and  vaccination,  the  more 
severe  the  former  is.  Similar  is  the  mildness  which  characterizes  small- 
pox produced  by  the  direct  inoculation  of  an  individual  from  the  pus  of 
another,  though  the  attack  thus  caused  is  more  severe  than  that  which 
follows  vaccination. 

Other  names  given  to  less  important  varieties  are  variola  sine  variolis, 
or  variolous  fever  -without  eruption;  the  "crystalline  pock,"  in  which  the 
eruption  continues  vesicular;  and  the  "stone  pock,"  "horn  pock,"  and 
"wart  pock,"  in  which  the  vesicles  dry  up  into  horny,  tuberculated  or 
warty  elevations. 

Complications. — Among  complications  of  smallpox  may  be  mentioned 
laryngitis  with  fatal  edema  of  the  glottis,  bronchopneumonia,  parotitis, 
diarrhea,  albuminuria,  but  rarely  nephritis.  Prolonged  delirium,  and 
even  insanity,  have  supervened,  while  neuritis  may  occur  during  con- 
valescence; so  may  arthritis.  On  the  skin  may  be  boils  and  painful  acne. 
A  troublesome  and  painful  conjunctivitis  used  to  be  the  result  of  indifferent 
care  of  the  eyes,  but  it  is  now  less  common  because  of  greater  care  in  this 
respect.  Corneal  ulceration  does,  however,  occur  in  two  per  cent,  of  cases 
and  complete  destruction  of  the  eye  has  occurred  in  24  hovu^s  in  confluent 
cases,  and  in  India  is  the  most  frequent  cause  of  blindness.  The  specific 
pock  does  not,  however,  invade  the  cornea.  Myocarditis  and  pericarditis 
sometimes  occur,  and  most  rarely  endocarditis. 

Diagnosis. — With  the  appearance  of  the  perfect  papule  all  doubt  in 
the  diagnosis  of  smallpox  generally  ceases.  Ignorance  of  the  initial  rashes, 
measly  and  scarlatinal,  has  often  led  to  errors  of  diagnosis.  On  the  other 
hand,  the  resemblance  of  the  eruption  of  measles  to  smallpox  has  also  given 
rise  to  errors  the  result  of  which  has  been  no  less  serious,  because  in  conse- 
quence cases  of  measles  have  more  than  once  been  sent  to  smallpox  hospitals 
with  disastrous  results.  Never  in  measles  is  there  such  severe  pain  in 
the  back  as  in  smallpox,  while  the  early  cough  and  coryza  are  found  only 
in  measles.  The  lesson  taught  is  to  defer  a  positive  diagnosis,  because  less 
serious  mischief  can  result  from  an  error  thus  occasioned  than  as  the  result 
of  an  opposite  course.  The  possibility  of  relapsing  fever  being  taken  for 
smallpox  has  been  alluded  to  in  considering  the  former  disease.  Cerebro- 
spinal fever  may  also  be  simulated  by  the  hemorrhagic  form  of  smallpox. 
Pustular  syphilids  and  accidental  croton-oil  eruption  have  been  mistaken  for 
smallpox,  as  has  also  chicken-pox.  Secondary  umbilication  in  the  croton- 
oil  pustule  from  collapse  of  the  pustule  may  simulate  the  umbilication  of  the 
smallpox  pustule,  but  it  occurs  late.  Mild  cases  have  been  mistaken  for 
acne. 

Prognosis. — Unmodified  smallpox  is  a  serious  disease,  and  the  death-rate 
is  alwavs  relativelv  large.     It  varies,  however,  at  different  ages,  in  different 


SMALLPOX  129 

races,  and  in  different  epidemics.  The  young  die  almost  always.  Thus,  in 
the  Montreal  epidemic  of  1885,  86  per  cent,  of  the  deaths  were  children 
under  ten  years.  The  African,  American  Indian  and  Native  Mexican  have 
perished  by  thousands.  The  range  of  the  mortality  in  different  epidemics 
is  put  down  at  25  per  cent,  to  35  per  cent.  The  recent  epidemic  in  the 
United  States  was  an  especially  mild  one,  the  mortality  being  but  3.3  per 
cent.  The  hemorrhagic  cases  are  always  serious;  those  of  purpura  variolosa 
all  die,  and  although  some  cases  of  variola  pustulosa  hemorrhagica  get  well, 
the  majority  are  usually  fatal  on  the  seventh,  eighth,  or  ninth  day.  The 
pregnant  woman  usually  aborts,  it  is  said  in  50  per  cent,  of  cases,  and 
commonly  perishes,  but  not  always.  The  complications  of  pneumonia 
and  laryngitis  are  serious. 

From  the  statistics  of  Gregory,  based  upon  London  hospital  practice, 
most  die  on  the  eighth  day;  but  in  private  practice,  according  to  the  ex- 
perience of  George  B.  Wood,  the  greatest  number  of  deaths  occur  between 
the  12th  and  iSth  days. 

Treatment. — Here  as  in  all  other  conditions,  prophylaxis  is  the  most  im- 
portant part  of  the  treatment.  Vaccination  should  be  imiversal.  An 
unvaccinated  community  should  not  be  allowed  to  exist.  It  is  not  possible 
to  cut  short  a  case  of  smallpox.  The  patient  should  be  isolated  and  taken 
to  a  smallpox  hospital,  if  possible.  If  at  home,  an  uppermost  room  should 
be  selected,  all  hangings  and  carpet  removed,  and  communication  with 
the  rest  of  the  house  cut  off  by  closed  doors  fortified  by  a  sheet  dampened 
with  a  solution  of  carbolic  acid,  i  to  60.  Separate  dishes  and  utensils  should 
be  provided,  and  nurses  should  hold  no  communication  with  other  members 
of  the  family.  All  clothing  removed  from  the  patient  should  be  put  in 
scalding  water,  and  sweepings  should  be  burned.  The  nurse  should  wear 
an  overall,  to  be  removed  on  leaving  the  room,  and  her  head  should  be 
covered  vdth  a  close  fitting  cap. 

The  treatment  must  consist  in  combating  the  symptoms.  Morphin,  or 
in  less  severe  cases  one  of  the  salicylates,  must  be  given  to  control  the  pain 
in  the  back.  Nourishing  liquid  food  and  stimulants  are  required  in  adynamic 
cases.  The  fever  is  treated  by  sudorifics  including  potassium  citrate, 
sweet  spirits  of  niter,  and  by  aconite,  or  by  cool  sponging  or  even  by  cold 
baths,  as  in  typhoid  fever,  if  the  temperature  be  high.  Cool  drinks  should 
be  permitted  ad  libitum.  The  complications  must  receive  the  treatment 
appropriate  to  them.  Tracheotomy  ma}'  be  demanded  by  edema  of  the 
larynx . 

To  Prevent  Pitting. — It  has  always  been  the  object  of  the  physician  to 
find  some  means  of  preventing  the  disfiguring  scars  which  so  invariably 
remain  after  very  severe  cases.  No  one  method  is  always  successfid.  It 
has  long  been  thought  that  the  absence  of  light  favored  healing  without 
leaving  pits.  For  the  painful  ophthalmia  that  so  often  attends  smallpox, 
darkness  is  certainly  a  comfort,  but  that  it  diminishes  the  pitting  is  doubt- 
ful. It  is  a  comforting  fact  that  even  the  deepest  and  ugliest  pits  gradu- 
ally lose  their  distinctness  as  time  passes,  and  that  much  of  the  marking 
disappears  in  the  course  of  a  few  years.  The  surface  should,  however,  be 
anointed  with  vaselin,  cold  cream,  or  similar  substance,  as  they  allay  the 
burning  and  itching,  keep  the  scabs  moist,  and  prevent  the  contagium  from 


130  INFECTIOUS  DISEASES 

spreading  through  the  air.  The  odor,  which  is  often  intolerable,  is  perhaps 
best  covered  by  adding  carbolic  acid  to  the  vaselin  or  other  unguent  em- 
ployed, say  10  grains  (0.666  gm.)  to  the  ounce  (30  gm.) ;  or  a  watery  solution 
of  carbolic  acid  may  be  made  of  the  same  strength  and  applied  on  cloths. 
Bichlorid  of  mercury,  i  to  2000,  may  be  used  in  the  same  way.  These 
preparations  applied  cold  on  lint  are  soothing  and  comforting.  Schamberg, 
the  assistant  physician  to  the  smallpox  hospital  in  Philadelphia,  says  that, 
as  the  result  of  his  experience  in  the  epidemic  of  igoi-1902  in  Philadelphia, 
painting  with  iodin  seems  to  be  more  efficient  in  averting  pitting  than  any 
other  treatment.  J.  F.  Romero  claims  to  have  used  with  most  satisfactory 
results  picric  acid  as  a  local  measure  to  prevent  pitting.  He  advises  a  lotion 
made  with  2  grams  (30  grains)  picric  acid,  15  grams  (1/2  ounce)  alcohol, 
and  185  grams  (6  1/2  ounces)  water.  An  ointment  may  be  made  instead. 
He  suggests  that  the  picric  acid  may  destroy  the  pyogenic  germs  that  may 
find  their  way  into  the  pustules. 

The  eyes,  nose,  mouth,  and  throat  should  be  kept  clean,  all  crusts  being 
carefully  removed.  This  may  be  accomplished  for  the  eyes  bj'  cold  com- 
presses frequently  changed,  while  the  nose,  mouth,  and  throat  should  be 
cleansed  with  borated  gargles  and  lotions.  As  soon  as  convalescence  is 
established  the  patient  should  bathe  daily,  using  carbolic  soap,  the  bathing 
being  kept  up  until  the  sldn  is  perfectly  smooth,  because  onlj^  then  does  the 
patient  cease  to  be  a  source  of  infection. 

Special  Modes  of  Treatment. — As  in  the  case  of  the  other  infectious 
diseases,  smallpox  offers  encouragement  to  similar  specific  modes  of  treat- 
ment. The  infecting  organism  of  smallpox,  whatever  it  may  be,  does  not 
seem  to  develop  a  toxic  substance  so  virulent  as  that  of  diphtheria.  The 
extensive  inflammation  and  suppuration  of  the  skin  is  probably  the  chief 
debilitating  agency.  The  internal  administration  of  antiseptics  has  been 
recommended,  but  seems  to  have  furnished  no  results  that  particularly 
commend  it.  The  substances  tried  are  the  usual  ones — namely,  sodium 
salicylate,  salol,  mercuric  chlorid,  carbolic  acid,  creosote,  the  sulphites,  and 
sulphocarbolates. 

Upon  the  same  principle  as  the  serum  treatment^for  diphtheria,  scrum 
from  vaccinated  subjects  both  human  and  lower  animal,  and  from  smallpox 
patients  in  the  advanced  stage  of  the  disease,  has  been  used  by  Kinyoun,  Lund- 
mann,  and  Beclere.  Analogy  would  lead  us  to  expect  similar  results  to  those 
obtained  by  antitoxin  in  diphtheria,  but  such  has  not  been  the  case  as  yet. 

Special  modes  of  external  treatment,  as  by  baths  impregnated  with 
antiseptics,  have  also  been  used  and  brilliant  results  claimed.  Galewouski^ 
used  solutions  of  potassium  permanganate  of  such  strengths  as  to  make  the 
baths  a  rose-red  color.  He  claims  reduction  of  temperature,  disappearance 
of  pustules,  and  speedy  recovery.  Talamon-  recommends  external  applica- 
tion of  mercuric  chlorid  spray  to  the  skin,  using  a  solution  made  up  of 

TJ      Corrosive  sublimate. 

Tartaric  acid,  of  each,  l  gram  (15  grains). 

90%  alcohol,  5  c.c.  (1.25  fluidrachms). 

Ether,  enough  to  make  50  c.c.  (l  .33  fluidounces). 

Spray  three  or  four  times  daily  for  a  minute,  being  careful  to 
protect  the  eyes. 

1  "Med.  Press  and  Circular."  1890. 

*"Jour.  of  Cutaneous  and  Venereal  Diseases,"  February,  1891;  "Gazette  medica  Lombarda,"  1890. 


VACCINIA  131 

The  treatment  is  commenced  on  the  first  day  of  the  eruption,  being  preceded 
by  thorough  washing  of  the  face  with  soap,  which  is  rinsed  off  with  boric- 
acid  solution,  and  the  skin  then  dried  with  absorbent  cotton.  After  the 
spray  has  been  used  the  face  should  be  covered  with  a  layer  of  50  per  cent, 
of  glycerolate  of  mercuric  chlorid  to  keep  the  skin  antiseptic.  After  the 
fourth  day  the  number  of  sprayings  is  gradually  diminished,  and  after  the 
seventh  day  they  are  discontinued,  though  the  glycerolate  dressings  are 
kept  up.  Talamon  also  recommended  in  the  confluent  and  grave  forms  of 
the  disease  mercuric-chlorid  baths  lasting  from  three-quarters  of  an  hour  to 
an  hour,  with  internal  treatment  including  the  usual  supporting  measures. 
These  treatments  commend  themselves  to  reason  and  common  sense  and  as 
being  at  least  disinfectant  and  cleansing. 


VACCINE  DISEASE. 

Synonyms. — Vaccinia;  Vaccina;  Cowpox;  Kinepox. 

Definition. — Vaccinia  is  an  infectious  disease  produced  by  inoculation 
of  man  with  lymph  from  the  vesicle  of  kinepox.  It  is  characterized  by  local 
and  general  symptoms.  Persons  successfully  vaccinated  are,  in  the  vast 
majority  of  cases,  immune  from  smallpox.  The  local  product  of  such  vac- 
cination is  the  vaccine  vesicle,  the  contents  of  which,  when  again  inoculated, 
are  capable  of  producing  the  same  disease  with  immunity  in  another  person 
not  previously  vaccinated.  It  is  pre-eminently  characteristic  of  vaccine 
disease  that  it  can  be  communicated  only  when  introduced  directly  into  the 
blood. 

Efficiency  of  Vaccination. — There  can  be  no  doubt  that,  if  vaccination 
were  thoroughly  carried  out,  smallpox  could  be  stamped  out.  This  is,  how- 
ever, not  done,  and  in  point  of  fact,  a  few  cases  occur  annually  everywhere, 
while  at  intervals  an  epidemic  of  greater  or  less  severity  occurs.  A  false 
sense  of  security  leads  to  indifference  about  vaccination  and  revaccination, 
and  thus  gradually  accumulate  a  number  of  susceptible  persons  who  are 
liable  to  the  disease.  In  Germany  the  nearest  approach  to  exemption  exists. 
In  1904,  189  cases  of  smallpox  occurred  in  the  German  Empire  of  which  25 
per  cent,  were  fatal  while  28  per  cent,  were  of  foreign  origin.  The  results 
of  organized  effort  are  better  appreciated  by  comparing  the  death-rate  from 
the  disease  per  100,000  in  that  country  compared  with  other  countries. 
In  the  German  Empire,  in  1904,  it  was  0.04;  in  Switzerland,  0.12 ;  in  Holland, 
0.22;  in  70  districts  and  cities  of  Austria-Hungary,  0.176;  in  77  Belgian  cities 
and  in  8  of  the  suburbs  of  Brussels,  14.11 ;  in  71  of  the  largest  cities  of  France, 
6.39,  and  in  76  of  the  largest  cities  of  England,  1.26. 

Nature  of  Vaccinia. — There  can  be  no  doubt  that  vaccinia  is  smallpox 
modified  by  transmission  through  the  cow. 

Etiology. — The  earlier  efforts  of  Quist,  Harold  Ernst  and  Martin,  of 
Boston,  and  of  Klein  and  Copeman  in  England,  to  establish  a  bacterial 
origin  for  vaccine  were  not  successful,  nor  were  those  of  Pfeiffer  and  Ruffer 
to  find  the  cause  a  psorosperm  any  more  so.  On  the  other  hand,  there 
is  every  reason  to  believe  that  the  inoculating  element  is  the  same  as  that  of 
smallpox — a  protozoon  though  of  diminished  virulence.    In  all  vaccine  lesions 


132  IXFKCTIOUS  DISEASES 

studied  by  Guarnieri,  Wasielewski,  Councilman  and  their  colleagues  (and 
especial  attention  is  called  to  the  work  of  Calkins  and  Tyzzer),  whether 
in  man,  in  monkeys  of  various  species,  or  in  the  calf  or  rabbit,  bodies  es- 
sentially similar  to  those  included  in  the  epithelial  cells  in  smallpox  in  man, 
and  undergoing  the  same  changes  and  development,  were  found.  There 
was  no  difference  in  size,  relative  numbers,  and  course  of  development, 
whether  the  seat  of  vaccination  was  the  skin,  mucous  membrane  or  cornea, 
the  only  difference  being  the  physiological  one  of  diminished  virulence, 
producing  vaccinia  instead  of  variola,  in  accordance  with  which  the  name 
cytoryctes  vaccinics  instead  of  cytoryrtes  variolcB  is  given  it.  As  Council- 
man further  says,  "The  result  of  the  two  processes  are  in  all  respects  the 
same,  and  immunity  from  both  smallpox  and  vaccinia  is  conferred.  Neither 
the  calf  nor  any  other  of  the  domestic  animals  is  susceptible  to  smallpox. 
The  disease  which  they  acquire  by  inoculation  with  smallpox  virus  is 
vaccinia." 

Lymph  in  Use. — At  the  present  time  it  is  almost  the  universal  practice 
to  use  animal  lymph  or  the  lymph  directly  from  the  cow,  although  human- 
ized lymph,  that  from  another  person  having  vaccine  disease,  can  also  be 
successfiilly  used.  The  chief  reason  for  using  animal  lymph  is  that  all  dan- 
ger of  communicating  other  affections,  especially  syphilis,  is  thus  avoided, 
although  there  is  reason  also  to  believe  that  protection  is  more  certainly 
secured  by  animal  lymph.  For  securing  the  cow-lj^mph  ntunerous  farms 
exist  in  this  country  and  in  Europe,  where,  under  the  most  perfect  sanitary 
precautions,  inoculation  is  practised  on  the  udder  of  heifers,  whence  the 
lymph  is  gathered  and  distributed.  In  Belgium  the  heifers  are  slaughtered 
after  the  lymph  is  taken,  and  if  they  are  found  diseased,  the  lymph  is  not 
used.  In  this  country  the  more  usual  method  is  to  allow  the  lymph  to  dry 
on  ivory  points  or  quills,  or  to  collect  it  in  capillary  tubes. 

Operation. — The  operation  of  vaccination  is  variously  performed.  After 
thorough  cleansing  the  skin  of  the  arm  with  alcohol,  the  contents  of  the 
capUlan,^  tube  are  expressed  on  the  cleansed  spot  of  skin.  With  a  needle 
sterilized  by  heat  or  the  sterile  needle  in  a  package,  a  small  area  not  exceed- 
ing one-eighth  of  an  inch  in  diameter  is  gently  scratched  through  the  drop  of 
virus.  Blood  should  not  be  drawn  if  that  is  possible.  This  area  is  then 
thoroughly  rubbed  by  a  sterile  piece  of  wood  or  the  same  sterile  needle  used 
in  making  the  inoculation.  It  is  best  to  make  the  inoculation  upon  the 
arm  in  the  region  of  the  insertion  of  the  deltoid  muscle.  If  the  left  arm 
is  always  used  it  will  facilitate  general  inspection  later.  Vaccination  upon 
the  leg  should  not  be  practised.  There  is  much  more  danger  of  infec- 
tion of  the  site.  After  the  spot  is  dried  (from  five  minutes  to  a  half  an 
hotir)  the  area  is  covered  by  a  small  pad  of  sterile  gauze  held  lightly  in  place 
by  small  adhesive  strips.  This  gauze  should  be  left  in  place  for  seven  or 
eight  days,  then  it  should  be  removed  for  inspection  of  the  area.  If  the 
vaccination  is  successful  another  pad  should  be  applied.  If  unsuccessful 
a  revaccination  should  at  once  be  done.  Vaccination  thus  performed  wnth 
perfect  Ij^mph  is  harmless.  Carelessly  done,  it  may  be  followed  by  dire 
results  and  bring  opprobrium  upon  this  great  boon  to  humanity.  Prolonged 
friction  after  the  scratchins;  is  desirable  to  secure  success. 

The  Phenomena  of  Vaccination. — Immediately  succeeding  the  opera- 


VACCINIA  133 

tion  a  slight  inflammatory  redness  appears,  which  usually  subsides  rapidly, 
and  sometimes  has  entirely  passed  away  before  the  first  phenomenon  of  the 
vaccine  disease  appears.  Thus,  there  is  a  true  period  of  incubation,  after 
which,  usually  on  the  third  day,  but  often  two  or  three  days  later,  a  slight 
red  elevation  or  papule  makes  its  appearance.  By  the  fifth  or  sixth  day  this 
has  already  become  an  umbilicate  vesicle  filled  with  a  transparent  viscid 
fluid,  surrounded  by  a  delicate  red  areola.  The  vesicle  presents  a  shining 
silvery  appearance;  by  the  eighth  day  it  becomes  a  lustrous  sUver-gray,  and 
by  the  tenth  day  the  vesicle  and  areola  have  both  reached  their  maximum. 
Each  individual  vesicle  is  about  one-eighth  of  an  inch  in  diameter.  The 
pock  is  by  this  time  1/3  inch  in  diameter  (about  i  cm.),  one  to  two  lines 
in  height,  umbilicated  at  its  center,  and  presenting  frequently  a  minute 
brown  spot  or  scab  in  the  same  situation.  This  larger  lesion  is  the  result  of 
the  fusion  of  two  or  more  of  the  primary  lesions.  The  areola  is  quite  angry 
looking,  often  two  inches  (5  cm.)  or  more  in  diameter,  and  shows  under  a 
magnifying  glass  numerous  minute  vesicles  on  its  surface,  and  the  skin  may 
be  indurated.  At  this  stage,  too,  it  itches  and  burns  to  a  degree  which 
causes  in  adults  an  almost  irresistible  desire  to  scratch,  while  in  the  child  it 
gives  rise  to  fretfulness,  peevishness  and  to  slight  fever.  Even  in  the  adult 
there  is  slight  rise  of  temperature.  On  the  nth  or  12th  day  the  disease  begins 
to  decline.  The  areola  narrows  and  becomes  less  bright,  the  lymph  more 
turbid  and  begins  to  dry.  By  the  end  of  two  weeks  the  vesicle  has  been 
converted  into  a  dry,  brown  scab,  which  generally  drops  off  on  the  21st  to 
25th  day.  A  scar  remains,  which  is  very  distinct  at  first,  but  gradually 
assumes  even  a  whiter  hue  than  the  surrormding  integument. 

The  course  described  is  the  typical  one  in  a  healthy  vaccinated  child. 
In  other  cases  the  amount  of  local  irritation  is  much  greater,  with  a  corre- 
sponding degree  of  constitutional  disturbance.  There  is  often  adenitis  in 
adjacent  glands.  Sometimes,  in  ill-conditioned  children,  deep,  unhealthy 
ulcers  supervene  that  are  very  slow  to  heal,  while  erysipelas  and  gangrenous 
tilcerations  have  even  occurred  and  been  followed  by  death.  Even  tetanus 
has  succeeded  upon  vaccination  and  it  has  been  claimed  that  the  bacillus  of 
tetanus  has  been  inoculated  with  the  germ  of  vaccine  resulting  in  the  simid- 
taneous  development  of  tetanus.  Tetanus  resulting  from  simultaneous 
inoculations  should  appear  five  to  nine  days  after  its  introduction,  whereas, 
in  the  cases  commonly  reported,  three  to  fotir  weeks  have  elapsed  before 
tetanus  developed.  This  seems  to  have  been  the  case  with  the  epidemic  in 
Camden,  N.  J.,  in  the  fall  of  igoi.  All  of  these  untoward  results  are  the 
outcome  either  of  bad  vaccine,  careless  vaccination  or  carelessness  in 
treating  the  case  after  vaccination. 

Since  the  incubation  period  of  vaccination  is  shorter  than  that  of  small- 
pox, the  prompt  vaccination  of  a  person  exposed  to  smallpox  may  protect 
him,  or  at  least  modify  the  disease. 

Vaccination  Rashes. — In  certain  cases,  especially  when  vaccination  is 
done  with  the  liquid  lymph  from  the  cow,  a  general  eruption  of  vesicles  takes 
place,  constituting  vaccinia  bullosa;  associated  with  miliary  vesicles  it  is 
called  vaccinia  miliaria.  At  times  a  roseolar  eruption  is  associated — roseola 
vaccinalis — not  unlike  the  roseolar  eruption  of  syphilis.  The  vesicles  may 
be  filled  with  blood — vaccinia  hcemorrhagica. 


134  INFECTIOUS  DISEASES 

Revaccination. — Should  a  considerable  time  elapse  after  vaccination,  a 
rcvaccination  will  generally  be  more  or  less  successful.  Usually,  the  entire 
set  of  phenomena  is  less  characteristic,  although  it  sometimes  happens  that 
the  same  typical  course  is  repeated.  Such  successful  vaccination  is  regarded 
as  evidence  that  immunity  from  smallpox  is  no  longer  present,  and  the  per- 
son, if  exposed  to  smallpox  before  vaccination,  would  have  taken  it.  Such 
an  attack  is  almost  invariably  less  severe,  and  presents  the  modified  sympto- 
matology known  as  that  of  varioloid.  The  period  of  exemption  after  vac- 
cination varies  greatly.  It  is  often  life  long.  More  frequently,  it  lasts  from 
ten  to  12  years,  and  every  person  should  be  revaccinated  at  7  to  8  years, 
and  thereafter  every-  seven  or  eight  years  and  whenever  an  epidemic  of 
smallpox  is  raging. 

At  times,  even  in  first  vaccinations,  an  abortive  result  obtains,  the 
vesicle  drying  and  dropping  off  much  too  early.  Should  this  occur,  the 
operation  should  be  repeated. 

Possibility  of  Transmitting  Disease  by  Humanized  Lymph. — The  pos- 
sibility of  transmitting  disease  by  vaccinating  with  humanized  lymph  has 
been  a  potent  influence  in  stimulating  the  employment  of  animal  lymph. 
Syphilis  seems  the  only  disease  that  can  be  thus  transmitted,  although  it 
has  been  claimed  also  for  tuberculosis.  It  is,  nevertheless,  important  that 
every  precaution  should  be  taken  against  such  accidents.  If  hvunanized 
lymph  be  used,  as  it  sometimes  must  be,  only  that  from  children  of  healthy 
parents,  free  from  syphilis  or  tuberculosis,  should  be  selected,  and  under 
all  circumstances  lymph  admixed  with  blood  should  be  rejected.  Lymph 
should  be  taken  from  fully  matured  and  perfect  vesicles  on  the  eighth  day. 
It  is  scarcely  justifiable  to  use  humanized  lymph. 

It  is  exceedingly  important  that  the  physician  should  have  at  hand  the 
data  of  discriminating  between  the  ulcer  of  vaccinoSyphilis  and  of  uncom- 
plicated vaccination;  and  between  secondary  vaccinosyphilis,  the  vaccina- 
tion rashes,  and  hereditary  syphilis  occurring  about  the  time  of  vaccination. 
Such  data  are  found  in  the  following  table  compiled  by  C.  S.  Shelly  from 
Fournier,  in  Fowler's  "Dictionary  of  Medicine": 

Vaccinosyphilis  or  Vaccino-Chan-cre.'  Vaccination  Ulcers. 

Chancre    never   developed   before   the    fif-  Ulceration  is  present  twelve  to  fifteen  days 

teenth   day   after  vaccination;   usually  after  vaccination  and  is  fully  devel- 

not  until  after  three  to  five  weeks;  it  is  oped  the  twelfth  day  after  vaccination. 

still  in  its  earlier  stage  twenty  days 

after  vaccination. 

Chancre  developed  on  the  site  of  usually  Ulceration  affects  all  the  punctures,  as  a 

one   or   two   only    of   the   vaccination  rule. 

punctures. 

Inflammation  is  shght.  Inflammation  and  ulceration  severe. 

Loss  of  substance  superficial  only.  Ulcer  deeply  excavated. 

Suppuration   scanty   or   absent,    scabs,    or  Much  suppuration. 

crusts. 

Border    of    chancre   smooth,    slightly    ele-  Margin    of    ulcer   irregular,    as    in    "soft 

vated,  gradually  merging  into  floor.  chancre." 

Surface  of  floor  smooth.  Floor  of  ulcer  uneven,  suppurating. 

Induration  "parchment-like,"  and  specific.  Induration  inflammatory  only. 

not  merely  inflammatory. 

Inflammatory  areola  very  slight.  Areola  inflammatory  and  erysipelatous. 

Gland    swelUng    constant,    indolent  [syph-  Gland   swelling   often  absent;  if  present, 

ilitic]  bubo.  merely  inflammatory,  i 

Complications  rare.  Complications— sloughing,    erysipelas,  etc. 

— often  present. 


CHICKEN-POX  135 

Secondary  Syphilitic  Eruption  due  to  Vaccination  Rashes. 

Vaccinosyphilis. 

[Including  roseola  vaccinalis,  miliaria 
vaccinalis,  vaccinia  bullosa,  vaccinia 
haemorrhagica ;  also  accidental  erup- 
tions— rubeola,  scarlatina,  lichen, 
urticaria,  etc.] 
Appears,  at  the  earliest,  nine  or  ten  weeks  A  true  vaccinal  rash  appears  between  the 
after  vaccination.  ninth  and  fifteenth  day  after  vaccina- 

tion. 
Requires,  in  every  case,  the  pre-existence  of     Absence  of  inoculation  chancre, 
a  specific  ulcer  [chancrej  at  the  site  of 
vaccination. 
Exhibits  the  character  of  a  true   specific     Eruption  does  not  exhibit   specific  char- 
eruption,  acters. 
Fever  often  slight.                                                   Fever  always  present. 
Lasts   for    a    long    time.     Usually    accom-     Evanescent, 
panied     by    specific    appearances    on 
mucous  membranes. 

Hereditary  Syphilis,  Showing  Itself 
Vaccinosyphilis.  about   the   Time   of   Vaccination. 

Begins    with   local   infection   chancre    and     No  chanere;  begins  with  general  phenom- 

indolent  bubo.  ena. 

Typical  development  in  four  stages — viz.,     Has  no  typical  development  in  connection 
incubation,    chancre,    second    incuba-  with  vaccination, 

tion,    generalization    [secondary    erup- 
tion], etc. 
Never  appears   earlier  than  the  ninth   or     Time  of  development  quite  independent  of 
tenth  week  after  vaccination.  vaccination.     Is     attended      by     the 

characteristic  syphilitic  bodily  as- 
pects. Other  manifestations  of  he- 
reditary syphihs  may  be  present. 
The  history  may  indicate  syphilis. 

Some  idea  of  the  efficiency  of  vaccination  may  be  obtained  from  the  fact 
that  through  it  smallpox  has  been  blotted  from  the  Germany  army.  Fur- 
ther, it  was  early  shown  by  Marson  that  of  those  who  have  acquired  small- 
pox after  vaccination,  the  disease  is  vastly  less  severe  than  in  those  who 
have  primary  smallpox.  This  is  confirmed  also  by  the  statistics  of  W.  M. 
Welch,  Physician-in-charge  of  the  Municipal  Hospital  of  Philadelphia. 
From  a  study  of  5000  cases,  he  showed  that  where  there  were  good  cicatrices, 
only  8  per  cent,  died;  with  fair  cicatrices,  14  per  cent.;  with  poor  cicatrices, 
27  per  cent.;  unvaccinated  cases,  58  per  cent.  The  history  of  vaccination 
in  the  province  of  Santiago,  Cuba,  where  smallpox  was  banished  by  its 
use  shoidd  be  read. 

Treatment. — No  treatment  for  the  vaccine  vesicle  is  usually  required 
beyond  protection  by  means  of  sterile  gauze  from  friction  and  contamination 
by  the  clothing.  Shields  should  not  be  used,  but  the  wound  covered  with 
a  piece  of  surgeon's  gauze  fastened  by  adhesive  plaster. 

CHICKEN-POX. 

Synonym. — Varicella. 

Definition. — Varicella  is  an  acute  contagious  disease  of  children,  char- 
acterized by  an  eruption  of  vesicles  with  pearly  contents  and  attended  with 
little  or  no  constitutional  disturbances. 

Etiology. — The  disease  is  eminently  contagious,  but  no  specific  causal 
organism  has  been  isolated.  It  is  almost  purely  a  disease  of  childhood, 
though  attacks  in  adults  are  known,  it  occurs  most  frequently  between 
the  second  and  sixth  year.  It  is  a  distinct  and  separate  disease  from  small- 
pox, an  attack  bringing  no  exemption  from  that  disease. 


136 


INFECTIOUS  DISEASES 


Symptoms. — The  period  oj  incubation  is  from  lo  to  15  days.  So  slight 
is  the  constitutional  disturbance  that  very  commonly  the  appearance  of 
the  eruption  is  the  first  notification  of  the  child's  illness.  At  times  there  are 
slight  prodromal  peevishness,  restlessness,  and  feverishness;  at  others  there  is 
a  slight  chill  followed  hy  fever.     Some  muscular  pain  may  be  present. 

A  prodromal  scarlatinal  rash  may  rarely  present  itself,  but  for  the  most 
part  the  suddenness  of  the  eruption  is  distinctive.  It  presents  itself  in  the 
shape  of  isolated  pimples  scattered  over  the  body  within  the  first  24  hours 
after  constitutional  disturbance.  They  arc  more  prone  to  occur  on  the 
parts  covered  by  clothing,  as  the  trunk,  but  they  may  appear  first  on  the 
face.  In  another  24  hours  they  are  vesicles  filled  with  perfectly  clear  fluid, 
as  a  rule,  without  umbilication  or  areola;  the  liquid  rapidly  becomes  turbid 
and  by  the  end  of  the  third  day  the  vesicles  begin  to  dry  up,  and  in  another 
day  are  converted  into  dark-brownish  crusts,  which  drop  off,  usually  lea\dng 
no  scar.  Sometimes,  however,  a  distinct  pit  is  left,  especially  if  the  pock 
be  scratched  by  the  child,  as  it  sometimes  is,  because  of  the  irritation  it 
excites.  Occasionally,  too,  the  pustule  is  distinctly  umbilicated  and  may 
also  have  a  pink  areola.  The  pustules  appear  in  crops,  so  that  on  the  fourth 
day  they  can  be  seen  in  all  stages,  but  at  the  end  of  a  week  again  all  have 
disappeared.  Rarely  are  there  more  than  half  a  dozen  on  the  face,  though 
they  may  be  quite  numerous  and  the  victim  well  dotted  over.  They  occur 
also  on  the  scalp  and  in  the  throat. 

Complications  are  rare  with  varicella,  and  in  most  cases  would  have  been 
overlooked  but  for  the  eruption.  It  is,  however,  true  that  hemorrhagic  pocks 
sometimes  occur  accompanied  by  hemorrhage  from  the  mucous  membranes ; 
that  nephritis  and  even  gangrene — varicella  gangrcenosa — have  occurred,  and 
infantile  paralysis  has  developed  during  an  attack  of  the  disease.  This 
paralysis  not  belonging,  however,  to  the  disease  anterior  poliomyelitis. 

Diagnosis. — The  diagnosis  should  not  detain  one  long.  The  trifling 
constitutional  disturbances,  the  rapid,  almost  sudden,  development  of  the 
pustules  during  the  first  day — all  distinguish  the  disease  from  smallpox. 

Prognosis. — This  is  invariably  favorable,  except  in  rare  cases  of  vari- 
cella gangrcenosa. 

Treatment. — Usually  none  is  needed  save  the  application  of  a  simple 
lotion  or  ointment  to  allay  the  itching.  The  principal  need  of  the  physician 
is  to  make  the  diagnosis. 

The  follo\ving  table,  somewhat  modified,  from  T.  M.  Rotch,  may  be  help- 
fvd  in  diagno.sis. 

^fewf         Measles  RubeUa  Variola  VariceUa 

Incubation Two  to  four    Seven  to      Fourteen  to  Seven  to          Ten  to  fif- 

days       ;    fourteen       twenty-one  twelve  days.      teen  days. 
days.                days. 

Prodrome Two  days.  Threedays.    A  few  hours.  Three    days.     Afewhours 

Efflorescence Erj'thema.;    Papules.          Papules.  Macules,  pap-     Vesicles. 

ules,  vesicles, 

;  pustules. 

Desquamation Lamellar.    Furfurace-  Large  crusts.         Small 

ous.  crusts. 

Complications     and       Kidney,        Eye  and     Larynx,  lungs 

sequels ear,   and          lung.  eyes. 

Heart. 


WHOOPING-COUGH  137 

WHOOPING-COUGH. 

Synonyms  . — Pertussis;  Whooping-cough . 

Definition. — Whooping-cough  is  an  infectious  disease,  characterized 
by  spells  of  coughing  accompanied  by  a  long  drawn  inspiration  producing 
the  "whoop,"  whence  the  disease  is  named. 

Etiology. — It  is  interesting  to  note  that  Linnseus  ascribed  whooping- 
cough  to  the  larvae  of  insects  in  the  nose.  The  infecting  organism  is  prob- 
ably the  Bordet  Bacillus — as  described  hj  Bordet  and  Genyou.' 

Whooping-cough  attacks  children  of  all  ages  not  rendered  immune  by 
previous  attacks,  though  it  is  most  usual  between  the  first  and  second  denti- 
tions; nor  is  it  a  very  rare  affection  in  adults,  in  whom  it  may  become  serious. 
It  is  said  to  be  more  frequent  in  girls.  Epidemics  are  more  common  in 
the  spring  and  winter,  and  often  precede  or  follow  those  of  scarlet  fever  and 
measles.  The  disease  is  generally  communicated  from  one  child  to  another, 
and  few  escape  who  are  exposed.  Sporadic  cases  also  occasionally  occur. 
The  delicate  and  those  suffering  from  bronchial  and  nasal  catarrh  are  more 
vulnerable.     Some  persons  are  immune. 

Morbid  Anatomy. — There  is  no  morbid  anatomy  peculiar  to  whooping- 
cough  beyond  the  catarrhal  inflammation.  According  to  Myer-Huni  and 
V.  Heroff,  this  is  most  marked  in  the  mucous  membrane  of  the  nose,  larj'nx, 
and  trachea  down  to  the  bifurcation,  but  especially  on  the  posterior  wall 
of  the  pharynx,  and  in  the  interarytenoid  region — the  so-called  "cough 
region. ' '  The  morbid  states  found  after  death  are  those  of  the  complications 
— viz.,  bronchitis,  bronchopneumonia,  and  collapse  of  the  lung.  Vesicular 
and  interstital  emphysema  are  sometimes  present,  the  former  from  over- 
distention  of  the  air-vessels,  and  the  latter  from  their  rupture. 

Symptoms. — Whooping-cough  has  a  period  of  incubation  of  from  seven 
to  ten  days.  There  is  no  prodrome  separable  from  the  preliminary  stage, 
beginning  with  cough  which  is  in  no  way  peculiar,  being  that  of  an  ordinary 
cold  with  slight  fever  and  without  expectoration.  There  may  be  coryza 
and  injection  of  the  conjunctiva.  This  cough  may  go  on  for  a  couple  of  weeks 
and,  if  there  be  nothing  in  the  history  to  suggest  the  nature  of  the  disease, 
may  occasion  no  suspicion.  Toward  the  end  of  this  period,  however,  the 
observing  mother  wUl  have  noted  that  the  cough  is  gradually  growing 
worse  and  becoming  paroxysmal,  that  it  occurs  "in  spells,"  and  frequently 
at  night.  Then  suddenly  a  "whoop "  is  noted  and  the  nature  of  the  disease 
is  suspected. 

The  paroxysmal  stage  has  replaced  the  catarrhal,  and  soon  the  diagnosis 
is  plain.  The  paroxysms  become  more  frequent  and  more  severe.  Each 
one  begins  in  a  succession  of  short  expiratory  coughs,  which  grow  in  intensit}-. 
All  efforts  lie  in  the  direction  of  expiration,  and  all  expiratory  muscles 
are  brought  into  play  to  this  end.  The  chest  is  compressed  laterally,  and 
bulges  in  the  sternal  region.  As  the  result  of  such  efforts,  the  face  is  flushed, 
turgid  and  sometimes  cyanotic,  the  eyes  are  injected  and  bulging,  the  tears 
start,  and  the  nose  discharges.  Finally,  the  paroxysm  terminates  or  is 
interrupted  by  a  loud,  whooping  inspiration — that  is,  it  may  end  for  the 

i"Soc.  Roy.  des  Sc.  Med.  et  Naturelles  de  Brex,"  vol.  Ijtiv.,  1906,  page  30s;  1907,  pageioy. 


138  INFECTIOUS  DISEASES 

time  or  be  immediately  succeeded  by  another  similarly  concluded  paroxysm. 
Severe  paroxysms  commonly  terminate  in  an  act  of  vomiting,  which  brings 
up  considerable  mucus,  often  accumulated  before  the  paroxysm  begins  and 
seeming  to  be  its  exciting  cause.  The  whoop  may  precede  or  begin  the 
paroxysm.  The  number  of  paroxysms  in  the  24  hours  varies  greatly. 
They  may  be  as  often  as  every  half-hour  or  only  four  or  five  times  in  the 
day.  Emotion  or  exertion  will  precipitate  a  paroxysm,  as  will  the  inhalation 
of  irritant  matters.  The  little  patient  resists  the  paroxysms  as  long  as 
possible,  and  when  the  inevitable  comes  it  will  run  to  the  basin  or  bowl, 
knowing  full  well  what  is  to  happen.  The  demure  method  pursued  by  little 
children  under  these  circumstances  is  often  at  once  touching  and  amusing. 
Rupture  of  a  conjunctival  or  nasal  blood-vessel  sometimes  occurs  and 
occasionally  an  involuntary  urination.  An  ulcer  may  form  at  the  frenum  of 
the  tongue,  said  to  be  done  to  pressure  of  that  part  of  the  organ  against  the 
incisor  teeth.  The  termination  of  the  paroxysm  is  followed  by  temporary- 
relief. 

The  paroxysmal  stage,  if  uncomplicated,  is  unattended  by  fever,  and 
physical  examination  of  the  chest  is  barren  of  results  as  compared  with  the 
severity  of  the  cough.  The  percussion  note  is  clear,  clearer  during  inspira- 
tion. Auscultation  may  discover  a  few  moist  rales  soon  after  a  paroxysm; 
but  during  it,  nothing.  Even  during  the  whoop  the  vesictilar  murmiir  may 
be  absent,  because  of  the  slowness  with  which  the  air  enters  the  chest. 

The  length  of  the  paroxysmal  stage  is  usually  from  four  to  six  weeks, 
although  in  mild  cases  it  may  be  shorter.  Indeed,  there  are  mild  cases  of 
whooping-cough  in  which  the  paroxysms  are  scared}'  noticeable  and  would 
not  be  noted  except  for  an  occasional  "whoop."  Toward  the  end  of  this 
period  the  paroxysms  become  less  severe  and  less  frequent,  and  soon  the 
stage  of  decline  or  convalescence  is  established.  In  the  course  of  it  the  par- 
oxysms become  still  milder  and  less  frequent,  and  finally  subside  altogether. 
They  are,  however,  liable  to  be  renewed  for  a  time  if  the  patient  takes  cold, 
and  even  digestive  disturbances  are  said  to  have  a  similar  effect.  The 
other  phenomena  of  the  stage  of  convalescence  are  return  of  appetite, 
weight,  and  strength.  The  period  of  convalescence  occupies  another  four 
weeks,  so  that  the  entire  length  of  an  ordinary  attack  of  whooping-cough  is 
from  ten  to  12  weeks,  and  even  longer. 

Complications  and  Sequelae. — The  complications  that  attend  whooping- 
cough  are  bronchitis,  bronchopneumonia,  collapse  of  the  lung,  pleurisy, 
and  interstitial  emphysema.  The  bronchopneumonia  is  apt  to  be  of  the 
insufflation  kind.  Collapse  of  the  limg  may  succeed  it.  Interstitial 
emphysema  and  even  pneumothorax  maj-  result  from  rupture  of  the  air- 
vesicles,  and  it  is  apt  to  become  general  and  serious.  In  a  case  of  this  kind 
under  the  care  of  my  friend,  Horace  WUUams,  which  terminated  fatally,  an 
abscess  formed  at  each  point  at  which  the  emphysema  approached  the  sur- 
face. Cerebral  palsy  and  death  from  subdural  hemorrhage  are  said  to  have 
occurred  in  whooping-cough.  Among  sequelae  may  be  mentioned,  as  a  rare 
event,  tubercular  consumption;  also  permanent  changes  in  the  shape  of  the 
chest  including  the  so-called  pigeon  breast,  sometimes  the  result  of  a  pro- 
longed attack  of  whooping-cough. 

Diagnosis. — The  diagnosis  cannot  be  delayed  after  the  appearance  of  the 


WHOOPING-COUGH  139 

whoop,  and  it  is  scarcely  possible  without  it.  Spasmodic  cough  may  occur 
from  other  causes,  but  it  is  not  whooping-cough  unless  there  be  the  whoop. 
A  differential  blood  count  shows  a  preponderance  of  lymphocytes,  as  many 
as  50  to  60  per  cent.     This  is  of  diagnostic  value. 

Prognosis. — Notwithstanding  the  enormous  nimiber  of  children  who 
have  whooping-cough  and  get  well  of  it,  many  of  them  without  any  treat- 
ment whatever,  it  is  not  so  harmless  a  disease  as  many  suppose.  Its 
mortality  is  greater  than  that  of  diphtheria  or  scarlet  fever.  At  the  same 
time  we  cannot  believe  that  the  position  assigned  to  whooping-cough  by 
Thomas  M.  Dolan,'  of  being  third  among  the  fatal  diseases  of  children  in 
England,  is  true  of  this  country-.  The  chief  danger  is  from  the  compHcation 
of  bronchopneumonia.  The  younger  the  child,  the  greater  the  danger. 
As  alread}^  stated,  cases  in  which  interstitial  emphysema  occurs  from  rupture 
of  the  air-vesicles  may  terminate  fatally.  The  disease  is  more  serious  in 
the  negro  race — more  than  twice  as  fatal  as  in  whites. 

Treatment. — Prophjdaxis  is  important.  The  Bordet  bacillus  is  found  in 
the  nasal  and  bronchial  discharges,  therefore  the  pernicious  habit  of  allowing 
children  to  vomit  the  mucus  on  the  street  and  in  the  cars  should  be  stopped. 
When  the  mucus  is  discharged  it  should  be  collected  in  a  suit  able  receptacle 
and  at  once  destroyed.  Children  affected  should  not  go  to  school.  The 
treatment  of  whooping-cough  is  one  of  the  opprobria  of  medicine.  Not- 
withstanding the  claims  of  many  to  the  contrary^  it  remains  a  fact  that  we 
possess  no  means  of  cutting  it  short.  We  may,  however,  palliate  the  disease 
by  diminishing  both  the  frequency  and  the  severity  of  its  paroxysms.  Fresh 
air  is  important.  The  patient  should  sleep  in  a  room  -nath  windows  vnAe 
open,  and  be  out  in  the  air  as  much  as  practicable,  during  the  day.  Violent 
exertion  should  be  prohibited.  The  best  remedies  are  the  opiates,  chloral, 
and  antispasmodics.  The  former  two,  as  a  rule,  should  be  reserv^ed  for 
night,  though  in  severe  cases  chloral  in  doses  sufficient  to  secure  somno- 
lence is  recommended  by  Willoughby.^  Of  the  latter,  the  most  efficient 
are  belladonna,  the  bromids,  and  asafetida.  Belladonna  should  be  given 
in  full  doses.  It  is  difficult  to  name  them,  and  they  must  for  the  most  part 
be  arrived  at  by  trial.  We  may  begin  with  i  minim  (0.066  gm.)  of  the 
tinctiore  every  two  hours  to  a  child  of  six  months,  or  1/12  grain  (0.0055  gm.) 
of  the  extract,  and  increase  the  dose  until  the  characteristic  redness  of  the 
skin  is  produced. 

.The  bromids,  preferably  of  sodium,  should  be  given  as  often,  in  doses  of 
2  or  5  grains  (o.i  to  0.3  gm.)  for  every  year  of  age.  Asafetida  is  useful. 
Antipyrin  has  acquired  some  reputation  and  has  been  especially  recom- 
mended by  F.  J.  Taylor,^  and  Von  Genser.  The  former  says  in  manj'  cases 
its  action  is  little  short  of  marvelous.  He  recommends  beginning  with  a 
small  dose,  increased  until  a  child  of  two  years  is  taking  2  or  3  grains 
every  three  hours.  The  bromids  of  potassiimi,  sodium,  and  anunonium 
may  be  combined  with  it.  The  same  writer  recommends  alum  to  check 
excessive  secretion  in  the  later  stages,  3  grains,  every  three  or  four  hours, 
to  a  child  two  years  old.     Von  Genser  recommends  2  grains  a  day  for  each 

1  "Whooping-cough."  London,  1882. 

2  "Am.  Jour.  Obstetrics."  June,  l8g8. 

^  "Annals  of  Gynecology  and  Pediatrics,"  July.  1899.  See  also  very  full  paper,  giving  the  expe- 
rience of  many  physicians  in  "Gazette  Hebdom.  de  Med.  et  Chirurg.,"  October  22,  1896,  by  Le  Goff. 
Abstracts  in  "New  York  Med.  Jour.."  November  14,  1896. 


140  INFECTIOUS  DISEASES 

year  of  age  and  reports  recovery  in  24  days.  Good  results  are  claimed 
for  quinin  in  doses  of  5  grains  a  day  for  a  child  five  years  old.  An  ab- 
dominal binder  very  tightly  applied  sometimes  controls  the  severity  of  the 
parox3''sms. 

The  intervals  between  the  paroxysms  at  night  may  be  prolonged  by  the 
judicious  use  of  paregoric,  deodorized  tincture  of  opium  or  codein  com- 
bined with  antispasmodics,  including  belladonna  and  the  bromids. 

The  inhalation  of  germicidal  solution  suggested  by  the  probable  germ 
origin  of  the  disease  has  not  as  yet  produced  any  results.  The  use  of  agents 
which  require  a  room  to  be  closed  so  the  air  may  be  impregnated  with  the 
drug  is  not  only  useless  but  it  is  harmful.  The  various  patent  preparations 
on  the  market  should  be  shunned. 

Parents  should  be  enjoined  to  protect  their  children  from  undue  expo- 
sure, because  it  is  this  that  causes  complications,  and  it  is  the  complications 
that  are  dangerous.  Such  complications,  and  other  symptoms  which  arise 
in  the  course  of  the  disease,  should  be  treated  by  appropriate  remedies. 

The  possibilities  of  serum  therapeutics  extend  to  the  treatment  of 
whooping-cough,  and  Walsh,  in  the  paper  alluded  to,  refers  to  results  ob- 
tained by  him  which  encoixrage  further  trial. 

MUMPS. 

Synonym. — Epidemic  Parotitis. 

Definition. — Mumps  is  an  acute  infectious  disease  characterized  by 
inflammation  of  the  partoid  gland,  sometimes  of  the  submaxillary. 

Etiology. — Although  a  bacillus  parotidis  has  been  described,  it  is  gen- 
erally conceded  that  the  real  contagium  of  mumps  has  not  been  isolated. 
Children  and  adolescents  are  its  favorite  subjects,  the  very  young  as  well  as 
adults  being  equally  exempt.  More  boys  are  attacked  than  girls.  The 
disease  is  more  common  in  the  spring  and  fall.  It  is  more  commonly 
epidemic,  but  may  be  sporadic.  It  may  be  associated  with  measles  and 
whooping-cough.     One  attack  protects  against  a  second. 

Morbid  Anatomy. — The  swollen  and  hardened  salivary  gland  is  the  sole 
morbid  product.     The  swelling  is  mainly  due  to  infiltration. 

Symptoms. — From  seven  to  14  days  intervene  between  exposure 
and  the  invasion,  which  is  ushered  in  by  moderate  fever,  rarely  exceeding 
101°  F.  (38.33°  C),  although  103°  and  104°  F.  (39.44°  and  40°  C.)  have 
been  noted.  The  first  symptom  is  usually  pain  below  and  in  front  of  the 
ear,  but  pain  in  swallowing  maj- be  first  experienced.  Simultaneously,  there 
may  be  swelling  about  the  ear,  which  extends  rapidly  in  front  of  the  ear 
and  below  it  until  the  entire  neck  in  this  vicinity  is  involved. 

The  maximum  swelling  is  reached  in  about  48  hours,  after  which  the 
involvement  of  the  other  side  begins  and  extends  with  equal  rapidity.  The 
most  prominent  point  is  in  front  of  the  ear.  The  swelling  does  not,  how- 
ever, subside  as  fast  as  it  comes  on,  but  presists  from  seven  to  ten  days. 

At  the  height  of  the  disease  the  pain  and  difficulty  in  swallowing  are 
extreme,  the  former  extending  often  to  the  interior  of  the  ear,  producing 
earache,  and  the  hearing  may  be  affected.     The  parts  are  so  tense  and 


MUMPS  141 

swollen  as  to  make  opening  of  the  mouth  almost  impossible,  mastication 
equally  difficult.  Suppuration  is  an  exceedingly  rare  event.  In  cases  of 
great  severity  delirium  is  sometimes  present  for  a  short  time. 

Occasionally  the  other  salivary  glands  are  affected. 

Complications. — The  most  frequent  complication  is  orchitis,  and  occur- 
ring, as  it  commonly  does,  after  inflammation  of  the  salivary  glands  has 
subsided,  it  has  been  regarded  as  a  metastasis;  but  this  is  probably  not  the 
case,  since  both  conditions  may  be  the  result  of  the  same  cause,  as  originally 
held  by  Niemeyer.  The  swelling  may  affect  one  or  both  testicles,  the  dura- 
tion being  longer  in  the  bilateral  form.  The  organs  are  heavy  and  painful, 
but  not  so  much  so  as  in  gonorrheal  epididymitis.  The  inflammation  lasts 
for  three  or  four  days  and  then  subsides  gradually.  Usually,  the  gland  itself 
is  involved,  but  occasionally  there  occurs  acute  epididymitis  with  acute 
hydrocele  and  edema  of  the  scrotum.  Atrophy  is  said  to  have  super- 
vened. 

Inflammation  of  the  mammary  glands  and  of  the  vulva  sometimes 
occurs  in  girls,  and  more  rarely  of  the  ovaries. 

Otitis  media  with  resulting  deafness,  meningitis,  and  facial  palsy  are 
occasional  complications. 

Diagnosis. — The  diagnosis  usually  presents  no  difficulties,  and  any 
doubt  is  commonly  cleared  by  the  acuteness  of  the  attack.  Certain  enlarge- 
ments of  the  cervical  lymphatic  glands  resemble  contagious  parotitis,  and 
in  tuberculous  children  the  swelling  in  mumps  is  sometimes  prolonged, 
but  the  physiognomy  in  this  disease  is  different  and  distinctive.  There 
is  more  swelling  in  front  of  the  ear  in -parotitis,  and  in  the  first  stage  a 
triangular  shape  is  produced  with  the  apex  downward,  while  the  lobe  of  the 
ear  is  raised  in  a  characteristic  manner. 

Prognosis. — The  prognosis  is  favorable,  no  fatal  cases  of  uncomplicated 
mumps  being  recorded. 

Treatment. — No  means  of  shortening  the  duration  of  the  disease  exists. 
The  patient  should  be  kept  uniformly  warm,  and  to  this  end  the  bed  is 
desirable.  It  is  usual  to  anoint  the  gland  with  some  simple  ointment,  as 
cold  cream,  and  it  may  be  that  the  feeling  of  drawing  and  tension  is  thus 
relieved.  No  commensurate  advantage  results  from  leeching.  It  is 
thought  by  some  that  the  so-called  metastasis  is  occasioned  by  exposirre  to 
cold,  and  if  this  be  true,  there  is  even  better  reason  for  keeping  the  patient 
warm.  Warm  applications  are  generally  better  borne  than  cold.  Cotton — 
wool  or  flannel,  warmed  and  greased,  gives  a  sense  of  comfort.  Fever 
should  be  treated  by  appropriate  remedies  and  other  symptoms  met  as  they 
arise. 

Secondary  Parotitis. — This  term  is  applied  to  parotitis  occurring  as  a 
complication  in  acute  infectious  diseases,  typhoid  fever,  typhus  fever,  and 
pneumonia  being  the  most  frequent.  It  may  be  a  complication  of  pyemia, 
phthisis,  and  carcinoma.  Except  in  pyemia,  when  it  is  metastatic,  it  is 
probably  caused  by  the  germ  of  the  disease  present,  or  the  bacteria  of  decom- 
posing matters  in  the  mouth,  which  reach  the  gland  through  the  duct  of 
Steno. 

It  is  a  much  more  serious  affection  than  mumps,  with  which  it  has 
nothing  in  common,   and  often  terminates  in  suppuration.     Facial  paral- 


142  lyFECTIOVS  DISEASES 

ysis  may  result  from  destruction  of  the  facial  nerve,  or  there  may  be  deafness 
from  invasion  of  the  middle  ear. 

The  treatment  of  secondary  parotitis  is  that  of  phlegmonous  inflammation 
elsewhere. 

INFLUENZA. 

Synonyms. — Catarrhal  Fever;  Grip;  La  Grippe. 

Definition. — Influenza  is  an  acute  infectious  disease  characterized  by 
fever,  by  catarrhal  irritation  of  any  or  all  of  the  mucous  tracts,  especially 
the  respiratory,  by  muscular  pain,  and  by  great  prostration.  It  is  com- 
monly epidemic. 

Etiology. — In  1892  Pfeiffer  discovered  in  the  pus-cells  of  tracheal 
mucus  an  organism  which  he  regarded  as  that  of  influenza.  It  is  0.8  to  i 
micron  long  and  o.i  to  0.2  micron  broad — i.  e.,  about  the  same  width  as  the 
bacillus  of  mouse  septicemia  and  half  as  long.  It  forms  colonies  on  glycerin 
agar  24  hours  after  inoculation,  visible  under  the  microscope  as  clear, 
water-like  drops.  These  drops  do  not  coalesce,  but  remain  separate.  The 
bacilli  are  best  stained  in  dilute  Ziehl-Neelsen  solution  of  carbol  fuchsin 
or  hot  Loeffler  methylene  blue  solution.  Later  studies  tend  to  sustain 
Loeffler's  claim.  The  bacilli  are  very  numerous  in  the  nasal  and  bronchial 
mucus,  whence  they  are  conveyed  to  others,  constituting  a  true  contagium. 
P.  Canon'  claims  to  have  found  them  in  the  blood,  in  large  numbers  and  in 
clumps,  although  he  admits  that  his  observations  have  not  as  yet  been 
confirmed.  The  contagious  nature  of  influenza  is  further  sustained  by  the 
fact  that  it  travels  only  as  fast  as  people  travel,  even  contrary  to  the  direc- 
tion of  prevailing  winds.  The  complications  and  sequelae  of  the  disease — 
pneumonia,  pleurisy,  endocarditis — may  be  the  result  of  a  toxin,  or  the 
bacillus  may  be  transmitted  in  the  blood  to  the  seat  of  secondary  infection. 
One  attack  does  not,  however,  protect  against  a  second,  and  I  know  persons 
who  have  had  an  attack  each  winter  for  several  winters. 

Varieties. — There  is  much  carelessness  at  the  present  day  in  the  ap- 
plication of  the  word  "grippe."  Commonly,  when  a  person  is  said  to  have 
"grippe"  it  means  that  he  has  a  bad  cold  in  the  head,  with  more  or  less 
bronchial  catarrh.  This  seemingly  is  what  Leichtenstem  calls  endemic 
influenza  nostras,  pseudo-influenza,  or  catarrhal  fever,  a  special  disease  of 
unknown  etiology,  which  bears  the  same  relation  to  the  true  influenza  as 
cholera  nostras  to  Asiatic  cholera.  In  addition,  Leichtenstem  makes  two 
other  divisions — (i)  epidemic  influenza  vera,  caused  by  Pfeiffer's  bacillus; 
(2)  endemic  influenza  vera,  which  often  develops  for  several  years  in  succes- 
sion after  a  pandemic,  also  due  to  Pfeiffer's  bacillus. 

Morbid  Anatomy. — The  anatomical  changes  are  those  of  the  compli- 
cations. Whatever  alterations  are  the  direct  result  of  the  disease  itself  for 
the  most  part  promptly  disappear  after  death. 

Symptoms. — Influenza  has  a  period  of  incubation  of  from  two  to  three 
days  or  longer.  It  attacks  all  ages,  infancy  less  commonly,  more  frequently 
persons  from  20  to  50  years  old.  The  mode  of  onset  is  by  no  means  the 
same.     The  attack  may  be  ushered  in  by  a  chill  or  continued  chilliness. 

•Canon.    "Die.  Bacteriologio  des  Blutes  bei  Infektionskrankheiten.    Jena,  igos.  p.  los. 


INFLUENZA  143 

Most  frequently,  perhaps,  there  are  coryza  and  sneezing,  with  or  without 
watering  of  the  eyes.  To  this  succeeds  cough,  to  which  is  commonly 
added,  very  soon,  copious  expectoration.  The  cough  may  be  paroxysmal 
and  be  attended  with  prostration  at  the  end  of  the  spell.  It  is  often  per- 
sistent, while  the  bronchitis  may  pass  into  bronchopneumonia  or  a  croupous 
pneumonia  may  supervene.  Less  frequently,  there  may  hefaucitis,  simple, 
however,  and  not  accompanied  by  ulceration  or  white  patches,  but  causing 
intense  pain  in  deglutition.  These  symptoms  are  more  or  less  associated 
with  muscular  pain  elsewhere,  although  not  invariabl3^  At  other  times 
the  attack  begins  with  severe  pain  in  the  back  or  back  of  the  head,  the  chest 
walls,  the  extremities,  or  throughout  the  muscular  system.  Such  pain  is 
sometimes  severe  and  sudden.  Severe  headache  may  be  a  symptom, 
associated  with  other  symptoms  such  as  pain  in  the  back  and  neck  with 
delirium  which  suggest  meningitis. 

Another  mode  of  onset  is  by  an  extreme  and  sudden  prostration.  This 
prostration  is  apt  to  be  prolonged  even  in  mild  cases  far  bej'ond  what  seems 
reasonable.  Mental  depression  is  a  frequent  symptom,  and  suicide  and  even 
manslughhter  have  been  said  to  be  its  terminal  acts. 

There  is  always  more  or  less  fever.  Commonly,  it  is  slight  at  first,  but 
sometimes  very  high,  ushering  in  the  febrile  variety  of  the  disease.  We  have 
known  it  to  be  106.2°  F.  (41.2°  C.)  at  the  first  observation  of  a  patient. 
More  frequently,  it  does  not  exceed  103°  F.  (39.4°  C),  and  it  is  often  but 
slightly  above  normal.  During  convalescence  the  temperature  may  become 
subnormal,  and  in  the  patient  alluded  to  there  was  a  fall  from  106°  F. 
(41.1°  C.)  to  96°  F.  (35.6°  C.)  in  a  very  short  space  of  time.  Further,  the 
temperature  chart  may  exhibit  fantastic  changes,  as  seen  in  that  of  the  case 
of  a  medical  student  who  made  a  good  recovery  after  28  days'  illness  (see 
Fig.  16).  Delirium  is  sometimes  associated  with  the  fever,  and  may  come 
on  suddenly  and  actively.  The  pulse  is  usually  corresponding  frequent,  but 
some  cases  of  uncommonly  slow  pulse  have  fallen  under  observation. 

While  pulmonary  catarrh  is  perhaps  the  most  frequent  catarrhal  mani- 
festation, it  is  by  no  means  always  present,  even  when  there  are  pulmonary 
symptoms.  An  obstinate  case  of  bronchial  spasm  was  seen  by  one  of  us 
without  any  secretion  whatever.  In  the  epidemic,  especially  of  1893-94, 
in  Philadelphia  and  vicinity,  gastric  catarrh  was  frequent,  producing  dis- 
tressing nausea  with  voraiting,  and  adding  greatly  to  the  physical  weakness. 
Severe  vomiting  may  even  usher  in  the  attack,  especially  in  children.  More 
rarely  there  is  diarrhea.  Other  cases  begin  with  nervous  symptoms  of  which 
headache  and  delirium  are  conspicuous,  suggesting  meningitis.  Herpes  is 
sometimes  present. 

According  as  one  or  another  set  of  symptoms  predominates,  the  disease 
is  said  to  belong  to  the  respiratory,  nervous,  muscular  or  rheumatic,  gastro- 
intestinal, or  febrile  form  of  influenza. 

Complications. — The  most  serious  complication  is  pneumonia.  It  is 
often  invited  by  exposure  during  convalescence  or  in  the  attempt  of  a 
patient  to  fight  out  the  disease  without  giving  up.  In  these  events  it  is 
usually  ushered  in  by  a  chill  and  extends  rapidly  through  the  whole  of  one 
lung  or  both  lungs.  When  a  part  of  the  primary  attack,,  the  pneumonia 
is  more  apt  to  be  catarrhal  and  circumscribed,  creeping  from  the  bronchi 


144 


INFECTIOUS  DISEASES 


into  the  air-vesicles,  and  is  less  serious,  although  it  may  also  be  fatal,  espe- 
cially in  old  persons.  At  other  times  the  inflammation  is  confined  to  the 
minute  bronchioles,  and  we  have  the  physical  signs  of  a  capillary  bronchitis. 
It  may  be  associated  with  pleurisy.  Of  cardiac  and  vascular  complications 
endocarditis,  pericarditis,  irregularity  of  the  heart  unassociated  with 
evident  endocarditis  or  pericarditis,  may  arise.  Sudden  heart  failure  is 
to  be  remembered  as  a  possible  cause  of  death. 


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Fig.  16. — Chart  of  a  Case  of  Influenza — Medical  Student. 

Of  nervous  lesions  meningitis  and  encephalitis  have  been  noted,  even 
abscess  of  the  brain;  also  neuritis  and  optic  neuritis;  in  fact,  almost  every 
form  of  nervous  disease,  though  some  of  the  conditions  must  be  referred  to 
errors  of  diagnosis,  cerebrospinal  fever  being  probably  responsible  for  some. 
Herpes,  when  present,  is  probably  a  result  of  neuritis.  Mention  should  not 
be  omitted  of  venous  thrombosis — phlegmasia  alba  dolens — as  a  complication 
of  influenza,  Leyden  and  Guttmann  having  collected  28  cases.' 

A  most  important  fact  to  be  remembered  in  tliis  connection  is  the  tend- 

^  "Deutsche  med.  Wochenschrift,"  No.  6,  1897, 


INFLUENZA  145 

ency  of  influenza  to  develop  latent  disease  into  active  disease,  and  to  make 
slight  grades  of  organic  affections  more  serious.  This  is  particulariy  seen 
in  connection  with  heart  disease  and  kidney  disease.  A  small  albuminuria 
with  no  other  symptoms  may  become,  after  an  attack  of  influenza,  an 
incurable  and  rapidly  fatal  Bright's  disease. '  A  mild  cardiac  affection, 
scarcely  noticeable  by  its  symptoms,  maj^  become  a  grave  illness  with 
degeneration  of  muscular  substance  and  dilatation  of  the  caNnties. 

Diagnosis. — The  diagnosis  is  ordinarily  easy,  although  doubtless 
during  an  epidemic  many  cases  are  called  influenza  that  are  cases  of  simple 
bronchitis,  faucial  angina,  or  nasal  catarrh.  The  diagnostic  features  in 
addition  to  the  catarrhal  factor  are  the  suddenness  of  attack,  fever  of  short 
duration,  extreme  disproportionate  prostration.  Muscular  pains  are  char- 
acteristic, but  not  always  present.  Cerebrospinal  fever  and  influenza  are 
sometimes  confounded.  The  distinction  will  be  considered  when  treating 
of  the  former.  Some  cases  in  their  incipiency  resemble  typhoid  fever, 
but  the  suddenness  of  onset,  absence  of  the  typical  temperatiu^e  of  typhoid, 
of  epistaxis,  of  diarrhea,  together  with  the  shorter  duration  of  the  illness, 
turned  the  scale  in  favor  of  influenza. 

Prognosis. — The  prognosis  is  generally .  favorable,  especially  if  the 
patient  goes  to  bed  at  once,  or  at  least  houses  himself.  Such  a  one  is 
almost  sure  to  be  well  in  three,  four  or  five  days.  It  is  possible,  however, 
for  one  attacked  to  fight  through  the  disease  without  losing  a  daj^'s  time. 
But  especially  unfortunate  is  he  if  he  fails  in  this  attempt  because  of  expos- 
ure or  inability  to  hold  out  longer  against  the  dibilitating  effect  of  the  dis- 
ease. In  the  former  he  is  apt  to  have  pneumonia,  in  the  latter  he  has  to 
contend  with  extreme  prostration.  The  prostration  of  the  epidemic  variet}* 
is  something  peculiar.  The  weakness  is  extreme,  and  the  slightest  effort, 
physical  or  mental,  promptly  convinces  the  patient  of  this.  The  duration 
of  the  weakness  may  be  greatly  prolonged,  months  being  sometimes 
necessary  to  overcome  it. 

Treatment. — The  treatment  in  the  majority  of  cases  is  very  simple. 
Rest  in  bed,  without  medicine  answers  for  a  large  mmiber.  Beyond  this 
the  treatment  is  mainly  symptomatic,  phenacetin,  acetanilid,  or  antipyrin 
being  generally  sufficient  to  subdue  the  pains  when  present.  Quinin  is 
necessary  in  many  cases  to  keep  up  the  strength.  In  ordinary  cases  requir- 
ing treatment  5  grains  (0.324  gm.)  of  phenacetin  with  5  grains  of  salol  if  of 
value  given  every  four  hours.  When  the  pains  are  very  severe,  the  phena- 
cetin may  be  given  more  frequently  and  even  in  larger  doses.  When  head- 
ache is  present  caffein  should  be  added  in  doses  of  i  1/2  to  3  grains  (o.i  to 
0.3  gm.).  Larger  doses  of  quinin  may  be  needed.  A  favorite  prescription 
is  a  capsule  of  2  1/2  grains  (0.16  gm.)  each  of  Dover's  powder,  salol,  and  phen- 
acetin, every  two  or  three  hoiurs.  Still  another  is  phenacetin  and  salicin, 
of  each  2  1/2  grains  (0.16  gm.),  and  powdered  camphor,  1/2  grain  (0.035 
gm.). 

The  cough  may  be  treated  with  turpentine  stupes  and  sinapisms  to 
the  chest;  and  when  there  are  positive  laryngeal  symptoms,  "Dobell's 
solution,"  sprayed  into  the  larynx,  is  very  soothing.     It  may  also  be  sprayed 


'  See  a  paper  by  G.  Baumgarten  on  "Renal  Affections  Following  Influenza,"  in  "Transactions  of  the 
Association  of  American  Physicians,"  vol.  x.,  1895.  j 


146  INFECTIOUS  DISEASES 

into  the  nasal  passages,  or  cocain  may  be  applied  locally.  Internally,  the 
officinal  solution  of  citrate  of  potassium  in  1/2  fluidounce  (15  c.c.)  doses, 
every  two  or  three  hours,  is  helpful.  When  the  cough  is  disturbing,  small 
doses  of  morphin  or  heroin  may  be  necessary;  and  if  secretion  has  set  in, 
ammoniiun  chlorid  in  5  to  10  grain  (0.324  to  0.648  gm.)  doses,  with  15 
minims  (i  gm.)  of  syrup  of  squills  and  2  drams  (7.4  c.c.)  of  compound 
licorice  mixture  are  sufficient  to  answer  the  purpose.  If  more  stimulating 
effect  is  required  on  the  secretion,  the  aromatic  spirit  of  ammonivun  in  1/2 
dram  doses  (2  gm.),  or  carbonate  of  ammonium  in  doses  of  5  to  10  grains 
(0.324  to  0.648  gm.)  may  be  substituted.  On  accoimt  of  the  fact  that 
hexamethylenamin  is  excreted  by  the  mucous  membranes  this  drug  maj'  be 
used  in  doses  of  3  to  5  grains  (0.2  to  0.4)  repeated  every  two  or  three  hours. 
Opium  may  be  given  in  large  doses,  or  morphin  in  corresponding  doses,  to 
relieve  pain,  if  required. 

For  the  prostration,  supporting  measures  are  necessary,  and  stimulants 
may  be  called  for.  Whisky  and  milk  are  efficient.  The  entire  absence 
of  appetite  and  the  complaint  that  all  things  taste  alike  are  to  be  ignored, 
and  the  patient  must  be  encouraged  to  take  food,  which  should  be  made 
as  attractive  as  possible.  Strychnin  is  an  admirable  heart  tonic,  and  may 
be  given,  1/30  grain  (0.00216  gm.),  every  six  hours,  increased,  if  necessarj\ 

Treatment  for  the  pneumonia,  often  so  grave  a  complication,  is  at  times 
extremely  difficult.  In  a  few  cases  "pneumonia  fidminans"  strikes  the 
patient  down  so  suddenly  and  violently  as  to  make  all  treatment  unavailing . 
Referring  the  reader  for  details  to  the  section  on  pneumonia,  it  may  be  said 
that,  as  a  rule,  in  the  pneumonia  of  influenza,  stimulating  and  restorative 
measures  of  a  very  positive  character,  rather  than  depressing  agents,  are 
indicated.  The  free  use  of  alcohol  and  ammonia  is  especialh'  necessary. 
Dry-cupping  is  never  out  of  place.  It  may  be  repeated  and  should  be 
followed  during  convalescence  by  a  jacket  of  wool,  to  maintain  warmth  and 
a  uniform  temperature,  but  this  is  of  doubtful  propriety  during  the  height 
of  fever  when  we  need  measixres  to  dissipate  heat  rather  than  retain  it. 

One  need  not  wait  for  the  physical  signs  of  pneumonia  to  present  them- 
selves before  beginning  the  treatment.  Given  a  chill  after  exposure,  with 
no  other  cause  to  explain  it,  a  pneumonia  is  almost  ine\atable.  Oftentimes 
a  pneumonic  focus  in  the  center  of  a  lung  does  not  furnish  any  physical 
signs,  while  to  wait  until  it  approaches  the  surface  causes  a  fatal  delay  in 
the  treatment. 

Other  complications  of  influenza  are  treated  as  when  they  are  simple 
diseases.     Overmedication  should  be  avoided. 


CEREBROSPINAL  FEVER. 

Synonyms. — Epidemic  Cerebrospinal  Meningitis;  Spotted  Fever;  Petechial 

Fever. 

Definition. — An  infectious  disease  of  sporadic  and  epidemic  occurrence, 
microbic  in  origin  and  especially  characterized  by  inflammation  of  the 
membranes  of  the  brain  and  spinal  cord. 

Etiology. — The  direct  cause   of   cerebrospinal  fever  is  a  lancet-shaped 


CEREBROSPINAL  FEVER  147 

diplococcus  resembling  the  pneumococcus,  discovered  by  Wcichcslbaum 
in  1887,  and  called  by  him  meningococcus  or  diplococcus  intracellularis 
meningitidis.  It  lies  largely  within  the  polynuclear  leukocyte  found  in  the 
spinal  fluid  in  the  disease.  Weichselbaum's  observations  were  confirmed 
by  Heubner'  in  1891,  by  Jaeger  in  1895,  and  by  Councilman,^  Mallory, 
and  Wright  in  1898,  and  Osier'  in  1899.  While  the  disease  may  be  re- 
garded as  contagious,  it  is  not  highly  so,  being  somewhat  like  tuberculosis 
in  this  respect.  That  the  infectious  agent  is  always  derived  from  an  in- 
fected person  is  at  least  doubtful,  the  disease  not  being,  as  a  rule,  traceable 
to  another  having  it,  but  appearing  to  arise  rather  in  certain  houses  or 
localities  where  the  necessary  conditions  prevail.  Neisser  has  shown 
that  the  bacillus  is  transmissible  by  feeble  atmospheric  currents. 

The  following  are  the  characteristic  features  of  this  bacillus:  It  occu- 
pies a  position  within  the  polynuclear  leukocyte,  whence  the  adjective 
term  intracellularis.  It  takes  the  usual  stains,  and  is  decolorized  by  the 
Gram  method.  It  forms  on  Loeffler's  blood-serum  "round,  whitish,  shin- 
ing, viscid-looking  colonies,  with  smooth,  sharply  defined  outlines,  which 
attain  a  diameter  of  i  to  i  1/2  microns  in  24  hours"  (Councilman).  It 
is  found  in  the  cerebrospinal  exudate,  and  has  been  isolated  from  blood, 
pus,  the  joints,  from  pneumonic  areas  in  the  lungs,  and  from  nasal  mucus. 

Predisposing  causes  are — cold,  moisture,  exposure,  defective  sanitation. 
Crowded  buildings,  barracks,  and  tenements  have  been  favorite  localities, 
especially  in  Europe.  Depressing  influences  and  the  fatigue  of  long  marches 
favor  it.  During  the  Civil  War  in  America  both  armies  suflfered  from  the 
disease,  but  the  mortality  was  not  large.  The  disease  is  more  prevalent 
at  times  in  the*  country  than  in  the  city.  It  is  more  common  in  the  young, 
attacking  even  infants  of  less  than  a  year  old.  Sex  and  race  seem  to  have 
no  influence  on  the  etiology.  The  organism  probably  reaches  the  blood 
stream  through  the  nasal  mucous  membrane. 

Morbid  Anatomy. — The  external  appearance  of  the  body  after  death 
is  not  peculiar.  Most  characteristic  are  the  remnants  of  the  eruption, 
petechial  or  herpetic,  but  they  are  not  constant.  The  brain  and  spinal 
cord  are  naturally  the  seats  to  which  we  look  for  morbid  changes,  and  we 
find  every  degree  of  inflammatory  condition,  from  slight  hyperemia,  such 
as  may  be  found  in  any  form  of  infectious  disease,  to  intense  congestion 
with  injection  of  the  pia-arachnoid,  and  flnally  a  stage  in  which  pus  and 
fibrinous  deposits,  more  particularly  in  connection  with  the  pia  mater,  are 
abundantly  present.  Higher  degrees  of  hyperemia  involve  even  the  cal- 
varium  as  well  as  the  dura  mater.  The  arachnoid  spaces  may  contain 
serum  and  pus,  but  it  is  under  the  pia  mater  that  we  look  for  the  inflam- 
matory products — serous,  fibrinous,  or  purulent,  especially  at  the  bottom 
of  the  sulci,  in  the  longitudinal  and  Sylvian  fissures  and  at  the  base  over  the 
pons,  the  chiasm,  and  cerebellum.  To  a  less  degree  the  convexity  of  the 
brain  is  also  involved,  and  even  the  brain  substance  may  share  in  thei  hy- 
peremia, while  actual  softening  has  been  noted.  Adhesions  between  the 
pia  and  the  cortex  are  common,  removal  of  the  pia  carrying  the  substance 

1  "Jahrbuch  ftir  Kinderhexlkunde,"  1891,  and  "Deutsche  med.  Wochenschrift,"  1897. 

2  "Epidemic  Cerebrospinal  Meningitis,"  "Report  of  the  State  Board  of  Health  of  Massachusetts, 
Boston,  1898." 

^  Cavendish  Lecture,  "On  the  Etiology  and  Diagnosis  of  Cerebrospinal  Fever,"  "West  London  Med. 
Jour.,",  1899. 


148  INFECTIOUS  DISEASES 

of  the  cortex  with  it.  More  rarely  there  is  an  effusion  into  the  ventricles 
and  the  choroid  plexus  is  congested.  The  walls  of  the  ventricles  may  be 
softened,  and  in  cases  of  long  standing  there  is  even  hydrocephalus. 

The  cranial  nerves,  especially  the  auditory  and  optic,  may  be  the  seat 
of  a  neuritis,  or  bathed  in  pus  infiltrating  the  lymph-sheaths.  The  muscular 
and  trophic  phenomena  resulting  from  such  involvement  may  be  permanent. 

The  spinal  membranes  are  similarly  hj'peremic,  even  to  the  extent  of 
extravasation  of  blood  at  times.  The  same  inflammatory  products  are 
found  upon  them  as  on  the  meninges  of  the  brain.  They  are  more  fre- 
quently seen  on  the  posterior  aspect  of  the  cord,  but  may  be  general. 
Ounces  of  pus  have  been  removed  from  the  spinal  canal.  Even  the  central 
spinal  canal  has  been  found  dilated  and  filled  with  pus.  There  may  be 
likewise  inflammation  of  the  substance  of  the  cord.  The  roots  of  the 
spinal  nerves  may  be  compressed  by  exudate,  producing  localized  paralysis, 
or  may  be  themselves  the  seat  of  a  neuritis,  whence  the  characteristic  clonic 
muscular  contractions  often  present,  while  the  irritation  of  the  sensory- 
roots  gives  rise  to  more  or  less  intense  pain.  Certain  malignant  cases  are  of 
so  short  duration  that  there  is  no  time  for  morbid  changes  to  occur.  In 
such  the  results  of  necropsy  are  negative. 

Minutely  examined,  the  exudate  consists  of  polynuclear  leckocytes 
inclosed  in  a  fibrinous  mass  in  which  also  diploccocci  are  found.  The  brain 
and  cord  may  also  be  infiltrated  with  pus-cells.  In  the  more  chronic  cases 
there  is  thickening  of  the  meninges,  with  scattered  yellow  patches  represent- 
ing exudate. 

As  to  other  organs,  there  is  no  characteristic  involvement.  The  spleen 
may  be  normal  in  size  or,  if  the  illness  has  lasted  some  time,  it  may  be 
slightly  enlarged.  There  may  be  congestion  of  the  liver,  kidney,  stomach, 
and  intestines,  and  even  extravasation  of  blood.  The  same  is  true  of  the 
lungs,  in  which  there  may  be  bronchitis  and  pneiamonia,  the  latter  not  very 
rarely.     Endocarditis  and  pleurisy  are  sometimes  found. 

Symptoms. — Cerebrospinal  fever  does  not  present  an  unvarying  picture 
in  its  symptomatology,  and  to  attempt  to  portray  every  unusual  symptom 
would  occupy  undue  space.  Several  varieties  are  described,  viz.,  (i)  the 
ordinary  form,  (2)  the  malignant  form,  (3)  the  mild  form,  (4)  the  abortive 
form,  (s)  the  intermittent  form,  (6)  the  chronic  form.  Only  the  most 
characteristic  symptoms  will  be  given,  first  of  the  ordinary  form  and  then  of 
the  most  important  modifications  of  it. 

I.  The  Ordinary  Form.  No  definite  time  of  incubation  is  known.  A 
prodromal  period  of  short  duration  with  headache  and  pain  in  the  back  or 
headache  and  vertigo  may  precede,  but  sudden  onset  is  characteristic,  often 
associated  with  a  decided  chill.  Projectile  vomiting  is  also  a  frequent  early 
sjTnptom.  Headache  and  pain  in  the  back  of  the  neck  and  back  promptly 
appear.  Though  usually  severe,  this  pain  is  sometimes  so  slight  as  to  cause 
the  feal  condition  to  be  overlooked.  It  is  sometimes  so  sudden  and  severe 
as  to  be  compared  to  the  sting  of  a  bee.  The  muscles  are  rigid,  and  pain  is 
increased  on  motion. 

There  is  fever,  but  the  temperature  does  not  usually  exceed  102°  F. 
(38.9°  C).  There  is  nothing  characteristic  in  the  fever,  and  the  graphic 
chart  shows  no  regular  evening  rise  and  morning  fall.     On  the  other  hand, 


CEREBROSPINAL  FEVER  149 

it  is  extremely  irregular.  Hyperesthesia  of  the  skin  is  a  characteristic 
symptom.  It  is  sometimes  extreme,  and  as  the  disease  increases  in  severity 
rigidity  of  the  muscles  of  the  neck  and  back  becomes  more  marked.  This 
muscular  contraction  may  cause  backward  curvature  of  the  head  and  even 
opisthotonos.  Clonic  spasm  may  also  occur,  though  less  frequent  than  tonic 
contraction.  It  is  more  common  in  children,  in  whom  it  may  amount  to 
convulsion  and  take  the  place  of  the  chill.  Spasm  of  the  muscles  of  the  face 
may  occur,  and  of  the  eye-muscles,  causing  strabismus .  Strabismus  in  any 
febrile  case  of  doubtful  nature  should  always  lead  to  suspicion  of  meningitis. 
On  the  other  hand,  there  may  be  paralysis  of  the  face  and  eye-muscles, 
producing  inequality  of  pupils,  nystagmus,  diplopia,  and  ptosis.  More, 
rarely  there  are  paralysis  and  wasting  of  trunk  muscles,  including  those  of 
respiration.  The  auditory  nerves  may  be  involved,  affecting  the  hearing. 
and  intolerance  of  sound  is  a  characteristic  symptom,  as  is  also  photophobia 
due  to  hyperemia  of  the  retina.  On  the  other  hand,  anesthesia  of  the 
cornea  is  found  in  some  cases. 

Delirium  is  very  frequent,  occurs  early  in  the  disease,  and  may  pass 
into  stupor  or  coma.  It  may  be  maniacal  considerable  effort  being  necessary 
to  control  the  patient. 

It  has  been  stated  of  the  temperature  in  this  disease  that  it  is  rarely 
high.  In  some  of  the  earliest  descriptions  of  the  disease — and  there  have 
been  most  interesting  ones  written  almost  a  century  ago — the  writers  speak 
of  the  skin  as  being  cool.  This  was  before  the  days  of  the  clinical  ther- 
mometer and  the  accurate  measurement  of  temperature  growing  out  of 
it.  High  temperatures  do  occur,  though  rarely,  105°  and  106°  F.  (40.5° 
and  41.1°  C.)  being  noted,  and  others  even  higher  just  before  death.  There 
is,  however,  no  constant  type.  The  temperature  chart  of  the  intermittent 
form  resembles  somewhat  that  of  remittent  fever,  whUe  sometimes  the 
chart  resembles  that  of  the  fastigium  of  typhoid  fever  in  its  spike-like 
delineation. 

The  pulse  goes  hand  in  hand  with  the  temperature — that  is,  it  is  not 
very  frequent  at  first,  at  least  in  adults.  As  the  disease  advances  it  grows 
more  feeble  and  more  frequent  as  the  result  of  increasing  debility  of  the 
patient.  So,  too,  the  breathing  rate  is  not  apt  to  be  markedly  influenced 
unless  there  be  a  lung  complication. 

The  urine,  as  in  other  infectious  fevers,  may  be  scanty  and  albuminous; 
but  it  may  also  be  increased  because  of  the  involvement  of  the  nervous 
system.  For  a  like  reason  there  is  sometimes  glycosuria  occasionally, 
associated,  in  severe  cases,  with  Cheyne-Stokes  breathing. 

Another  characteristic  symptom  is  the  eruption,  although  it  is  not 
present  in  more  than  one-half  the  cases.  It  is  of  at  least  two  kinds — 
herpetic  and  petechial.  Herpes  labialis,  although  not  always  present,  is 
nevertheless  more  frequent  than  in  pneumonia.  The  herpes  may  be  noted 
elsewhere  than  on  the  face — viz.,  on  the  trunk  and  extremities,  extending 
exceptionally  even  to  the  ends  of  the  fingers.  The  contents  of  the  vesicles 
may  be  purulent;  they  may  coalesce,  break  and  dry,  forming  crusts.  The 
petechial  eruption  is  more  general.  It  is  an  extravasation,  and,  like  the 
similar  eruption  in  typhus,  does  not  disappear  on  pressure.  The  number 
of  spots  varies  greatly ;  there  may  be  only  a  few,  or  they  may  be  very  numer- 


150  INFECTIOUS  DISEASES 

ous,  fully  justifying  one  of  the  names  of  the  disease — spotted  fever.  It 
will  not  do,  however,  to  exclude  the  disease  by  reason  of  the  absence  of 
these  skin  symptoms.  The  petechial  eruption  seems  less  common  in  the 
sporadic  than  in  the  epidemic  form. 

Other  eruptions,  as  erythema,  urticaria,  sudamina,  rose-colored  spots 
like  those  of  typhoid  fever,  pemphigus  and  ecthyma,  have  been  noted. 
Gangrene  of  the  skin  has  occured  as  the  result  of  pressure.  Some  trophic 
influence  may,  however,  be  responsible  for  it. 

Arthritis  is  not  infrequent,  varying  in  different  epidemics,  reaching 
nearly  20  per  cent,  of  the  severe  cases  in  the  epidemic  described  by  S. 
Flexner  and  L.  S.  Barker. ^  The  arthritis  is  deforming  and  is  analogous  to 
the  arthropathies  more  or  less  common  in  spinal  cord  diseases. 

Sometimes  the  disease  sets  in  with  diarrhea,  though  more  commonly 
there  is  constipation.  The  tongue  is  less  apt  to  be  dry  than  in  typhus, 
probably  because  the  patient  is  less  disposed  to  breathe  through  his  mouth. 
Jaundice  has  been  met  with,  and  may  be  due  to  infectious  inflammation  of 
the  bile-ducts. 

Leukocytosis  is  a  constant  symptom,  ths  increase  being  chiefly  of  the 
multinuclear  variety  of  white  cells.  Vacuolation  of  blood-cells  has  also 
been  noted. 

Kernig's  Sign. — Kernig,  of  St.  Petersburg,  called  attention  to  a  symp- 
tom which  is  at  times  a  valuable  aid  to  diagnosis  in  meningitis  where  the 
spinal  membranes  are  involved.  It  is  tested  for  in  the  following  way: 
The  patient  is  propped  up  in  bed  in  a  sitting  posture,  with  the  thighs 
flexed  upon  the  abdomen  and  the  legs  partially  flexed  upon  the  thigh — a 
position  commonly  assumed  by  patients  with  prolonged  spinal  meningitis. 
An  attempt  is  then  made  to  extend  the  leg,  when  it  will  be  found  to  be 
resisted  bj--  contraction  of  the  flexor  muscles,  preventing  its  full  straight- 
ening. When  the  patient  cannot  sit  up  in  bed,  the  thigh  may  be  flexed 
upon  the  abdomen  and  then  an  attempt  made  to  extend  the  leg,  which 
again  fails  if  meningitis  be  present.  Friis  found  the  sign  in  53  out  of  63 
cases,  Netter  in  45  out  of  50,  and  J.  B.  Herrick  in  17  out  of  19.^ 

Recent  studies  by  J.  E.  Miller  and  Robert  N.  Willson  go  to  show  that 
not  only  in  this  sign  wanting  in  a  certain  proportion  of  cases  of  meningitis, 
but  that  it  maj^  also  be  present  in  a  few  normal  individuals  and  others  ill 
of  other  diseases.  Of  the  nonmeningeal  cases  examined  by  Miller  (190) 
the  sign  was  found  in  23.6  per  cent,  and  by  Willson  in  26. 8  of  120  cases. 
The  sign  is  apparently  no  measure  of  the  degree  of  intensity  of  the  disease. 
Netter  explains  it  as  follows:  "In  consequence  of  the  inflammation  of  the 
meninges  the  roots  of  the  nerves  become  irritable,  and  the  flexion  of  the 
thighs  upon  the  pelvis  when  the  patient  is  in  the  sitting  posture  elongates 
and  consequently  stretches  the  lumbar  and  sacral  roots,  and  thus  increases 
their  irritability.  The  attempt  to  extend  the  knee  is  insufficient  to  provoke 
a  reflex  contraction  of  the  flexors  while  the  patient  lies  on  his  back  with 
the  thighs  extended  upon  the  pelvis,  but  it  does  so  when  he  assumes  a 
sitting  posture." 

The  Babinski  or  extension  toe  reflex  may  be  sought,  though  it  is  incon- 


'  "Am.  Jour,  of  the  Med.  Sc.i."  1894,  vol.  cvii. 
'  "Am.  Jour,  of  the  Med.  Sci.,"  July,  1899. 


CEREBROSPINAL  FEVER  151 

stant  and  occurs  in  hemiplegia  and  other  results  of  lesions  of  the  motor 
tract.  Brudzenski's  sign  is  a  flexure  movement  in  the  ankle,  knee  and  hip 
joints  when  attempt  is  made  to  flex  the  head  on  the  chest.  Passive  flexion  of 
the  leg  may  cause  the  fellow  limb  to  draw  up  a  Macewen's  sign  is  a  hollow 
note  developed  on  percussing  the  inferior  frontal  bone  and  is  said  to  indicate 
fluid  in  the  ventricle. 

II.  Malignant  Form. — The  malignant  form  of  cerebrospinal  fever  is 
characterized  by  the  suddenness  of  its  onset  and  severity  of  its  cardinal 
symptoms — the  chill,  headache,  coma,  collapse — followed  .by  early  fatal 
termination.  There  is  little  or  no  fever;  indeed,  the  temperature  may  be 
subnormal.  The  pulse  is  feeble  and  slow,  falling  to  50  or  60  a  minute,  in- 
creasing, however,  in  frequency,  as  the  disease  progresses.  The  breathing  is 
labored.  The  urine  is  scanty  and  albuminous.  But  for  the  prevalence  of 
the  epidemic  such  fulminating  cases  could  not  be  distinguished  from  like 
attacks  of  other  infectious  diseases.  Such  cases  may,  however,  occur  even 
sporadically.  They  last  but  a  few  hours.  They  are  more  frequent  in 
the  beginning  of  an  epidemic.  The  malignant  form  of  smallpox  is  similar, 
and  the  presence  of  an  epidemic  of  one  or  other  disease  must  settle  the 
question. 

III.  The  mild  form  presents  a  corresponding  mildness  of  symptoms,  and 
only  the  presence  of  an  epidemic  leads  to  its  recognition. 

IV.  The  abortive  form  terminates  abruptly  after  a  sharp  development  of 
characteristic  symptoms. 

V.  The  intermittent  form  is  characterized  by  remissions  and  exacer- 
bations in  the  fever  every  day  or  second  day,  without,  however,  the  regu- 
larity of  intermittent  fever,  for  which  it  is  sometimes  mistaken.  The  fever 
resembles  somewhat  that  of  pyemia.  This  form  is  very  trying,  the  remis- 
sions and  intermissions  giving  rise  to  delusive  hopes  which  are  as  often 
shattered. 

VI.  Finally,  the  term  chronic  form  is  applied  to  cases  prolonged  beyond 
the  usual  duration,  in  which  the  headache,  gastric  irritability,  and  vague 
neuritic  pains  reduce  the  patient  to  such  an  extremity  of  exhaustion  and 
emaciation  that  he  welcomes  death  as  a  relief  to  his  suffering;  or  partial 
recovery  may  take  place  with  crippled  motion,  defective  senses,  and  severe 
pains,  which  are  a  source  of  constant  discomfort.  On  the  other  hand,  some 
remarkable  recoveries,  even  in  these  advanced  stages,  are  reported,  so  that 
one  should  not  be  discouraged  from  continuing  therapeutic  effort. 

Complications  and  Sequelae. — Of  the  complications  of  cerebrospinal 
fever,  croupous  pneumonia  has  already  been  mentioned  as  not  infrequent 
as  well  as  that  it  is  sometimes  difficult  to  say  which  disease  is  primary. 
The  initial  chill  and  herpes  are  characteristic  of  both  affections,  and  close 
attention  to  other  conditions  must  be  given,  such  as  the  presence  or  absence 
of  an  epidemic,  the  order  of  appearance  of  the  symptoms,  the  nervous  and 
muscular  preceding  in  cerebrospinal  fever,  and  coming  on  later  in  pneu- 
monia. Other  complications  are  those  which  not  infrequently  accompany  in- 
fectious diseases,  including  pleurisy,  endocarditis,  pericarditis,  polyarthritis 
with  possible  suppuration,  and  others. 

Of  the  sequelae  the  most  important  are  blindness  due  to  optic  neuritis 
and  more  rarely  keratitis,  deafness  from  disease  of  the  labyrinth,  paralysis 


152  INFECTIOUS  DISEASES 

more  or  less  extensive,  invading  especially  groups  of  muscles,  including 
those  of  the  face.  There  may  be  aphasia  and  defective  articulation.  There 
may  be  also '  persistent  headache,  shooting  muscular  pains,  and  mental 
weakness.  Next  to  scarlet  fever  cerebrospinal  meningitis  is  the  most 
frequent  cause  of  deafness.  Even  chronic  hydrocephalus  and  abscess  of  the 
brain  are  included  among  sequelae.  Von  Ziemssen  says  the  former  is 
indicated  by  "paroxysms  of  severe  headache,  pain  in  the  neck  and  extremi- 
ties, without  vomiting,  loss  of  consciousness,  convulsions  and  involuntary 
discharges  of  feces  and  urine."  He  also  says  that  of  the  deaf  and  dumb  in 
the  institutions  of  Bamberg  and  Nuremberg,  in  1S74,  a  majority  of  the 
pupils  had  become  deaf  from  cerebrospinal  meningitis. 

Nasal  catarrh  may  be  an  early  symptom,  and  Strumpell  suggests  it 
may  precede  and  be  the  starting  point  of  the  invasion.  The  discharge 
often  contains  the  meningococcus,  as  in  ten  out  of  15  cases  in  the  Boston 
epidemic  alluded  to. 

Diagnosis. — A  certain  diagnosis  may  be  arrived  at  by  the  use  of  spinal 
puncture  described  below.  This  should  be  done  in  every  suspicious  case. 
The  fluid  obtained  which  is  usually  cloud}'  should  be  centrif  ugated  also  and  the 
cells  stained  after  Gram's  method.  If  the  diplococci  are  found  within  the 
cells  by  the  use  of  a  simple  stain  and  do  not  stain  by  Gram's  method  the 
case  may  be  considered  as  one  of  epidemic  cerebrospinal  meningitis  and 
treated  as  described  below.  The  diagnosis  in  epidemic  cases  is  usually  easy, 
although  it  is  more  than  probable  that  under  such  circumstances  some  cases 
are  classified  as  cerebrospinal  fever  when  they  are  really  something  else. 
During  epidemics  typhus  fever  is  the  disease  with  which  it  is  most  f  requentlj' 
confounded,  especially  as  epidemics  of  tj'phus  and  cerebrospinal  fever  some- 
times prevail  simultaneously.  The  difficulty  is  greatest  at  the  beginning  of 
the  attack,  for  as  time  passes,  the  diseases  diverge  in  symptoms.  Typhus 
fever  is  not  characterized  by  the  severe  pain  in  the  head  and  back  of  the 
neck,  nor  by  opisthotonos,  both  of  which  may,  however,  be  absent  in 
cerebrospinal  fever  or  be  so  slight  as  not  to  attract  attention.  In  typhus 
fever  the  spots  are  more  constant  and  numerous  than  in  cerebrospinal  fever. 
Herpes  does  not  occur  in  typhus.  The  tj'phoid  state  may  be  equally  pro- 
nounced in  both,  but  in  general  it  may  be  said  to  be  more  marked  in  typhus. 
The  two  diseases  differ  in  their  duration,  typhus  having  a  pretty  definite 
duration  of  about  two  weeks,  whereas  cerebrospinal  fever  is  either  shorter 
or  longer. 

The  joint  complications  not  infrequently  associated  cause  a  resemblance 
to  articular  rheumatism,  which  may  lead  to  confusion  at  first. 

The  isolated  cases  give  most  trouble.  Typhoid  fever,  especially  the 
meningeal  from  of  typhoid,  in  which  there  is  extreme  headache  and  active 
delirium,  sometimes  simulates  cerebrospinal  fever  in  the  beginning.  The 
onset  of  typhoid  is  also  slow;  as  a  rule,  there  is  no  vomiting  nor  severe 
muscular  pain.  In  typhoid  fever  there  is  no  leukoc}i;osis.  Widal  reaction 
is  present  and  the  spinal  fluid  is  clear  as  a  rule  and  does  not  contain  diplococci 
within  the  cells  of  the  fluid. 

Pneumonia  is  another  source  of  confusion,  especially  as  the  two  diseases 
are  sometimes  associated,  and  it  is  almost  impossible  to  saj^  which  is  primary. 
Here  too  spinal  puncture  will  make  the  diagnosis      If  there  is  a  cloudy 


CEREBROSPINAL  FEVER  153 

spinal  fluid  the  diplococci  will  stain  by  Gram's  method,  and  will  be  found 
largely  outside  the  cells.  The  meningeal  complications  in  pneumonia  are 
more  apt  to  invade  the  convexity,  whence  there  arise  muscular  contraction 
and  tremor,  but  not  retraction  of  the  head. 

Tuberculous  meningitis  presents  some  resemblance  to  cerebrospinal  fever. 
While  usually  less  sudden  in  its  development,  it  is  not  always  so.  Delirium 
and  stiffness  of  the  neck,  retraction,  and  even  opisthotonos  occur.  It  is, 
however,  scarcely  ever  primary,  and  there  are  no  skin  symptoms.  The 
termination  of  tubercular  meningitis  is  invariably'  fatal.  The  presence  of  a 
focus  of  tuberculosis  is  a  great  aid  to  diagnosis.  Here  also  the  character 
of  the  cerebrospinal  fluid  is  diagnostic.  It  is  usually  perfectly  clear,  if 
turbid  the  lymphocytes  prevail,  and  tubercle  bacilli  may  be  demonstrated 
by  carefully  centrifuging  the  fluid  and  examination  of  the  pellicle  which 
forms  on  standing. 

Influenza,  too,  in  one  of  its  many  forms  occasionally  simulates  cere- 
brospinal fever,  at  times  very  closely.  Extreme  muscular  pain  is  character- 
istic of  both,  and  when  influenza  is  associated  with  actual  cerebrospinal 
meningitis,  with  delirium  and  stupor,  as  it  sometimes  is,  one  maj^  be  excused 
for  being  in  doubt.  Although  both  are  diseases  of  short  duration,  influ- 
enza spends  its  fury  earlier,  and  is  thus  a  shorter  disease  unless  prolonged  by 
one  of  its  complications. 

Quincke's  lumbar  puncture  is  necessary  to  establish  a  diagnosis.  The 
operation  is  done  with  the  patient  Ijang  on  the  side,  with  knees  drawn  up, 
and  the  upper  shoulder  turned  forward.  A  needle  furnished  with  a  stillette 
lo  to  20  cm.  in  length  and  of  large  caliber  and  a  short  beveled  point.  In 
lieu  of  this  needle  one  in  use  in  an  ordinary  aspiration  set  may  be  used,  and 
is  introduced  midway  between  the  third  and  fourth  or  the  fourth  and 
fifth  lumbar  vertebrae,  below  the  spinous  process,  a  Httle  to  one  side  of  the 
median  line,  the  thumb  of  the  left  hand  of  the  operator  being  placed  be- 
tween the  spinous  processes  as  a  guide.  The  needle  should  enter  one 
centimeter  from  the  median  line  on  a  level  with  the  thumb,  and  be  directed 
slightly  upward  and  inward,  or  the  patient  may  be  held  upright  and  the 
punctixre  made.  Under  these  circumstances  the  needle  need  not  be  pointed 
upward.  At  the  depth  of  two  centimeters  in  infants  and  four  to  six  in 
adults  it  should  enter  the  canal.  The  fluid  may  be  collected  in  a  steri- 
lized test-tube,  care  being  taken  not  to  allow  it  to  run  down  the  side  of  the 
tube.  Fifteen  to  30  cubic  centimeters  should  be  withdrawn,  for  chemical, 
bacteriological,  and  microscopical  examination.  A  cloudy  fluid  is  almost 
always  present  in  epidemic  meningitis;  rarely,  it  may  be  clear,  or  the  fluid 
from  an  upper  puncture  may  be  clear,  and  from  a  lower  turbid.  Blood 
may  be  present  in  both.  Marfan's  site  is  in  the  median  line  and  is  pre- 
ferred by  J.  P.  Crozer  Griffith.  Chipault's  site  is  between  the  fifth  lumbar 
vertebra   and  the  sacrum. 

Prognosis. — Cerebrospinal  fever  is  a  grave  disease,  but  the  mortality 
varies  greatly  in  different  epidemics,  ranging  from  20  to  75  per  cent,  accord- 
ing to  Hirsch,  while  v.  Ziemssen  places  it  for  mild  epidemics  at  30  per  cent., 
and  for  severe  ones  at  70  per  cent.  The  death-rate  is  higher  for  children, 
those  under  two  years  almost  invariably  perishing,  while  few  under  five 
survive.     The  old  likewise  succumb  easily. 


154 


INFECT  10 US  DISEA  SES 


Of  few  diseases  is  the  course  more  variable  and  uncertain.  It  is  favorably 
affected  by  the  early  use  of  Flexner's  serum.  From  a  duration  of  two  to 
three  days  only  it  may  be  prolonged  to  weeks  and  even  months,  and  its 
consequences  may  be  permanent.  Usually,  however,  improvement  may 
be  looked  for  if  the  patient  survives  five  days,  more  than  half  the  deaths 
occurring  within  this  period.  A  remission  of  symptoms  may  take  place  on 
the  third  day,  to  be  followed  after  a  very  short  time  by  a  relapse.  This 
often  misleads  and  gives  the  illusive  hope  of  permanent  improvement. 
Convalescence  is  characteristically  slow,  the  symptoms  yielding  gradually. 
If  the  termination  be  fatal,  the  cardinal  symptoms  likewise  gradually  sub- 
side, but  are  replaced  by  growing  debility  and  exhaustion. 

Relapses  are  prone  to  occur,  prolonging  the  case  indefinitely,  while  a 
chronic  or  protracted  form,  to  which  reference  has  been  made  is  probably 
due  to  the  presence  of  one  of  the  persistent  or  progressive  lesions  above 
referred  to. 


Fig  19. — Slethod  of  Puncture  (or  Spinal  Drainage.     A.  Quincke's  site.     B    !Marfan's  site. 
C.    Chipault's  site. — [ChipauU.) 

Sporadic  Cerebrospinal  Meningitis. — This  form  of  cerebrospinal  menin- 
gitis may  not  be  surely  diiferentiated  from  the  epidemic  form  without  exam- 
ination of  the  cerebrospinal  fluid.  It  requires  a  separate,  though  brief, 
consideration  It  has  been  already  said  that  such  cases  occur  at  intervals, 
and  more  especially  at  odd  times  succeeding  the  prevalence  of  an  epidemic 
in  a  city.  Osier,  in  his  Cavendish  lecture,  1899,  has  taken  some  pains  to 
analyze  the  cases  of  cerebrospinal  meningitis  treated  at  the  Johns  Hopkins 
Hospital,  Baltimore,  with  a  view  to  ascertaining  what  proportion  was 
strictly  sporadic  and  noncomplicating.  He  finds  that  after  eliminating 
pneumococcic  meningitis  complicating  pneumonia  and  pneumococcic 
meningitis  due  to  local  infection  and  streptococcic  cases  of  the  same  class 
(surgical  cases),  there  remained  a  few  primary  cases  due  to  the  pneumo- 
coccus,  a  few  of  miscellaneous  meningitis — i.  e.,  caused  by  unidentified 
bacilli — and  a  few  due  to  the  diplococcus  intracellularis.  The  following 
table  will  show  the  organisms  causing  the  various  forms  of  cerebrospinal 
meningitis. 


CEREBROSPINAL  FEVER 


155 


TABLE  OF  CHIEF  FORMS  OF  ACUTE  LEPTOMENINGITIS. 


Primary. 


Secondary. 


I.  Cerebrospinal  fever  < 


(a)  Sporadic 

(b)  Epidemic 


'  Diplococcus  intracellularis. 


2.  Pneumococcic  M. 


3.  Pyogenic. 


Miscellaneous 
acute  infections. 


Pneumococcic  M.  (  Meninges   alone  involved  in   a  \  ^^^^^^^^^^ 
J.  iiv.uiii>j.,vj._i,ii.  i.ri.  I    ggj^^    pneumococcic    infection.  J 

Tubercular  M.  Bacillus  tuberculosis. 

f    (a)  Secondary  to  pneumonia, 
I  endocarditis,  etc. 

(b)  Secondary    to    disease    or  |-   Pneumococcus. 
injury  of  cranium  or  its 
fossae. 

(a)  Following  local  disease  of 
cranium  (or  a  local  infec- 
tion elsewhere). 

(b)  Terminal  infection  in  va- 
rious chronic  maladies. 

In  typhoid  fever,  influen-  1    Typhoid  bacillus 
za,    diphtheria,    gonorrhea,   [   Influenza        " 
anthrax,  actinomycocis,  and   f   Diphtheria      " 
other  acute  diseases.  J    Gonococcus. 


Treatment.  Serum  Therapy. — Every  case  of  cerebrospinal  meningitis 
due  to  micrococcus  intracellularis,  indeed  every  case  of  cerebrospinal 
meningitis  where  the  infecting  organism  in  unknown  should  be  given  at 
once  a  dose  of  Flexner's  serum.  This  may  now  be  obtained  from  reliable 
manufacturers  under  the  name  of  Antimeningitic  serum.  The  use  of  this 
serum  has  reduced  the  mortality  to  about  20  per  cent._  It  must  be  given  into 
the  spinal  canal.  A  needle  is  introduced,  the  fluid  withdrawn  and  the  serum 
introduced  through  the  same  needle.  The  amount  of  serum  should  be  in- 
jected should  about  equal  the  serum  withdrawn.  Quiet  and  the  absence 
of  disturbing  causes,  such  as  excess  of  light,  too  much  company,  are  ab- 
solutely essential.  The  food  should  be  simple  and  liquid,  with  an  abun- 
dance of  water.  The  symptom  demanding  the  promptest  relief  is  pain, 
and  for  this  there  is  no  substitute  for  opiates,  and  of  these  the  best  prepara- 
tion is  morphin,  and  the  best  mode  of  administration  is  by  hj^podermic  in- 
jection. Doses  sufficient  to  accomplish  their  purpose  should  be  given, 
say  1/4  grain  (0.016  gm.)  to  1/2  grain  (0.032  gm.),  night  and  morning, 
for  an  adult.  The  tolerance  for  the  drug  is  great.  It  may  be  combined 
with  1/150  grain  (0.00054  gm.)  to  i/ioo  grain  (0.00064  gm-)  of  atropin. 
The  same  preparation  may  be  given  by  the  mouth  if  the  hypodermic  ad- 
ministration is  not  convenient,  but  the  deodorized  tincture  of  opium  may  be 
better  borne,  and  where  the  more  frequent  administration  of  opiates  is 
necessary,  as  hourly  or  bihourly,  this  preparation  is  to  be  preferred  because 
of  the  possible  harmful  effects  of  the  too  frequent  use  of  the  hj'podermic 
syringe.  The  action  of  the  drug  is,  of  course,  to  be  carefully  watched. 
Phenacetin,  antipyrin,  salicylic  acid,  and  this  class  of  drugs  are  no  substi- 
tute for  opium  in  this  painftil  malady.  Hexamethylenamin  (urotropin) 
should  be  given  at  once  in  doses  of  5  grains  (0.3)  every  3  hours  when  the 
disease  is  suspected.     Hot  baths  may  be  employed  for  the  same  purpose. 

When  there  are  spasms  or  convulsions  there  is  no  remedy  equal  to 
chloral.  If  it  cannot  be  administered  by  the  mouth,  a  dram  (4  gm.)  dis- 
solved in  2  ounces  (60  c.c.)  of  water  may  be  given  to  an  adult,  without 
hesitation,  per  rectum.  In  extreme  cases  chloroform  or  ether  may  be  in- 
haled for  the  same  purpose.  The  bromids  may  be  used  as  adjuvants  in 
mild  cases,  but  of  themselves  are  altogether  inefficient. 


156  INFECTIOUS  DISEASES 

Cold  may  be  applied  to  the  head  for  the  headache  and  other  meningeal 
symptoms,  and  is  best  used  in  the  shape  of  an  ice-cap  or  ice-bladder  or 
Leiter's  coU.  Cold  may  also  be  applied  to  the  back  of  the  neck  and  spine, 
and  according  to  James  Barr  over  the  splanchnic  region.  These  measures 
must  be  discontinued  when  the  temperatiu'e  falls  to  normal.  Counterirrita- 
tion  to  the  back  of  the  neck  and  spine  has  long  been  employed,  by  blisters, 
but  is  not  recommended.  General  bleeding  is  not  recommended.  Free 
movements  of  the  bowels  must  be  maintained  by  castor  oil  or  calomel, 
and  the  bladder  watched. 

Measures  of  a  very  decided  character  to  reduce  the  temperature  are 
not,  as  a  rule,  needed.  Simple  sponging  suffices  for  the  most  part.  Should 
this  be  insufficient,  however,  tub  bathing  may  be  used  as  in  typhoid  fever. 

The  nourishment  should  be  of  the  best,  including  animal  broths  and 
milk,  and  where,  as  is  frequently  the  case  in  the  early  stages,  they  cannot 
be  tolerated  by  the  stomach,  they  may  be  given  peptonized  per  rectum,  not 
more  than  4  ounces  (120  c.c.)  at  one  time.  I  have  thus  nourished  for 
several  days  until  the  stomach  became  retentive  a  case  despaired  of,  which 
ultimately  recovered.  Forced  alimentation  by  the  stomach-tube  is  recom- 
mended by  Heubner.  Alcohol  is  contraindicated  in  the  early  stages  unless 
there  be  unusual  adynamia.  Later,  when  exhaustion  begins  to  show 
itself,  it  may  be  used  and  pushed  as  under  similar  conditions  in  other 
diseases. 

The  lumbar  puncture  is  strongly  recommended  by  Williams,  Brower, 
W.  Cuthbertson,'  and  others  as  a  curative  measure;  Osier  admits  possible 
benefit  therefrom.  Temporary  relief  undoubtedly  ensues.  Laminectomy 
and  local  therapeutics,  including  drainage,  have  not  furnished  encouraging 
results  at  the  Johns  Hopkins  Hospital.^ 

The  resulting  paralyses  should  be  treated  bj^  massage  and  electricity, 
and  as  already  suggested  we  should  not  be  discouraged  from  persisting,  as 
remarkable  cures  have  been  accomplished. 

Satisfactory  results  have  followed  the  subaqueous  treatment  recom- 
mended by  Goldscheider'  to  which  attention '  was  called  by  William  G. 
Spiller.  It  consists  in  active  movements  by  the  patient  while'  submerged 
in  a  bath  at  a  comfortable  temperature.  The  mo^'ements  are  not  passive, 
but  active  and  voluntary. 

ERYSIPELAS. 
Synonyms. — The  Rose;  St.  Anthony's  Fire. 

Definition. — An  acute,  contagious  dermatitis  associated  with  the  usual 
signs  of  infiammation — swelling,  heat,  pain,  redness,  the  formation  of  blebs 
and  a  peculiar  disposition  to  spread. 

Etiology. — The  streptococcus  erysipelatis  of  Fehleisen  is  a  minute,  cleft 
fungus,  a  micrococcus  in  the  narrow  sense,  three  to  four  microns  in  diame- 
ter, arranged  in  pairs  (diplococci)  or  chains  (streptococci)  of  from  six 
to   12    cells.     The  erysipelas   coccus    resembles  closely  the    streptococcus 

^  "Chicago  Med.  Recorder,"  June,  1899. 
2  Osier.  "Cavendish  Lecture."  June,  1899. 

8  "Ueber  Bewegungstherapie  bei  Erkrankungen  des  Nervensysteras,"  Goldscheider,  "Deutsche  medi- 
cinische  Woschenschr.,"  January  27,  1808. 


ERYSIPELAS  157 

pyogenes  of  Rosenbach — in  fact,  cannot  be  distinguished  from  it  micro- 
scopically, while  even  the  cultures  of  the  two  organisms  resemble  each 
other  very  closely.  The  streptococcus  pyogenes  is  said  by  Hoffa  to  grow 
more  slowly  and  less  uniformly  than  that  of  erysipelas,  and  presents  also  a 
brownish  discoloration  in  the  middle  of  its  colony.  They  behave  very 
similarly  when  inoculated  in  animals.  Simon  asserts  that  the  micrococcus 
of  erysipelas  is  identical  with  that  of  pyemia,  and  this  belief  is  now  quite 
general.  Klebs  suggests  that  more  than  one  organism  may  be  concerned 
in  the  causation  of  erysipelas. 

The  organism  probably  operates  as  a  local  irritant  producing  the  der- 
matitis. From  this  as  a  focus  constitutional  infection  is  set  up,  as  in  diph- 
theria, probably  through  the  influence  of  a  toxin  generated  b}^  the  micrococ- 
cus. The  bacterium  is  found  in  the  lymph-vessels  and  IjTnph-spaces  of  the 
periphery  of  the  inflamed  area,  and  not  in  the  center,  by  which  fact  the 
peripheral  spread  of  the  disease  is  explained.  It  is  readily  found  by  cultures 
made  from  the  blood  of  the  veins  and  heart  and  even  the  urine. 

The  organism  is  transferred  from  one  person  to  another  by  direct  con- 
tact, or  by  the  intermediation  of  a  third  person,  or  through  the  atmosphere. 
It  cannot  be  said,  however,  that  the  disease  is  highly  contagious  in  the 
absence  of  surgical  injury,  for  in  Tyson's  experience  as  a  hospital  interne 
at  the  Pennsylvania  Hospital  and  later  as  a  visiting  physician  in  the  Phila- 
delphia Hospital,  though  it  was  the  custom  to  keep  the  erysipelas  cases  in 
the  ordinary  medical  wards,  he  cannot  recall  a  single  instance  where  the 
disease  was  communicated  to  another  patient  in  the  ward.  It  was  very 
different,  however,  in  the  surgical  wards,  where  the  disease  would  spread 

rapidly  from  one  patient  to  another,  showing  the  importance  of  the  open 
surface  as  a  condition  of  the  spread.  The  lying-in  woman  is  very  readily 
inoculated,  so  that  no  physician  should  attend  a  case  of  labor  while  attend- 
ing one  of  erysipelas.  Certain  kinds  of  wounds,  as  lacerated  wounds  and 
scalp  wounds,  are  especially  prone  to  erysipelas.  Clean-cut  wounds  in 
other  locations  suffer  less  frequently.  Leech-bites,  vaccination  punctures, 
the  wounds  of  the  cupping  scarificator  and  of  the  subcutaneous  syringe, 
are  also  favorable  starting  points.  Chronic  inflammatory^  processes  and 
skin  diseases  may  also  have  erysipelas  engrafted  upon  them. 

Erysipelas  is  prone  to  occur  in  the  epidemic  form,  more  especially  in 
the  spring!  of  the  year  in  old  and  unclean  hospitals,  but  such  epidemics  have 
become  much  rarer  in  the  last  20  years.  This  is  doubtless  one  of  the 
results  of  antisepsis,  now  so  generally  practised.  The  feeble,  the  intem- 
perate, and  those  having  Bright's  disease  or  other  aft'ections  weakening 
natural  resistance  are  more  prone  to  the  disease.  An  interesting  case  of 
Bright's  disease  in  the  Philadelphia  Hospital  had  frequent  attacks  of  facial 
erysipelas,   always  accompanied  by  hematuria.     Relapses  and  recurrences 


*  The  influence  of  the  seasons  is  very  well  set  forth  by  James  M.  Anders  in  a  paper  on  "Seasonal  In- 
fluences in  Erysipelas,  with  Statistics,"  wherein  he  has  shown,  as  the  result  of  an  analysis  of  2010  cases 
collected  from  different  sources,  that  the  various  seasons  of  the  year  exercise  a  potent  influence  upon  the 
frequency  of  this  affection.  Thus,  month  by  month  the  cases  increase,  in  slightly  varying  ratio,  from 
August  to  April,  the  latter  month  giving  the  greatest  number,  and  then  there  is  a  rapid  decrease  from 
April  to  August,  when  we  find  the  smallest  number.  Again,  one-half  of  all  the  cases  occur  during  the 
months  of  February,  March,  April  and  May,  and  15.Q  per  cent,  during  the  months  of  April  alone.  It  was 
found  that  a  low  barometer  and  mean  relative  humidity  invariably  correspond  with  the  annual  period  in 
which  the  greatest  number  of  cases  occur,  and  that  the  highest  percentage  of  relative  humidity  corresponds 
with  the  months  affording  the  fewest  cases. 


158  INFECTIOUS  DISEASES 

of  er^'sipelas  are  prone  to  occur,  and  a  person  once  attacked  by  erysipelas, 
far  from  being  protected,  is  rather  predisposed  to  a  second  attack.  A 
family  predisposition  of  erv^sipelas  may  exist. 

Morbid  Anatomy. — Like  all  acute  inflammatory  states  of  the  skin, 
erysipelas  fades  away  after  death  and  leaves  little,  if  anything,  to  be  seen 
unless  it  has  proceeded  to  the  formation  of  blebs  or  abscesses.  Swelling  and 
corresponding  deformity  of  the  part,  especially  of  the  face,  when  extensive, 
may  remain,  but  even  this  subsides  with  the  lapse  of  time  after  death  and 
may  totally  disappear. 

Minute  examination  finds  the  cocci  in  the  lymph-vessels  and  spaces  at 
the  periphery  of  the  inflamed  area,  as  already  stated,  and  even  in  the  unin- 
flamed  tissue  beyond  the  margin. 

Various  complications  attend  erysipelas  and  add  their  morbid  anatomy 
to  that  which  is  more  essentially  that  of  the  disease.  The  most  important 
of  these  are  pyemic  abscesses  of  internal  viscera  and  hemorrhagic  infarcts  of 
the  lung,  spleen,  and  kidneys.  The  kidneys  are  especially  apt  to  be  con- 
gested, and  the  lesions  of  acute  or  subacute  nephritis  are  sometimes  found, 
and  more  rarely  suppurative  orchitis. 

Symptoms. — The  form  of  erysipelas  which  more  particularly  concerns 
the  physician  is  the  so-called  idiopathic  erysipelas,  which  arises  independ- 
ently of  any  apparent  traumatic  lesion,  but  since  all  erysipelas  implies  some 
lesion,  however  minute,  the  term  is  a  misnomer.  The  fact  remains,  how- 
ever, that  the  physician  is  most  frequently  called  upon  to  treat  the  form 
of  erysipelas  in  which  there  is  no  discoverable  local  lesion. 

There  is  a  period  of  incubation  of  from  one  to  eight  days,  after  which 
this  varietj^  of  erysipelas  begins  at  times  with  a  chill  or  succession  of  chills 
associated  with  a  loss  of  appetite  and  feeling  of  general  discomfort.  At 
other  times  the  chill  is  wanting.  In  either  event  there  soon  appears  a 
small,  red,  burning  spot  a  few  lines  in  diameter,  usually  on  the  face,  oftenest 
on  the  bridge  of  the  nose  or  on  the  chin.  It  spreads  rapidly,  and  as  soon  as 
sufficient  size  is  attained  there  is  a  very  characteristic  elevation  of  the  patch 
above  the  surrounding  tissue,  which  can  be  recognized  by  carn-ing  the 
finger  across  it.  This  is  of  diagnostic  value.  The  future  extension  of  the 
process  is  upward  over  the  forehead  and  lateralh^  toward  the  ears  until  the 
whole  face,  and  more  rarely  also  the  neck,  is  invaded.  The  eyes  become 
closed  by  swelling,  the  features  are  distorted,  and  the  sum  of  changes  pro- 
duces an  appearance  not  soon  to  be  forgotten.  In  other  parts  of  the  body, 
as  the  arms  and  legs,  the  same  process  may  go  on,  but  there  is  not  the 
unsightly  distortion  found  as  in  the  case  of  the  face  and  head.  In  some 
cases  the  process  proceeds  to  suppuration,  and  deep-seated  abscesses  form. 
These  must  restdt  from  mixed  infection  with  other  pyogenic  organisms, 
unless  indeed  the  organism  be  the  same  as  that  of  suppuration.  Blebs  form, 
]5articularly  on  the  lobes  of  the  ears  and  on  the  eyelids,  while  little  vesicles 
are  always  visible  through  a  lens.  From  these  a  serum  may  exude  and  dry 
on  the  skin.  As  the  dermatitis  extends  to  new  areas,  the  earlier  spots  dry 
up  and  desquamate.  The  disease  seldom  lasts  more  than  four  days  in 
one  spot,  although  it  may  revisit  the  same  spot  during  one  attack. 

There  may  be  er>'sipelas  of  the  mucous  membranes,  which  may  extend 


ERYSIPELAS  159 

to  the  skin,  or  the  reverse  may  take  place — extension  from  the  skin  to  the 
mucous  membrane. 

Fever  probably  always  precedes,  though  not  noted  in  the  beginning, 
and  it  rapidly  becomes  higher,  reaching  as  high  as  105°  F.  (40.5°  C.)-  There 
is  a  corresponding  frequency  of  pulse,  associated  with  headache  and  some- 
times delirium.  The  fever  continues  as  long  as  the  disease  continues  to 
spread.  Often  a  sudden  drop,  a  crisis,  occurs  on  the  fifth  to  the  seventh 
day,  followed  by  another  rise  if  the  disease  takes  a  fresh  start. 

In  more  serious  cases  fever  and  delirium  may  be  followed  by  drowsi- 
ness, stupor  and  a  coated,  dry  tongue — all  the  symptoms,  in  fact,  of  a  typhoid 
state.  The  urine  is  scanty  and  a  febrile  albuminuria  may  be  present — 
in  fact,  to  a  degree,  may  be  said  to  be  constant' — and  nephritis  sometimes 
results,  while  a  pre-existing  nephritis  maj'  have  an  acute  exacerbation 
engrafted  upon  it.  Mention  has  already  been  made,  under  the  head  of 
Etiology,  of  hematuria  occurring  in  these  cases. 

Gangrene  may  be  associated  with  the  deep-seated  varieties,  constituting 
gangrenous  erysipelas. 

Complications  and  Sequelae. — The  possible  complications  are  numer- 
ous, but  in  practice  are  really  not  often  encountered.  The  most  frequent 
is  meningitis,  the  result  of  extension  by  continuity  through  the  openings  of 
the  cribriform  plate  of  the  ethmoid  bone  or  by  contiguity  from  the  scalp 
through  emissary  veins  of  the  skull,  but  I  have  never  seen  such  a  case. 
William  Osier,  however,  traced  the  extension  from  the  face  along  the  fifth 
nerve  to  the  meninges,  causing  an  acute  meningitis  and  thrombosis  of  the 
lateral  sinus. 

Edema  of  the  glottis  is  the  result  of  extension  of  the  disease  to  the  mucous 
membrane  of  the  glottis.     It  is  promptly  fatal,  unless  relieved. 

Malignant  ulcerative  endocarditis  is  also  with  comparative  frequency 
secondary  to  erysipelas,  three  cases  out  of  23  being  sequelae  of  this  disease. 
Of  cardiac  complications,  pericarditis,  endocarditis,  and  myocarditis;  of 
pulmonary,  bronchitis,  pneumonia,  and  pleurisy  may  be  mentioned  as 
possible;  also  jaundice,  dysentery,  and  hemorrhages  from  the  nose  and 
bowels.  Purpura  is  an  occasional  complication.  Nephritis  of  hemor- 
rhagic variety  has  already  been  mentioned,  and  even  glycosuria  has  been 
noted,  possibly  an  accidental  association.  Septic  and  pyemic  complications 
do,  however,  occur  and  are  among  the  causes  of  death.  Suppuration  in 
the  testicle  has  been  referred  to. 

Among  the  sequelae  may  be  mentioned  a  loss  of  hair.  Cicatricial  new 
formations  replace  the  parts  destroyed  by  gangrene  and  may  produce  de- 
formity by  their  contraction.  On  the  other  hand,  hyperplastic  new  forma- 
tions resembling  elephantiasis  Arabum  may  result.  Hyperesthesia  and 
neuralgia  of  the  involved  areas,  anesthesia  with  which  atrophy  of  the  skin 
may  be  associated,  symmetrical  gangrene  of  the  fingers,  and  painful  affec- 
tions of  the  joints  have  all  occurred  as  sequelae. 

Erysipelas  may  be  associated  with  other  infectious  diseases,  such  as 
typhoid  and  typhus  fevers,  diphtheria,  scarlet  fever,  and  the  like. 

Diagnosis. — The  diagnosis  of  erysipelas  is  usually  not  difficult,  although 


1  See  paijer  by  J.  M.  DaCosta  on  "The  Internal  Complications  of  Acute  Erysipelas,"  "Am.  Jour,  of 
the  Med.  Sci.,"  October.  1877.    ' 


160  INFECTIOUS  DISEASES 

many  conditions  are  called  erysipelas  by  the  ignorant  which  are  not  of 
this  nature.  The  acuteness  of  the  disease,  the  rapidity  of  its  spread,  the 
constitutional  disturbance  and  fever  distinguish  it  from  other  conditions 
that  superficially  resemble  it. 

Prognosis. — The  prognosis,  in  the  vast  majority  of  instances,  is  fa- 
vorable. Only  in  the  aged,  the  intemperate,  and  those  of  broken  health  from 
other  causes  does  it  prove  fatal,  as  a  rule.  Complications,  especially  menin- 
gitis and  septic  states,  are  causes  of  death.  On  the  other  hand,  erysipelas  is 
said  to  exert  a  favorable  influence  on  certain  acute  diseases,  such  as  acute 
rheumatism,  choroiditis,  and  even  morbid  growths.  It  has  even  been  sug- 
gested to  inoculate  erysipelas  for  the  cure  of  such  affections. 

Treatment. — The  patient  should,  of  course,  be  isolated.  It  is  more 
than  likely  that  a  decided  majority  of  cases  of  idiopathic  erj-sipelas  would 
get  well  without  any  treatment  whatever.  In  other  words,  the  disease 
is  self-limiting.  As  the  disease  is  exhausting,  internal  treatment  should 
be  restorative  and  supporting.  Quinin,  iron,  nutritious  food,  and  stimulants 
are  indicated,  while  the  patient  should  be  kept  at  rest.  The  tincture  of 
the  chlorid  of  iron  is  used  throughout  North  America  because  of  some  sup- 
posed specific  influence  over  the  disease,  and  doses  as  large  as  a  dram  every 
three  or  four  hours  have  been  given.  We  have  always  given  iron,  but  never 
in  such  doses,  and  we  are  doubtful  whether  it  exerts  an}'  specific  effect  of 
the  kind  claimed.  The  natiu-al  duration  of  the  disease  is  short,  and  the 
effect  claimed  from  the  iron  is  no  prompter  than  that  which  nature  brings. 
Ten  minims  (0.666  gm.)  every  two  or  three  hours  are  sufficient,  and  it  is 
exceedingly  doubtful  whether  larger  quantities  than  this  are  absorbed. 
Where  debility  is  marked,  alcohol  in  some  of  its  forms  should  be  administered. 

J.  M.  DaCosta  first  suggested  the  use  of  pilocarpin  in  the  treatment  of 
erysipelas,  more  particularly  in  the  early  stages.  J.  L.  Salinger,'  A.  A. 
Eshner,  and  S.  D.  Barr  also  report  favorably  on  the  same  treatment,  which 
should,  however,  be  employed  cautiously.  It  is  recommended  that  1/6 
grain  (o.oi  gm.)  be  administered  hypodermicaUy  every  three  hours  until 
free  sweating  ensues.  After  this  the  interval  is  increased  to  four  or  six 
hours. 

Serum  Treatment. — Antistreptococcic  serum  may  be  tried.  It  is  far 
better  to  use  an  autogenous  vaccine,  however,  the  stains  of  streptococci  are 
so  numerous  that  a  stock  serum  made  by  their  use  may  be  easily  useless 
in  any  given  case. 

An  infinite  variety  of  local  measures  has  been  suggested  to  arrest  the 
spread  of  the  disease,  all  of  which  are  useless  to  this  end,  although  some  of 
them  are  useful  in  allaying  the  biu-ning.  For  this  purpose  nothing  is 
better  than  the  old-fashioned  mixtiu-e  of  lead-water  and  laudanum  in 
the  proportion  of  four  parts  of  the  liquor  plumbi  subacetatis  dilutus,  U.  S. 
P.,  to  two  of  laudanum.  Or  a  mixture  may  be  made  of  acetate  of  lead 
I  3  (1.3  gm.),  powdered  opium  90  grains  (6  gm.),  and  water  6  fg  (180 
CO.).  Lead-water  alone  is  an  efficient  local  application  for  this  purpose; 
so  is  cold  water.  Dusting  the  surface  with  finely  levigated  oxid  of  zinc  or 
subnitrate  of  bismuth  also  has  a  soothing  effect.  Of  late,  ichthyol  has  become 
a  popular  local  dressing.     It  should  be  added  to  glycerin  or  collodion  in  the 

1  "Therapeutic  Gazette,"  March  15,  1894. 


SEPTICEMIA— PYEMIA  161 

proportion  of  2  drams  (8  c.c.)  to  the  ounce  (30  c.c.)  of  glycerin  or  collodion. 
A  saturated  solution  of  magnesium  sulphate,  epsom  salts,  is  grateful  and 
efficient. 

SEPTICEMIA  AND   PYEMIA. 

Synonym. — Bacteriemia. 

Definition. — Pyemia  and  septicemia  are  general  febrile  conditions 
caused  by  the  entrance  into  the  blood  of  pathogenic  micro-organisms. 
They  are  distinguished  from  sapremia,  which  is  the  condition  of  local 
development  of  micro-organisms  associated  with  the  entrance  of  their  toxic 
products  into  the  circulation  but  not  of  the  organisms  themselves.  Septi- 
cemia and  pyemia  are  sometimes  included  under  the  single  designation  of 
bacteriemia.  They  are  in  man  caused  usually  by  the  entrance  of  pyogenic 
organisms — streptococcus  pyogenes  and  staphylococcus  pyogenes  aureus  or 
albus — into  the  blood.  In  septicemia  the  development  of  the  organisms 
is  not  associated  with  a  special  localization  of  the  micro-organisms  in  the 
internal  organs  with  the  production  of  abscesses,  whereas  in  pyemia  the 
presence  of  secondary  pus  foci  in  different  organs  of  the  body  constitutes 
the  distinguishing  feature  of  the  condition. 

Etiology. — While  the  pus  organisms  have  been  heretofore  held  respon- 
sible for  the  majority  of  intoxications  of  the  blood  by  their  pathogenic 
products  or  toxins,  from  the  medical  standpoint  the  term  septicemia  may  be 
applied  to  the  toxic  condition  produced  by  any  of  the  pathogenic  bacteria 
which  invade  the  blood  and  tissues  with  or  without  a  visible  site  of  infection. 
The  proportion  of  these  last  has  of  late  enormously  decreased,  because  of  the 
antisepsis  practised  by  surgeons,  while  the  medical  septicemias  have  not 
much  diminished. 

Illustrative  cases  of  the  more  usual  form  of  septicemia  are  puerperal 
fever  following  retained  placenta,  infection  by  scarlet  fever  or  erysipelas  or 
during  difficult  labor  involving  laceration,  and  the  poisoning  by  a  dissecting 
wound.  Among  medical  septicemias  may  be  mentioned  those  arising  from 
typhoid  fever,  pneumonia,  diphtheria,  and  gonorrhea.  These  are  all  pri- 
marily local  infections.  The  symptoms  set  in  in  from  three  to  four  hours 
to  three  or  four  days,  more  frequently  within  24  hours. 

The  same  essential  cause  lies  at  the  bottom  of  pyemia  as  of  septicemia, 
but  associated  with  the  former  as  important  etiological  factors  are  thrombosis 
and  embolism.  To  this  association  Virchow  first  drew  attention,  and  it  is  to 
thrombosis  or  embolism  that  the  pyemic  abscesses  are  due.  Fragments  of 
a  venous  thrombus  due  to  phlebitis  at  the  seat  of  putrid  inflaramation  are 
broken  off  and  carried  in  the  circulation  until  a  lodgment  is  affected.  These 
fragments  swarm  with  bacteria,  causing  intense  inflammation  which  goes 
on  to  abscess  formation,  producing  the  metastatic  or  embolic  abscess.  Em- 
boli may  be  multiple  and  there  will  be  as  many  abscesses  as  lodged  emboli. 
A  frequent  source  of  multiple  abscesses  is  the  disease,  malignant  or  ulcera- 
tive endocarditis,  itself  a  specific  inflammation  caused  by  some  patho- 
genic organism  floating  in  the  blood  and  lodging  on  the  heart  valves, 
where  it  excites  a  septic  valvulitis.  The  vegetations  produced  by  this 
may  be  broken  off  and  become  emboli.     These  are  carried  through  the 


162  INFECTIOUS  DISEASES 

arterial  system  to  points  of  lodgment  and  constitute  the  arterial  pyemia 
of  Wilks.  Osteomyelitis  is  also  a  cause  of  pyemia.  The  term  idiopathic 
pyemia  is  applied  to  that  form  in  which  multiple  abscesses  coexist  with 
the  other  symptoms  of  pyemia,  but  no  infective  focus  is  discoverable. 
It  will  be  remembered  that  the  noninfectious  embolus  produces  simple 
hemorrhagic  infarct. 

The  seats  oj  election  for  abscess  in  pyemia  in  their  order  of  frequency 
are  as  follows:  The  lungs,  liver,  spleen,  kidneys,  brain,  and  joints,  the 
subcutaneous  connective  tissue,  and  subperitoneal  connective  tissue, 
including  pelvic  connective  tissue.  The  marrow  of  long  bones  and  the  parts 
about  the  cavity  of  the  middle  ear  are  also  seats. 

Abscesses  occur  in  the  lungs  when  the  septic  emboli  originate  in  osteo- 
myelitis or  in  inflammatory  affections  of  the  periphery;  in  the  liver,  when 
they  arise  from  septic  foci  in  the  portal  area,  especially  in  the  intestines;  the 
pelvic  connective  tissue,  when  they  start  in  the  uterus  and  its  appendages ;  in 
the  spleen,  kidneys,  and  brain,  if  the  emboli  arise  in  the  left  heart  or  are  so 
small  that  they  can  pass  from  the  right  heart  through  the  lungs  to  the  left 
heart.  Emboli  may  also,  in  rare  instances,  pass  from  the  right  heart  to 
the  left  heart  through  a  pabulous  foramen  o\ade.  Suppuration  is  not 
limited  to  the  agency  of  streptococci  and  staphylococci.  The  gonococcus, 
the  bacillus  coK  communis,  the  typhoid  bacillus,  the  bacillus  lanceolatus ,  and 
others  are  equally  capable  of  producing  suppuration. 

Symptoms. — A  rapidly  rising  jever  is  the  first  symptom  of  pyemia  and 
septicemia,  often  so  closely  followed  by  a  chill  that  its  pre-existence  is 
not  suspected.  The  severity  of  the  chill  corresponds  with  the  intensity  of 
the  infection  and  the  degree  of  inflammation  resulting  from  it.  The  tem- 
perature diiring  the  chill  reaches  103°  to  104°  and  105°  F.  (39.4°  to  40°  and 
40.5°  C.)  and  is  followed  by  a  sweat  and  fall  of  temperature,  after  which 
the  latter  again  arises  to  a  point  even  higher  than  that  first  attained.  Then 
follows  another  sweat  and  fall  and  thereafter  a  succession  of  intermissions, 
variable  but  quite  characteristic.  The  rise  is  generall}'-  toward  evening,  and 
thus  there  is  a  certain  resemblance  to  typhoid  fever,  while  the  rigors  and 
sweats  suggest  malaria.  The  evening  rise  is  by  no  means  constant,  and 
irregular  fluctuations  in  the  temperature  are  characteristic.  There  are 
other  symptoms  of  fever — viz.,  thirst,  loss  of  appetite,  and  nausea.  The 
strength  of  the  patient  rapidly  wanes,  he  soon  sinks  into  a  condition  of 
exhaustion  and  semiconsciousness,  from  which,  however,  he  may  be  aroused 
to  take  medicine  and  nourishment. 

The  various  local  involvements  cause  localized  symptoms.  Emboli  in 
the  lungs  cause  cough  and  hurried  breathing,  but  there  may  be  no  dis- 
tinctive physical  signs ;  in  the  liver,  they  ma}^  cause  tenderness  and  enlarge- 
ment with  jaundice;  if  in  the  kidney,  there  may  be  no  sign  or  there  may  be 
albuminuria  and  hematuria;  if  in  the  intestines,  diarrhea;  if  in  the  skin, 
superficial  abscesses;  if  in  the  joints,  swelling,  tenderness,  and  fluctuation; 
if  in  the  brain,  paralyses  occvu:  depending  upon  the  seat  of  the  abscess. 
Delirium  and  unconsciousness  are  common.  There  may  also  be  secondary- 
abscesses  of  the  parotid  gland  and  pancreas,  the  former,  producing  hard 
painful  swelling  and  the  latter  deep-seated  pain  in  the  epigastric  and 
umbilical  regions. 


SEPTICEMIA—PYEMIA  163 

The  abscesses  contain  the  pyogenic  bacteria,  which  are  responsible  for 
them. 

Diagnosis. — The  diagnosis  is  not  usually  difficult,  though  sometimes 
the  disease  is  overlooked  and  the  symptoms  ascribed  to  some  other  cause. 
Reference  has  always  been  made  to  its  resemblance  to  typhoid  fever  and 
malarial  fever,  but  the  physician  should  not  be  long  in  doubt.  A  careful 
study  of  the  case  will  show  marked  differences  in  history,  while  the  status 
prcBsens  exhibit  only  a  superficial  resemblance.  There  are  no  rigors  fol- 
lowed by  sweats  in  typhoid  fever,  as  a  rule,  and  the  temperature  chart  in 
pyemia  is  much  more  irregular.  Especially  confusing  are  those  cases  of 
septicemia  in  which  the  blood  responds  to  the  Widal  test  of  which  two  are 
in  the  wards  at  this  writing.  The  suddenness  of  the  pyemia  is  character- 
istic, though  it  is  by  no  means  invariable.  In  reni,ittent  fever  the  chill, 
fever,  and  sweat  are  more  regular,  the  prostration  is  not  so  extreme,  and, 
above  all,  it  is  promptly  cured  with  quinin.  The  Plasmodium,  if  found, 
definitely  settles  the  question  as  to  the  malarial  fever,  and  the  Widal  test 
that  of  typhoid  fever.  There  should  be  no  confounding  of  pyemia  with 
simple  intermittent  fever.  The  complete  absence  of  symptoms  between 
paroxysms  is  in  no  way  comparable  to  the  evident  desperate  illness  despite 
the  temporary  absence  of  fever  in  pyemia. 

Among  the  causes  of  pyemia  that  have  been  overlooked  is  osteomyelitis. 
Gunshot  injuries  of  bones  and  compound  fractures,  if  followed  by  suspicious 
symptoms  should  lead  to  investigation.  Malignant  or  lilcerative  endocar- 
ditis is  often  overlooked,  and  not  without  reason,  as  it  is  so  often  overshadowed 
by  other  symptoms.  A  cardiac  murmur,  with  irregular  temperature  and 
sweating  and  unusual  prostration,  should  excite  suspicion. 

Gonorrhea  and  prostatic  abscess  are  occasionally  causes,  as  are  also 
tuberculosis  of  the  kidney  and  calculous  pyelitis,  the  last  two,  perhaps,  more 
frequently  than  the  first  two. 

Prognosis. — The  prognosis  is  very  grave.  Even  when  recovery  takes 
place  in  comparatively  mUd  cases,  it  is  with  shattered  health.  Alore 
fortunate  are  the  rarer  instances  of  recovery  after  puerperal  pyemia,  which, 
when  they  do  occur,  are  more  apt  to  be  complete.  When  calculous  pyelitis 
and  even  tuberculous  pyelitis  are  causes,  operation  often  furnishes  prompt 
relief  more  or  less  complete. 

Not  all  fatal  cases  are  promptly  so.  There  is  a  form  of  chronic  pyemia 
lasting  for  months,  in  which  the  symptoms  are  less  distinctive  and  in  the 
history  of  an  infected  wound  may  be  the  only  cue  to  its  real  natiu"e.  One 
such  case  came  under  Tyson's  observation,  that  of  a  young  physician  who 
received  a  dissecting  wound  from  which  the  symptoms  started  and  which, 
terminated  fatally  with  meningitis  after  many  months'  illness. 

Treatment  of  Septicemia  and  Pyemia. — First  remove,  if  possible,  the 
primary  surgical  focus  and  relieve  secondary  foci  as  they  appear.  After 
that  the  symptoms  are  to  be  combated  and  the  strength  supported  to  the 
utmost.  To  the  latter  end  the  most  nutritious  and  easily  assimilable  food, 
alcohol  moderately,  and  strychnin  are  the  sheet  anchors.  To  these  may  be 
added  sponging  to  lower  the  temperature.  To  check  sweating,  atropin, 
oil  of  erigeron  in  doses  of  lo  to  30  minims  (0.65  to  2  gm.)  in  a  capsule  or  on 
sugar;  ergot  15  to  30  minims  (i  to  2  gm.) ;  the  dilute  mineral  acids,  15  to  30 


164  INFECTIOUS  DISEASES 

minims  (i  to  2  c.c).  Antipyretics  shovild  not  be  used  to  reduce  tempera- 
ture, it  is  better  to  accomplish  the  same  thing  by  hydrotherapy. 

Among  the  more  favorable  cases,  in  which  operative  treatment  is 
followed  by  prompt  and  sometimes  more  than  temporary  relief,  are  cases  of 
septicemia  originating  in  vesical  and  prostatic  disease  and  calculous  and 
tuberculous  pyelitis.  In  tuberculosis  of  the  kidney,  as  tuberculosis  else- 
where, especially  illustrated  in  the  peritoneum,  exposure  to  the  air  seems  to 
have  a  destructive  influence  upon  the  bacillus.  If  the  source  of  the  infec- 
tion cannot  be  reached  by  surgical  measures,  antistreptococcic  serum  should 
be  tried  without  hesitation  though  frequently  there  is  no  relief  by  its  use. 
Twenty  to  30  cubic  centimeters  should  be  injected  every  six  to  eight  hours 
daily  until  decided  improvement  in  symptoms  takes  place,  after  which  the 
interval  between  injections  should  be  increased.  Smaller  doses  may  be 
injected  in  milder  degrees  of  the  poisoning. 

Prophylaxis  is  much  more  efficient  than  treatment,  and  with  modem 
aseptic  surgery  and  aseptic  obstetrics  septicemia  and  pyemia  are  becoming 
much  more  infrequent. 

HYDROPHOBIA. 

Synonyms. — Rabies;    Lyssa. 

Definition. — Hydrophobia  is  an  acute  infectious  disease  of  animals, 
communicable  to  man,  and  characterized  by  intense  tonic  spasm  beginning 
in  the  larynx. 

Etiology. — All  warm-blooded  animals  are  subject  to  the  disease.  The 
dog  is  the  most  frequent  victim,  and  it  is  from  that  it  is  almost  invariably 
communicated  to  man.  The  wolf,  cat,  and  skunk  are  also  frequent  subjects, 
and  may  communicate  the  disease  to  himaan  beings  by  their  bites,  that  of  the 
wolf  being  especially  virulent.  In  such  cases,  whatever  the  contagium  may 
be,  its  bearer  is  conceded  to  be  the  saliva  of  the  animal.  The  contagium  is 
a  fixed  and  not  a  volatile  one.  The  researches  of  Pasteur  go  to  show  that 
it  is  also  contained  in  the  central  nervous  system,  especially  the  spinal  cord, 
medulla  and  brain.  Klebs  suggested  that  the  disease  is  caused  by  a 
bacterium  found  in  the  salivary  glands  of  those  affected  with  hydrophobia. 
Gibier,  Fol  and  Bab^s  claim  to  have  found  micrococci  in  the  brain-substance, 
but  these  claims  have  not  been  confirmed  by  others,  though  their  experi- 
ments have  been  repeated.  There  can  scarcely  be  a  doubt  that  an  organism 
is  the  medium  of  infection. 

The  period  of  incubation  is  extremely  variable,  ranging  from  one  week 
to  two  months  or  longer.  Even  two  years  are  said  to  have  elapsed  before 
symptoms  set  in.  The  average  may  be  put  down  at  from  six  weeks  to  two 
months;  Stevenson's  records  in  Public  Health  reports  for  1912  confirm 
the  above  statements.  In  65  cases  in  which  the  incubation  time  is  discussed 
S7  developed  the  disease  in  less  than  four  months,  and  three  over  12  months 
— but  by  no  means  all  persons  bitten  take  the  disease,  a  most  important 
point  to  be  remembered  in  estimating  the  efficacy  of  supposed  curative 
measures.  Not  more  than  15  per  cent,  of  those  bitten  by  dogs,  according 
to  Horsley,  become  affected.  Various  causes  contribute  to  this.  Thus,  the 
saliva  may  be  waped  off  in  the  transit  of  the  tooth  through  the  clothing,  and 


HYDROPHOBIA  165 

such  removal  or  virus  may  reduce  the  danger  of  the  second  bite  of  the  same 
animal,  even  though  it  be  on  the  unprotected  skin.  Again,  the  young  are 
more  susceptible.  Statistics  by  Watson,  in  America,  and  by  Bollinger,  in 
Germany,  show  more  cases  to  have  resulted  from  bites  in  the  upper  extermi- 
ties,  while,  according  to  Horsley,  wounds  about  the  face  and  head  are  more 
apt  to  cause  the  disease  than  those  on  the  hands,  which  are  second  in  order, 
and  after  these  comes  bites  on  other  parts  of  the  body.  A  much  larger 
proportion  of  those  bitten  by  wolves  perish,  from  40  to  80  per  cent.,  accord- 
ing to  different  authorities.  Wounds  about  the  face  and  hands  are  much 
more  serious  than  in  parts  covered  by  clothing. 

To  a  very  important  practical  question.  How  long  after  a  bite  may  the 
dreaded  suspense  of  an  expected  outbreak  last  ?  Accurate  answer  seems 
now  possible.  Cases  treated  promptly  by  inoculation  after  the  Pasteur 
method  rarely  develop  the  disease.     Cases  not  so  treated  are  still  uncertain. 

Morbid  Anatomy. — The  morbid  anatomy  of  rabies,  so  far  as  recog- 
nized, is  limited  to  the  upper  spinal  cord,  medulla,  pons,  and  cortex  of  the 
brain,  and  is  revealed  only  by  the  microscope.  The  blood-vessels  are 
dilated  and  congested,  the  perivascular  sheaths  are  invaded  with  leuko- 
cytes, and  there  are  even  small  hemorrhages.  There  is  hyperemia  of  the 
pharynx,  larynx,  trachea,  bronchi,  and  even  of  the  mucous  membrane  of 
the  stomach,  which  may  be  covered  with  blood-stained  mucus.  Often 
there  are  no  discoverable  changes. 

During  the  year  1900,  important  discoveries  in  the  minute  morbid 
anatomy  of  rabies  were  announced  by  Van  Gehuchten  and  Nelis.  The 
changes  were  found  in  the  peripheral  ganglia  of  the  cerebrospinal  and  sym- 
pathetic systems,  and  are  especially  marked  in  the  plexiform  ganglion  of 
the  pneumogastric  nerve  and  Gasserian  ganglion.  In  the  normal  state 
these  ganglia  are  composed  of  a  framework  of  tissue  in  the  meshes  of  which 
lie  the  nerve  cells,  each  one  inclosed  in  a  capsule  made  up  of  a  single  layer 
of  endothelial  cells.  The  rabic  virus  stimulates  these  cells  to  proliferation 
leading  to  the  ultimate  destruction  of  the  normal  ganglion  cell  and  re- 
placing it  by  a  collection  of  round  cells.  The  ganglion  cells  are  sometimes 
only  slightly  altered,  at  others  destroyed,  the  extent  of  the  process  varying 
in  different  animals,  being  most  pronounced  in  the  dog  and  less  so  in  man 
and  rabbit. 

These  changes  are  claimed  to  be  especially  valuable  in  diagnosis,  since 
the  examination  can  be  completed  within  six  hours  after  the  death  of  the 
animal.  It  is  important,  however,  that  the  animal  should  be  allowed  to 
die  and  not  be  killed  prematurely.  The  ganglion  selected  for  examination 
is  by  preference  that  of  the  pneumogastric  nerve.  The  laboratory  of  the 
State  Live  Stock  Sanitary  Board  of  Pennsylvania  was  the  first  in  this 
country  to  take  up  this  method,  under  the  direction  of  Mazyck  P.  Ravenel, 
bacteriologist  to  the  board.  Fifty-two  cases  were  examined  between  May, 
1900,  and  July,  1901,  without  a  single  failure.  In  1903  Negri  described 
certain  bodies  within  the  plasma  of  the  nerve  cells  which  he  claims  are  pro- 
tozoa. Whether  the  latter  fact  is  correct  or  not,  it  is  now  agreed  by  ob- 
servers that  when  they  are  present  with  the  changes  described  by  Van 
Gehuchten  and  N^lis  biological  diagnosis  becomes  entirely  unnecessar5^ 

Symptoms. — Rabies  is  usually   divided,    corresponding    to   the  promi- 


166  INFECTIOUS  DISEASES 

nence  of  symptoms,  into  two  varieties — furious  or  convulsive  and  "dumb" 
or  -paralytic  rabies.  Professor  W.  H.  Welch,  of  Johns  Hopkins  University, 
suggests  a  third  form  of  mixed  rabies,  representing  a  combination  of  con- 
vidsive  and  dumb  rabies.  The  variety  common  to  human  beings  is  the 
furious  or  convulsive,  though  paralytic  rabies  also  occurs  in  man,  espe- 
cially after  bites  on  the  lower  extremities,  and  would  seem  to  be  increasing 
as  compared  with  the  convulsive  form.  So,  too,  in  dogs  furious  rabies  is 
the  more  usual,  while  in  rabbits  the  paralytic  form  is  more  common. 

It  is  true,  also,  that  a  sharp  distinction  cannot  always  be  made  between 
the  two  forms,  while  a  stage  of  excitation  and  a  stage  of  paralysis  may  be 
made  out  in  the  same  case,  and  it  amounts  largely  to  this :  that  in  the  furious 
form,  the  stage  of  paralysis  may  be  short  or  wanting,  while  in  the  paralytic 
form  the  stage  of  excitement  may  be  short  and  may  be  manifested  only  b>' 
acceleration  of  breathing,  elevation  of  temperature,  and  symptoms  referable 
to  irritation  of  the  vagus  nerve.  The  most  reliable  observations  go  to  show 
that  there  is  no  difference  in  the  quality  of  the  virus  producing  the  two 
forms,  but  that  the  differences  are  due  rather  to  peculiarities  in  the  individual , 
the  seat  of  inoculation,  or  perhaps  the  quantity  of  the  virus. 

The  first  or  premonitory  stage  succeeds  upon  the  period  of  incubation 
and  lasts  about  24  hoturs.  The  cicatrix  of  the  bite,  which  has  been  for  some 
time  healed,  may  become  painful  or  the  seat  of  radiating  pain,  or  become 
livid,  or  even  break  out  again.  The  patient  is  morbidly  depressed  or  irritable, 
\s' feverish,  loses  appetite,  and  is  sleepless;  there  is  hoarseness  or  huskiness  of 
voice.  A  feeling  of  intense  anxiety  and  a  moodiness  are  very  characteristic, 
his  probable  fate  being  the  sole  subject  of  contemplation.  There  is  an  in- 
creased excitability,  as  a  result  of  which  the  banging  of  a  door  or  a  flash  of 
light  causes  the  patient  to  start.     Fever  is  not  marked. 

The  second  or  spasmodic  stage  is  the  true  hydrophobic  stage,  setting 
in  usually  after  the  first  24  hours.  It  is  also  called  the  furious  stage.  The 
sum  of  its  symptomatology  depends  upon  an  exalted  irritability  of  the 
muscles  of  the  larynx,  as  the  result  of  which  they  contract  upon  the  slightest 
irritation  in  their  vicinity,  the  act  of  swallowing  being  the  most  frequent 
exciting  cause.  Attempt  at  swallowing  is  followed  by  the  most  powerful 
contraction  associated  with  dyspnea,  even  when  the  glottis  is  open  or  trache- 
otomy has  been  performed;  whence  the  fear  of  water,  the  contact  of  which 
with  the  throat  is  followed  by  such  frightfvd  spasm  of  the  muscles  of  the 
larynx  and  elevators  of  the  hyoid  bone.  Even  the  saliva,  which  is  secreted 
in  increased  quantity,  cannot  be  swallowed  without  exciting  paroxysms. 
Hence  it  is  discharged  from  the  mouth,  sometimes  forcibly,  gi^dng  rise  to 
the  popular  idea  that  the  patient  is  frothing  at  the  mouth.  A  breath  of  air 
or  the  slamming  of  a  door  may  produce  a  paroxj^sm. 

The  paroxysm  ma^^  be  associated  with  maniacal  excitement  in  which 
the  patient  is  sometimes  uncontrollable,  rolling  his  eyes,  striking  about 
with  his  arms,  and  making  snapping  noises  with  the  mouth,  which  are  com- 
pared to  the  biting  of  dogs.  These  noises  are  altogether  due  to  uncontrol- 
lable spasmodic  shutting  of  the  mouth.  On  the  other  hand,  between  the 
paroxysms,  when  the  mind  is  clear  and  the  reason  sound,  there  is  often 
found  a  touching  concern  on  the  part  of  the  patient  lest  he  does  some  harm 
to  those  whom  he  loves.     There  is  more  decided  feverishness  in  this  stage, 


HYDROPHOBIA  167 

the  temperature  rising  as  high  as  103°  F.  (39.4°  C.),  while  the  pulse  is  fre- 
quent and  sometimes  irregular.  Albuminuria  and  glycosuria  have  both 
been  found  in  this  stage.  The  second  stage  lasts  from  one  to  three  days, 
sometimes  a  little  longer. 

In  the  third  or  paralytic  stage  the  patient  has  become  exhausted.  There 
are  no  more  paroxysms  and  he  is  quiet.  His  heart  gradually  fails,  and  he 
dies  by  syncope,  although  he  may  die  in  a  convulsion  or  in  asphyxia.  This 
stage  usually  lasts  from  six  to  18  hours.  Happily,  the  disease  is  one  of 
short  duration,  ranging  from  two  to  six  days,  notwithstanding  its  long 
period  of  incubation. 

Diagnosis. — Hydrophobia  most  resembles  tetanus.  Yet  the  diseases 
are  very  different.  Hydrophobia  has  a  long  period  of  incubation,  whil^ 
tetanus  has  a  short  one  from  three  to  ten  days.  Tetanus  begins  mth  tris- 
mus and  is  associated  with  opisthotonos.  Neither  of  these  symptoms  is 
present  in  hydrophobia.  Tetanus  has  no  laryngeal  symptoms,  no  spasms 
in  swallowing.  The  mental  depression  so  characteristic  of  hydrophobia  is 
wanting  in  tetanus.  . 

More  difficult  is  it  to  distinguish  hydrophobia  from  the  imaginary  conT 
dition  known  as  pseudophobia  or  lyssophohia,  numerous  cases  of  which  have 
been  reported,  and  the  occurrence  of  which  doubtless  furnished  the  founda- 
tion for  the  relief  by  some  that  there  is  no  such  disease  as  hydrophobia, 
and  that  all  cases  are  lyssophobia.  The  resemblance  is  often  very  close, 
especially  the  depression  and  mania,  and  it  is  even  said  that  strong  men 
have  been  so  overcome  by  this  fear  that  they  die  as  a  consequence.  The 
condition,  however,  generally  passes  away.  Especially  is  this  the  case 
when  it  transpires  that  the  biting  dog  was  not  rabid.  Hence,  the  usual 
practice  of  immediately  killing  the  dog  supposed  to  be  rabid  is  not  a  wise 
one,  since  it  makes  it  impossible  to  settle  the  question  conclusively  as  to 
its  madness.  It  is  better  to  confine  the  animal  until  the  possibility  of  re- 
covery is  settled.  If  the  dog  be  killed  careful  microscopic  examination  of 
the  ganglion  of  the  brain  and  medulla  shoidd  be  made  by  an  expert  and 
inoculations  from  the  medulla  should  be  made  under  the  dura  mater  of 
rabbits  and  results  awaited.  If  true  rabies,  the  paralytic  form. of  the  dis- 
ease will  be  developed  in  from  15  to  20  days.  A  much  more  rapid  method 
of  diagnosis  is  that  recently  announced  by  Van  Gehuchten  and  Nelis,  for 
which  see  Morbid  Anatomy. 

Prognosis. — The  diagnosis  once  established  of  hydrophobia,  the  prog- 
nosis is,  unfortunately,  totally  unfavorable.  The  possibility  of  spontaneous 
recovery  cannot  be  denied,  but  it  is  certainly  exceptional.  The  preventive 
treatment  is  eminently  successful.  The  claims  of  Pasteur  will  be  considered 
under  treatment.  Bollinger's  statistics  go  to  show  that  out  of  134  cases  in 
which  the  bite  was  cauterized,  92,  or  69  per  cent.,  were  attacked,  while  42, 
or  31  per  cent.,  died  of  the  disease;  of  66  not  cauterized  83  per  cent,  died  of 
the  disease. 

Prophylaxis. — Statistics  show  that  hydrophobia  can  practically  be  ban- 
ished as  a  human  disease  by  the  muzzling  of  dogs  in  countries  where  the 
dog  is  the  chief  animal  which  disseminates  the  disease.  Care  in  regard  to 
the  bites  received  from  unknown  dogs  wiU  also  help  to  lower,  the  incidence 
of  the  disease. 


168  INFECTIOUS  DISEASES 

Treatment. — The  preventive  treatment  consists  first  in  prompt  meas- 
ures to  eliminate  the  poison.  Suction  is  the  promptest  measure  available 
and  should  be  practised,  if  possible,  by  the  victim  himself,  as  it  is  not 
without  danger  to  a  second  person.  An  abrasion  in  the  mouth  or  a  carious 
tooth  may  be  the  medium  of  inoculating  such  person  •with  the  dreaded  virus. 
If  suction  be  practised,  the  mouth  should  be  promptly  rinsed.  It  is  doubt- 
ful if  the  cupping-glass  is  as  efficient,  even  if  at  hand. 

Next  in  availability  is  cauterization,  which  should  be  practised  by  a 
glowing  hot  iron  or  other  instrument  of  the  kind,  a  galvanocautery  or 
Paquelin's  cautery,  failing  this  pure  carbolic  acid  or  pure  nitric  acid  should 
be  applied  to  ever>'  part  of  the  wound — or  the  wound  being  thoroughly 
opened  should  be  washed  ^vith  i-iooo  solution  of  bichloride  of  merctirj'. 
When  the  symptoms  once  set  in,  palliation  alone  is  possible.  A  case  is 
reported  of  true  hydrophobia  which  was  treated  by  Tonin  in  19 12  by  the 
use  of  salvarsan.  This  obsen^er  is  a  physician  in  charge  of  the  Pasteur 
Hospital  at  Cairo.  As  no  case  has  heretofore  been  reported  which  gives 
any  good  evidence  of  cvue  after  the  symptoms  have  developed,  this  method 
should  be  tried. 

Pasteur's  Treatment  by  Attenuated  Virus. — This  is  of  the  nature  of 
preventive  treatment  and  should  be  used  in  every  suspected  case.  It  is  of 
no  value  once  the  symptoms  of  the  disease  are  present.  Pasteur  dis- 
covered that  the  virus  of  hydrophobia  is  located  in  the  ner\^ous  system, 
especially  in  the  brain,  medulla,  and  spinal  cord.  He  then  ascertained 
that  inoculations  by  virus  from  this  soiu"ce  in  rabbits  produced  a  virus  of 
such  increased  virulence  that  after  2  5  successive  inoculations  there  resulted 
a  virus  that  acted  after  a  period  of  incubation  of  eight  days;  and  after  25 
additional  inoculations  in  seven  days.  The  virus  from  the  medulla  of 
rabbits,  with  this  short  period  of  incubation,  is  called  "fixed"  virus  as  con- 
trasted with  the  "street"  virus.  Now,  although  the  spinal  cords  of  such 
animals  contain  the  \drus  in  a  state  of  great  intensity,  Pasteur  ascertained 
that  its  intensity  could  be  greatly  reduced  by  preserving  the  cords  in  dry 
air,  and  that  it  disappeared  altogether  in  two  weeks. 

Careful  examination  of  the  results  of  this  treatment  b>'  the  most  exact 
and  conscientious  observers,  such  as  Victor  Horsley,  of  London,  and  William 
H.  Welch,  of  Johns  Hopkins  University,  as  well  as  the  records  of  the  numer- 
ous Pasteur  institutes  throughout  the  world,  goes  to  show  that  the  treatment 
is  a  powerful  agent  in  saving  life.  As  soon  as  a  person  is  bitten  by  a  rabid 
dog  or  one  supposed  to  be  rabid,  the  person  should  at  once  be  subjected  to 
the  Pasteur  treatment.  This  can  be  done  either  in  one  of  the  Pasteur 
institutions,  which  now  cover  practically  the  entire  globe,  or  by  purchasing 
the  \Trus  from  one  of  the  various  Health  Boards.  In  the  eastern  part  of 
the  United  States  and  probably  in  other  portions  of  the  country,  the  New 
York  Board  of  Health  ^\all  under  proper  regulations  send  the  virus  to 
responsible  individuals  \vith  proper  directions  for  its  use.  Various  manu- 
factiuing  firms  now  dispense  the  virus  in  forms  that  can  be  used  at  home. 
The  use  of  the  Thermos  bottle  makes  it  practicable  to  ship  the  virus  to 
long  distances  and  have  it  perfectly  efficacious. 

If  the  dog  is  not  certainly  kno\\'ii  to  be  rabid,  it  should  be  confined  tmtil 
it  shows  some  symptoms  of  disease  or  is  known  to  be  healthy.     If  there  is 


TETANUS  169 

an  opporttmit}'  for  examination,  the  dog  should  be  killed  and  the  head 
packed  in  ice  and  sent  to  a  laboratory  for  examination. 

The  paroxysms  should  be  controlled  by  inhalations  of  chloroform,  and 
averted  as  far  as  possible  by  full  doses  of  opium,  preferably,  as  a  rule,  mor- 
phin  hypodermically.  Chloral  may  at  first  suffice.  As  light  and  noise 
excite  paroxysms,  the  patient  should  be  kept  quiet  and  secluded,  and  even 
in  a  dark  room  with  two  attendants.  Water  and  nourishment  may  be  gi\'en 
by  enema. 

Beyond  these  measures  the  treatment  of  the  disease  is  the  treatment  of 
the  sj^mptoms. 

TETANUS. 

Synonym. — Lock-jaw. 

Definition. — Tetanus  is  an  infectious  disease  characterized  b}'  parox- 
ysms of  tonic  spasm,  repeating  themselves  with  increasing  severitj-.  It  is 
a  disease  of  human  beings  and  lower  animals. 

Etiology. — The  specific  cause  of  tetanus  is  a  bacillus,  which  was  isolated 
by  Nicolaier  in  1884  and  obtained  in  pure  culture  by  Kitasato  in  1889.  It 
is  a  slender  rod  with  rounded  ends,  develops  at  ordinary  temperatures,  and 
is  found  in  the  soil,  in  the  alimentary  canal  of  animals,  in  manure,  in  pus 
and  putrefying  fluids  of  wounds;  sometimes  forming  threads,  sometimes 
irregular  masses.  It  is  slightly  motile,  anaerobic,  refusing  utterly  to  grow 
in  the  presence  of  oxygen;  develops  spores  within  itself,  though  when  studied 
early  in  pus  is  often  sporeless.  During  sporulation  one  end  becomes 
rounded,  giving  the  bacillus  a  drum-stick  like  appearance. 

It  is  one  of  the  most  invulnerable  of  bacUli,  its  spores  resisting  a  tem- 
peratiire  of  176°  P.  (80°  C),  while  the  bacUli  retain  their  ^'itality  in  the 
dried  condition  for  months.  According  to  G.  M.  Sternberg,  they  resist 
a  five  per  cent,  carbolic  solution  for  ten  hours,  but  will  not  grow  after  15 
hours'  immersion.  If  five  per  cent,  hydrochloric  acid  be  added,  they  are 
destroyed  in  two  hours.  They  are  destroyed  in  three  hours  by  a  i  to  1000 
bichlorid  solution,  but  when  five  per  cent,  hydrochloric  acid  is  added  the 
spores  are  destroyed  in  30  minutes.  Exposure  to  passing  steam  for  from 
five  to  eight  minutes  kills  the  spores.  The  toxin,  on  the  other  hand,  is 
rapidly  destroyed  by  heat  and  light,  being  unable  to  resist  a  temperature 
above  140°  to  149°  F.  (60°  to  65°  C).  In  the  dark  in  a  refrigerator  it  can 
be  kept  indefinitely.  Cultures  of  the  tetanus  bacillus  in  all  media  give  off 
a  peculiar  characteristic  odor — a  bumt-onion  smell  with  a  suggestion  of 
putrefaction. 

The  bacilli  do  not,  however,  pass  into  the  blood,  as  a  rule,  but  at  the 
site  of  the  wound  manufacture  with  great  rapidity  a  ptomain  or  toxin,  which 
is  absorbed  by  the  ends  of  the  motor  nerve  trunks,  carried  along  them  to 
the  motor  center  where  it  excites  the  disease.  This  was  first  shown  in  1890 
by  Kitasato,  who  found  that  the  bacteria-free  filtrates  of  bouillon  cultures 
of  the  tetanus  bacillus  produce  the  same  symptoms  as  inoculation  with  cul- 
tures containing  the  bacillus,  including  ultimate  death.  Indeed,  Brieger, 
in  1886,  isolated  from  impure  ctoltures  three  ptomains,  which  he  called 
tetanin,  tetanotoxin,  and  spasmatoxin.     The  first  of  these  causes  the  char- 


170  INFECTIOUS  DISEASES 

acteristic  symptoms  of  tetanus;  the  second,  tremors,  convulsions,  and  sub- 
sequentU'  paralysis;  and  the  third,  intense  tonic  and  clonic  spasms.  More 
recently,  Kitasato  and  Weyl  obtained  Brieger's  tetanin  and  tetanotoxin 
from  pure  cultures;  while  Briegcr  himself,  with  Frankel  and  Kitasato,  has 
succeeded  in  isolating  from  tetanus  cultures  a  far  more  deadly  ptomain, 
toxalbumin,  which  was  purified  by  Brieger  and  Cohn,  who  have  shown 
that  it  is  not  a  pure  albuminous  body.  Brieger  has  also  isolated  such 
poisons  from  the  organs  of  those  dead  of  tetanus,  and  Nissen  has  demon- 
strated toxin  in  the  blood  of  those  ill  of  tetanus. 

Further,  it  has  been  shown  by  Behring  and  Kitasato  that  there  exists 
in  the  blood  of  animals  immune  to  tetanus  a  substance  with  opposite  prop- 
erties, therefore  called  antitoxin,  and  by  the  gradual  introduction  of  the 
toxin  into  animals  these  observers  have  been  able  to  produce  in  their  blood 
a  potent  antitoxic  substance.  Such  serum  is  prepared  by  Behring  and  by 
Roux  abroad,  and  by  manufacturing  chemists  in  America.  The  methods 
for  its  production  is  similar  to  that  for  diphtheria  antitoxin,  but  slower. 
Tizzoni  and  Cantani  have  successfully  prepared  it  in  a  solid  form,  in  which, 
it  is  claimed,  it  can  be  kept  indefinitely  and  shipped  as  wanted,  and  applied 
to  treatment  of  cases  of  traumatic  tetanus  with  success. 

Predisposing  Causes. — The  excitation  of  tetanus  is  favored  by  certain 
conditions.  Wounds,  particularly  contused  and  punctured  wounds,  espe- 
cially of  the  hands  and  feet,  are  favorite  foci,  whence  the  term  traumatic 
for  such  cases  of  tetanus.  A  similar  focus  is  the  badly  cared-for  umbilical 
cord  whence  tetanus  neonatorum,  affecting  especially  the  colored  race.  In 
certain  parts  of  the  West  Indies  it  is  said  that  more  than  half  the  deaths 
among  negro  children  are  due  to  this  cause.  It  is  probably  because  the 
contused  wound  affords  a  more  favorable  nidus  for  the  growth  of  the  bacilli 
rather  than  that  there  is  any  peculiar  laceration  of  nerves,  as  formerly 
thought.  It  is  more  common,  too,  in  hot  countries  and  in  places  and  seasons 
where  there  are  decided  alternations  of  heat  and  cold.  It  affects  both  sexes 
and  all  ages,  but  it  is  more  frequent  in  men  for  obvious  reasons.  Children 
are  especially  susceptible.' 

Tetanus  occasionally  prevails  in  the  epidemic  form. 

Morbid  Anatomy. — There  is  no  essential  morbid  anatomy  of  tetanus. 
There  may  be  congestion,  extravasations,  and  perivascular  exudates  due 
to  impediment  of  the  movement  of  the  blood  during  spasm,  granular  changes 
in  cells  from  modified  nutrition — all  results  rather  than  causes  of  symptoms. 

Symptoms. — A  period  oj  incubation  of  from  ten  to  15  days  is  required 
for  the  operation  of  the  specific  cause  of  tetanus.  Occasionally  only  docs 
a  chill  precede  the  other  symptoms.  There  appears  first  usually  a  stiffness 
in  the  neck  and  jaws  and  the  patient  opens  his  mouth  with  difficulty,  but 
not  with  pain.  Then  the  stiffness  extends  to  the  back  and  abdominal 
muscles  and  to  the  legs,  which  may  be  fixed  in  extension,  more  usually 
during  a  paroxysm.  The  result  is  that  the  abdominal  muscles  feel  like 
a  board  and  the  whole  trunk  is  inflexible.  If  an  attempt  be  made  to  flex 
the  thighs  on  the  abdomen  the  whole  body  comes  up  in  single  piece;  if  the 
body  is  turned  over,  it  is  like  turning  over  a  wooden  man.  There  is,  in  a 
word,  orihotonos.     Again,  as  in  a  striking  case  of  Tyson's,  the  symptoms 

'  Article  "Tetanus."  Keating's  "Cyclopedia  of  Diseases  of  Children,"  vol.  iv..  p.  913.  1890. 


TETANUS  171 

may  begin  in  the  abdomen  and  by  their  intermittent  character  simulate 
cramp.  1  These  symptoms  are  present  in  various  degrees,  less  marked  in 
the  mild  cases,  more  so  in  the  severe  ones.  In  severe  cases  the  jaws  be- 
come locked,  in  mUder  ones  they  may  partly  yield  to  forcible  extension. 
The  eyebrows  may  be  raised  and  the  angle  of  the  mouth  drawn  up,  pro- 
ducing the  risus  sardonicus,  or  tetanic  grin. 

In  the  so-called  head  tetanus  described  by  E.  Rose,  there  may  be  paral- 
ysis of  the  facial  muscles  and  difficulty  of  swallowing,  with  violent  spasm 
of  the  pharynx  and  esophagus.  It  is  associated  more  particvdarly  with 
injuries  to  the  fifth  nerve. 

These  symptoms  are  more  or  less  constant  in  various  degrees.  All  are 
further  increased  during  the  paroxysm,  which  is  excited  by  various  sensors- 
impressions,  sometimes  exceedingly  trifling,  as  a  breath  of  air  or  the  con- 
tact of  a  dress,  a  footfall,  or  the  slamming  of  a  door.  The  muscles  of  the 
trunk  contract  more  strongly,  and  if  the  patient  be  on  his  back,  the  body 
may  be  so  bowed  that  only  the  back  of  the  head  and  heels  touch  the  bed — 
opisthotonos;  or  the  side  of  the  face  and  leg,  producing  pleurosthotonos ; 
or  the  abdominal  muscles  may  bend  the  body  forward — emprosthotonos. 
Spasmodic  closure  of  the  jaws  sometimes  causes  the  tongue  to  be  bitten. 
The  paroxysm  may  then  relax,  and  during  its  relaxation  the  patient  will 
be  able  to  walk  about.  In  severe  cases  the  spasm  may  involve  also  the 
muscles  surrounding  cavities,  as  the  thorax,  compressing  as  in  a  vise  their 
contents,  causing  extreme  pain.  Indeed,  pain  is  almost  everywhere  an 
accompaniment  of  these  spasmodic  contractions,  and  the  perspiration 
stands  out  in  great  drops  on  the  face  and  covers  the  body.  An  attempt 
to  speak  is  transformed  into  a  fit  of  crying.  The  frequency  of  the  spasms 
varies  greatly;  they  may  occur  every  couple  of  hours  or  minutes  or  almost 
incessantly. 

The  temperature  is  generally,  but  slightly,  if  at  all,  elevated,  rising  to 
101°  F.  (38.3°  C.)  and  more  rarely  to  102°  F.  (38.9°  C).  At  times,  however, 
it  rises  higher,  to  105°  to  106°  F.  (40.5°  to  41.1°  C),  and  it  is  said  also  in 
fatal  cases  to  reach  108°  to  110°  F.  (42.2°  to  43.3°  C).  The  pulse  is  gener- 
ally frequent,  130  to  150,  respirations  30  to  45.  There  is  often  constipation, 
which  is  a  more  serious  symptom  in  severe  cases,  because  the  efforts  to 
rdieve  it  are  apt  to  bring  on  a  spasm.  Among  the  rare  events  have  been 
the  rupture  of  muscles  and  spasmodic  closure  of  the  glottis,  producing  fatal 
asphyxia.  Generally,  death  is  produced  by  exhaustion,  the  mind  remaining 
unclouded  throughout. 

Diagnosis. — Tetanus  is  liable  to  be  confounded  with  strychnin  poison- 
ing, cerebrospinal  meningitis,  and  hydrophobia.  Strychnin  poisoning  differs 
from  tetanus  in  the  absence  of  rigidity  between  the  paroxysms  and  of  tris- 
mus, and  in  the  more  marked  involvement  of  the  extremities,  as  well  as  in 
the  history  of  the  case.  In  hydrophobia  there  is  no  trismus,  and  while  con- 
vidsive  dysphagia  occurs  sometimes  in  tetanus,  it  is  very  rare.  (See  also 
hydrophobia.)  As  in  strychnin  poisoning,  too,  the  individual  paroxysms 
are  more  distinct. 

Cerebrospinal  meningitis  produces  a  rigidity  similar  to  that  of  tetanus, 
but  the  cerebral  symptoms  give  it  its  stamp,  and  fever  is  a  much  earlier 

•  "Philadelphia  Med.  Times,"  vol.  :.,  1871,  p.  418. 


172  INFECTIOUS  DISEASES 

symjDtom  than  in  tetanus.  Leucocytosis  is  present  in  ccrebro  spinal 
meningitis  and  a  spinal  puncture  will  fix  the  diagnosis.  The  stiffness  of 
the  jaws  in  parotitis  and  severe  tonsillitis  is  similar  to  that  of  tetanus,  but 
there  the  resemblance  ends. 

The  interesting  and  rare  condition  known  as  tetany,  or  intermittent 
tetanus,  characterized  by  the  paroxy.smal  tonic  contraction  in  groups  of 
muscles,  more  frequently  in  the  extremities,  is  hardly  likely  to  be  confounded 
with  tetanus. 

Prognosis. — The  prognosis  of  traumatic  tetanus  once  established  is 
exceedingly  unfavorable,  not  less  than  80  per  cent,  perishing. 

In  children  the  prognosis  is  more  favorable  than  in  adults,  and  some 
very  severe  cases  get  well.  Most  cases  die  within  the  first  six  days,  and  cases 
living  to  the  sixth  day  are  very  much  more  apt  to  get  weU.  The  aphorism 
of  Hippocrates,  that  "such  persons  as  are  seized  with  tetanus  die  within 
four  days,  or  if  they  pass  these  they  recover,"  is  frequently  substantiated. 
On  the  other  hand,  a  late  onset  makes  a  case  more  hopeful.  Localization 
of  the  spasm  to  the  muscles  of  the  face,  neck,  and  jaw  is  favorable  to  re- 
covery, and  the  so-called  Rose's  head  tetanus  most  commonly  gets  well. 
The  cases  in  which  there  is  very  little  elevation  of  temperature  are  more  apt 
to  do  well.     Convalescence  is  likely  to  be  protracted  even  in  mild  cases. 

Treatment. — Prompt  local  treatment  is  important.  The  wound  should 
be  excised  and  cauterized  by  the  hot  iron  or  nitrate  of  silver,  and  antiseptic 
dressings  should  be  applied.  The  patient  ought  then  to  be  secluded  and 
surrounded  by  the  utmost  quiet.  After  such  seclusion  BaceUi  recommends 
the  subcutaneous  injection  of  ten  drops  of  a  ten  per  cent,  solution  of  car- 
bolic acid  every  two  or  three  hours.  The  injection  is  made  deep  into  the 
muscles.  He  claims  that  carbolic  acid  gives  better  results  than  the  anti- 
toxin by  antagonizing  the  toxin  and  quieting  the  nervous  system. 

Recent  studies,  however,  give  the  palm  to  the  antitoxin  treatment.  To 
be  of  any  value  it  must  anticipate  the  symptoms  of  the  disease,  since  if 
tetanus  is  fully  established  serum  therapy,  however  administered,  avails 
little.  As  a  prophylactic  it  is  to  be  confidently  relied  upon.  To  be  of  the 
greatest  service  it  must  be  administered  before  the  motor  nerves  have 
absorbed  any  toxin.  It  should,  therefore,  be  administered  as  soon  as 
possible  after  the  infliction  of  the  injury  and  to  every  person  who  has  sus- 
tained an  injtrry  in  which  dirt,  manure  or  foreign  substance  of  any  kind, 
such  as  powder  or  fragments  of  fire-arms,  could  have  entered  the  wound. 
Ten  c.c.  of  a  reliable  serum  should  be  injected  early  into  the  muscles,  re- 
peated on  the  third  and  fifth  days,  and  on  the  15th  to  20th  day  if  suppura- 
tion continue.  Of  Tizzoni's  solid  antitoxin  2.25  grams  should  be  the  first 
dose,  and  0.6  gram  afterward  at  about  the  same  interval.  It  is  also  recom- 
mended to  use  the  dried  serum  locally  in  the  wound,  dusting  it  over  before 
the  dressing  is  applied.  Thus  used,  the  antitoxin  acts  locally,  but  when 
injected  it  travels  along  the  blood  stream  in  contrast  to  the  route  of  toxin. 
The  use  of  antitoxin  in  no  way  precludes  the  employment  of  spinal  anti- 
spasmodic remedies,  such  as  chloral,  bromids,  morphin,  eserin,  etc. 

The  further  treatment  of  tetanus  must  be  the  treatment  of  the  symp- 
toms. Morphin  is  indispensable  to  control  the  pain  and  defer  the  paroxysms 
or  diminish  their  severity,  and  anesthesia  by  ether  or  chloroform', may  be 


TETANUS  173 

required  during  the  paroxysm.  The  milder  sedatives,  like  chloral,  maj'' 
suffice  in  mild  cases,  but  they  are  insufficient  in  severe  ones.  Chloral  may  be 
used  as  an  adjuvant  in  not  less  than  15  grain  (i  gm.)  doses  for  adults  when 
the  quantity  of  morphin  otherwise  required  would  be  excessive.  Even 
larger  doses  of  chloral  than  those  named  may  be  given  in  connection  with 
the  antitoxin  treatment. 

Subdural  injection  through  a  trephined  opening  is  recommended  by 
A.  E.  Barker,'  who  injected  7.5  c.c.  of  antitoxin  at  one  time,  and  20  c.c. 
subcutaneously  daily  for  the  following  four  days.  In  addition  massive 
doses  of  chloral  were  given.  A  week  later  the  rigidity  commenced  to 
diminish,  and  in  the  course  of  three  weeks  the  patient  had  completely 
recovered.  The  efficiency  of  chloral  is  also  increased  when  combined  with 
double  the  dose  of  bromid  of  potassium.  To  a  less  degree  phenacetin, 
antipyrin,  and  antifebrin  may  be  useful.  Salicylic  acid  in  large  doses  has 
been  thought  to  be  of  value.  Later  studies  have  shown  that  neither  the 
subdural  nor  intracerebral  method  of  injection  of  antitoxin  has  any  peculiar 
advantages. 

The  intraspinal  injection  of  magnesium  sulphate  was  suggested  by 
Meltzer,  the  thought  arising  from  the  fact  that  a  long,  deep,  lasting  anes- 
thesia with  complete  relaxation  of  the  voluntary  muscles  and  abolition  of 
some  of  the  less  important  reflex  activities  terminating  in  recovery,  succeeds 
upon  such  injection  in  the  lower  animals.  The  same  effect  was  produced 
on  the  human  being,  25  per  cent,  solutions,  i  c.c.  to  every  20  pounds  of 
body  weight.  There  were  some  untoward  effects,  the  most  serious  being 
slowing  of  respiration,  relieved  by  washing  out  the  spinal  canal  mth  normal 
salt  solution.  Following  this  treatment  some  excellent  results  have  been 
obtained  in  the  treatment  of  tetanus.  Up  to  this  writing  four  cases  of 
tetanus  thus  treated  have  been  reported,  of  which  two  recovered,  one  at  the 
Pennsylvania  Hospital  by  Canby  Robinson.  Robinson  pleads  for  the  use 
of  the  remedy.  He  injected  i  c.c.  of  the  25  per  cent,  solution  for  each  23 
pounds  at  first  injection,  i  c.c.  for  20  pounds  at  second  injection,  and  finally 
I  c.c.  for  17.5  pounds.  The  injections  were  given  daily  or  every  two  or 
three  days  whenever  the  symptoms  returned.  Later  three  more  cases  were 
treated  at  the  Pennsylvania  Hospital  by  the  magnesium  solution  with 
fatal  results,  although  the  control  of  the  paroxysms  was  striking. 

Reasoning  from  its  physiological  action  on  the  nerve-centers,  calabar 
bean  ought  to  be  a  useful  remedy,  and  it  is  commonly  used  in  doses  of  1/4  to 
1/2  grain  (0.0165  to  0.033  g™-)  three  to  five  times  a  day.  Curare  should 
also  be  useful  for  its  sedative  effect  on  the  terminal  nerves,  but  experience 
has  not  confirmed  expectation  as  yet;  1/25  grain  (0.0026  gm.)  may  be  given 
hypodermically  and  cautiously  increased.  The  strength  of  curare  varies 
greatly.  Warm  baths  are  serviceable  in  relaxing  spasm  and  often  very  com- 
forting to  the  patient. 

The  most  nourishing  food  in  liquid  form  is  necessary,  and  usually,  also, 
stimulants  are  freely  administered,  in  tetanus,  with  a  view  to  sustaining  the 
patient  against  the  exhaustion  that  sooner  or  later  causes  death  unless  the 
disease  is  arrested. 


'  "Philadelphia  Med.  Jour.,"  December  8,  1900. 


174  INFECTIOUS  DISEASES 

ANTHRAX. 

Synonyms. — Malignant  Pustule;  Contagious  Carbuncle;  Splenic  Fever; 
Splenic  Apoplexy;  Gangrene  oj  the  Spleen;  Carbuncle  Fever;  Blood- 
striking  Choking;  Quinsy  and  Bloody  Murrain;  Wool-sorters'  Disease; 
Rag-sorters'  Disease.  In  France  it  is  known  as  " Charbon,"  and  in  Ger- 
many as  "  Miltzbrand." 

Definition. — An  acute  infectious  disease  of  animals,  especially  affecting 
cattle  and  sheep,  but  transmissible  also  to  man;  caused  by  the  implantation 
and  multiplication  of  the  bacillus  of  anthrax. 

Etiology. — The  bacillus  of  anthrax,  the  largest  of  the  pathogenic  bacilli, 
is  a  minute  cylinder  $  to  20  microns  in  length  and  one  to  1.25  microns  in 
breadth.  It  is  found  in  enormous  niunbers  in  the  blood  and  tissues  of  the 
animal  infected  with  anthrax,  where  it  multiplies  rapidly  by  division  and 
whence  it  may  be  obtained  by  cioltures.  In  artificial  cultures  it  grows  in 
long  threads,  in  the  interior  of  which  appear  minute  ovoid  spores,  which 
are  loosed  by  disintegration  of  the  bacilli,  which  have  but  a  transient  exist- 
ence, while  the  spores  are  very  tenacious  of  life.  Their  vitality  may  remain 
in  abeyance  for  long  periods  of  time,  and  revive  with  the  return  of  favorable 
condition  of  heat  and  moisture.'  Introduced  into  the  blood  of  animals 
they  develop  into  bacilli.  The  medium  of  their  transfer  to  others,  including 
human  beings,  is  the  blood,  secretions,  flesh,  and  hair  from  those  infected. 
An  extremely  common  source  of  the  infection  in  America  is  infected  hides 
and  hair.  Malignant  pustules  not  uncoromonly  appear  on  the  exposed 
portions  of  the  bodies  of  workmen.  Here,  as  in  glanders  and  hydrophobia, 
an  abraded  surface  is  necessary  for  successful  inoculation,  although  the 
possibility  of  absorption  through  intact  mucous  membrane  and  skin  is 
asserted.  Those  most  frequently  infected  are  herdsmen,  stable-hands, 
butchers,  and  wool-sorters. 

It  is  thought  that  anthrax  baciUi  may  exist  elsewhere  than  in  animals, 
as  in  marshes  and  on  the  banks  of  streams,  whence  they  may  be  carried  b^" 
freshets  into  pastures  and  so  infect  the  grazing  animals.  Commonly,  how- 
ever, the  affection  spreads  from  other  animals  having  the  disease.  Pasteur 
has  found  the  bacilli  in  the  herbage  over  the  buried  bodies  of  animals  dead  of 
the  disease.  It  is  primarily  a  disease  of  herbivora,  from  which  it  is  trans- 
mitted to  camivora  and  man. 

Hoffa  has  isolated  a  toxin,  which  he  calls  anthracin. 

Morbid  Anatomy. — The  body  after  death  is  cyanotic.  The  blood  is 
dark  and  viscid,  coagidating  slowly;  the  spleen  is  enlarged  and  soft.  On  the 
skin  are  carbuncular  and  gangrenous  patches,  the  subcutaneous  tissue  is 
infiltrated  with  bloody  serum,  the  blood  is  uncoagidated,  and  all  the  tissues 
and  organs  are  more  or  less  infiltrated  with  blood.  The  gastrointestinal 
mucous  membrane  is  edematous  and  ecchymotic,  there  are  enlarged  follicles 
and  gangrenous  patches  infiltrated  with  bacilli,  constituting  the  so-called 
carbuncle  of  mucous  membrane.  Even  the  nerv^ous  tissues  are  the  seat  of 
analogous  lesions. 

Symptoms. — Anthrax  has  a  period  of  incubation  of  about  seven  days, 
after  which  there  are  several  ways  in  which  the  disease  shows  itself,  of  which 
the  chief  are  external  anthrax  and  internal  anthrax. 


ANTHRAX  175 

External  Anthrax  manifests  itself  as  malignant  pustule  and  malig- 
nant anthrax  edema. 

1 .  Malignant  pustule  starts  most  frequently  on  exposed  surfaces  of  the 
skin — the  anus,  hands,  or  face — at  the  seat  of  inoculation.  It  begins  as  an 
itching  and  a  burning,  smarting  pain,  resembling  often  that  from  the  bite  of 
an  insect.  The  spot  becomes  red  and  develops  rapidly  into  a  papule,  in  the 
center  of  which  a  vesicle  soon  appears,  which  is  filled  with  clear,  or  at  times 
bloody  serum.  The  vesicle  bursts,  the  papule  enlarges  and  becomes  indu- 
rated, surrounded  by  a  number  of  small  vesicles.  The  induration  extends, 
while  the  center  becomes  dark  and  discolored.  Within  36  hours  a  brown 
eschar  makes  its  appearance  and  rapidly  undergoes  disintegration.  The 
vicinity  becomes  edematous,  the  lymphatics  inflamed,  swollen,  and  painful. 

To  these  local  symptoms  are  added  those  of  general  infection,  with  its 
thirst,  high  temperature,  and  frequent  pulse.  The  tongue  becomes  dry,  the 
liver  and  spleen  enlarged,  the  breathing  rapid,  and  death  supervenes  in  from 
three  to  five  days,  in  fatal  cases. 

Frequently,  recovery  takes  place,  but  it  is  only  in  mild  cases,  in  which 
all  the  symptoms,  local  and  general,  are  less  severe,  that  the  vesicles  dry  up 
into  a  crust  or  scab,  and  the  induration  dies  away. 

2.  Malignant  anthrax  edema  begins  in  the  eyelids  and  passes  thence  to 
the  head,  hands,  and  arms.  The  skin  reddens  and  becomes  edematous, 
vesicles  may  arise,  but  there  are  no  papules,  although  the  edema  may  pro- 
ceed to  extensive  gangrene.  The  local  symptoms  in  this  form  follow  rather 
than  precede  the  constitutional  disturbance,  as  is  the  case  with  the  papular 
form,  and  the  termination  is  even  more  invariably  fatal  than  in  the  latter. 

Anthrax  presents  an  interesting  contrast  to  hydrophobia  in  the  absence 
of  the  anxious  mental  condition  so  characteristic  of  the  latter. 

Internal  anthrax  manifests  itself  as  mycosis  intestinalis  or  intestinal 
anthrax,  and  pulmonary  anthrax.  The  latter  is  also  called  wool-sorters' 
disease. 

1.  Intestinal  anthrax,  or  mycosis  intestinalis,  is  often  ushered  in  by 
chill  followed  by  nausea,  vomiting,  bloody  diarrhea,  abdominal  pain  and 
tenderness.  With  these  S5rmptoms  are  found  after  death  endmatous  and 
ecchymotic  gastrointestinal  mucous  membrane,  enlarged  follicles  and 
gangrenous  patches.  In  addition  to  these  symptoms  pustules  may  form 
on  the  skin.     It  arises  from  the  ingestion  of  meat  infected  with  anthrax. 

2.  Wool-sorters'  disease  is  a  form  of  internal  anthrax  acquired  by  inhal- 
ing the  bacilli  into  the  lungs  by  those  engaged  in  sorting  wool,  especially 
that  imported  from  Russia  and  South  America.  It  begins  with  chill,  fever, 
high  temperature,  pain,  dyspnea,  bronchitis  and  cough,  together  with  the 
physical  signs  of  lung  involvement.  There  are  rarely  premonitory  symp- 
toms and  often  no  external  lesion.  It  is  rapidly  fatal,  the  patient  often 
dying  in  24  hours  in  collapse.  Other  cases  are  more  protracted,  and  there 
may  be  vomiting,  diarrhea,  delirium,  and  unconsciousness,  while  the  brain 
may  be  the  chief  seat  of  involvement,  the  capillaries  being  filled  with  bacUli. 
Rag-pickers'  disease  is  a  special  etiological  variety,  invading  the  lungs  and 
pleura,  with  general  infection. 

Diagnosis. — The  diagnosis  of  external  anthrax  is  usually  easy  from  the 
symptoms,  in  connection  with  the  history  of  exposure  to  the  cause.     The 


176  INFECTIOUS  DISEASES 

fluid  of  the  pustule  may  be  examined  for  the  bacilli,  which  are  large  and 
easily  recognized.  Cultures  may  be  made  and  a  mouse  or  gtunea-pig 
inoculated. 

Internal  anthrax  is  more  difficult  to  recognize  and  may  escape  it  alto- 
gether unless  a  knowledge  of  the  occupation  of  the  patient  suggests  it. 

Prognosis. — The  prognosis  is  unfavorable;  yet  not  all  cases  perish.  The 
anthrax  carbuncles  common  in  American  workmen  frequently  recover.  They 
vary  from  a  mere  irritated  patch  of  skin  without  general  symptoms  to  severe 
large  gangrenous  carbuncles  with  general  toxemia.  The  intestinal  form 
and  wool-sorters'  disease  are  especially  fatal,  though  it  is  said  also  that 
those  who  survive  the  latter  one  week  recover. 

Treatment. — Prophylaxis  is  exceedingly  important.  Animals  dead  of 
the  disease  should  be  cremated — burying  is  not  safe  a  plan ;  their  hides  should 
not  be  used;  infected  pastures  should  be  shut  off;  disinfectants  should  be 
freely  used  in  the  wake  of  the  disease.  Hides,  wool,  and  rags  shovild  be  dis- 
infected by  superheated  steam.  In  the  case  of  wool  and  rags  this  is  quite 
possible,  but  the  necessary  temperature  is  so  high  that  hides  are  damaged 
by  it,  hence  the  latter  should  be  destroyed. 

The  treatment  of  the  local  lesion  varies  with  various  practitioners  and 
cases  encountered.  Wolf  and  Weinvowoski  report  thirteen  cases  with  no 
mortality.  Conservative  treatment  was  applied  in  ten  cases.  Absolute 
rest  of  the  part  with  boric  acid  poultice.  The  excision  practised  in  one 
case  was  followed  by  severe  fever  and  general  symptoms.  Other  cases 
demand  operation.  Deep  crucial  incisions  should  be  made,  and  to  these  the 
actual  cautery,  caustic  potash  or  strong  carbolic  acid  should  be  applied  and 
the  wound  dressed  with  a  strong  solution  of  carbolic  acid,  i  to  20  or  the 
entire  diseased  part  may  be  excised  under  ether  and  the  excavation  treated 
with  carbolic  acid. 

With  the  local  treatment  should  be  associated  stimulating  and  restora- 
tive measures,  including  alcohol,  highly  nutritious  food,  quinin,  and  strych- 
nin. Sclavo's  serum  has  been  used.  Lazaretti  treated  23  cases  with  but 
one  death. 

Bacillus  pyocaneus  toxin  has  been  used  also  with  apparently  brilliant 
results. 

GLANDERS  AND  FARCY. 

Synonyms. — Farcy;  Malleus  hmnidus;  Wtirm  (German). 

Definition. — Glanders  is  an  infectious  disease  more  especially  of  the 
horse,  communicable  to  man  and  certain  domesticated  animals  but  not  to 
cows;  characterized  by  nodular  gro'wths  in  the  nares,  when  it  is  known  as 
glanders,  and  under  the  skin,  when  it  is  called  farcy.  Among  animals  to 
which  it  is  communicable  are  the  lion,  sheep,  rabbit,  guinea-pig,  cat,  dog, 
and  mouse. 

Etiology. — Glanders  and  farcy  are  the  direct  results  of  a  bacillus — the 
bacillus  mallei — described  by  Leoffler  and  Schiitz  in  1882.  It  is  a  short 
nonmotile  bacillus  not  unlike  that  of  tubercle  and  leprosy,  but  shorter  than 
either.  It  is  commonly  seen  among  the  cells  of  the  growth,  but  has  also 
been  found  in  the  blood.     The  disease  is  communicated  by  the  discharge 


GLANDERS—FARCY  177 

from  the  infected  animals  to  an  abraded  skin  surface  or  intact  mucous  mem- 
brane. The  human  victims  are  usually  hostlers  or  others  working  among 
horses. 

Morbid  Anatomy.^-The  infection  presents  itself  in  the  shape  of  nodules 
ranging  in  size  from  that  of  a  lentil  to  that  of  a  fist,  or  in  many  infiltrate  more 
diffusely.  It  is  composed  of  round  cells  which  invade  the  skin,  mucous  mem- 
brane, and  muscles.  Internal  organs — as  the  lungs,  liver,  spleen,  kidnej-s 
and  even  the  stomach,  the  nervous  system,  bone,  and  cartilage — may  be 
invaded.  The  ulcers  on  the  skin  are  often  serpiginous,  whence  the  name 
Wurni  among  Germans.  A  few  of  the  cells  develop  into  epithelioid  cells, 
but  all  soon  break  down,  leaving  ulcers  on  mucous  membrane  and  skin,  and 
abscesses  under  the  latter. 

Symptoms. — Glanders  and  farcy  have  a  period  of  incubation  of  from 
three  to  five  days,  rarely  a  week.  There  is  an  acute  and  chronic  form.  The 
acute  terminates  within  three  weeks,  while  the  chronic  may  last  for  months 
and  even  years. 

In  acute  glanders  of  the  nasal  mucous  membrane  there  is,  first,  redness 
and  swelling  at  the  point  of  inoculation  with  burning  and  dryness  of  the 
adjacent  mucous  membrane.  Intense  pain  in  the  forehead  from  involvement 
of  the  frontal  sinuses  may  also  be  present.  This  is  promptly  followed  by 
nodule-formation  and  the  rapid  breaking  down  of  the  nodules  and  discharge 
of  fetid  hemorrhagic  or  muco-pus.  The  destructive  process  extends  to  the 
nasal  septum,  the  mouth  and  pharynx,  and  even  the  larynx,  lung,  and  other 
organs.  The  submaxillary  glands  swell  and  suppurate.  From  these  lesions 
result  the  usual  symptoms  of  painfid  deglutition,  cough,  and  hoarseness,  ■ndth 
fetid  expectoration. 

Chronic  glanders  is  less  easy  of  recognition.  The  sj-mptoms  are  more 
like  those  of  incurable  coryza  and  sometimes  of  chronic  larjTigitis.  It  may 
be  necessarj'  to  make  cultures  and  inoculate  an  animal,  preferably  the 
guinea-pig,  which  perishes  in  30  days  and  presents  already  testicles  swollen 
and  suppurating. 

In  acute  farcy,  after  the  period  of  incubation,  a  feverish  state  develops. 
At  the  point  of  infection  on  the  skin  there  appears  a  nodular  swelling,  or  an 
ulcer  which  tends  to  spread  and  discharge  a  fetid  hemorrhagic  pus.  The  ad- 
jacent tissue  becomes  red  and  edematous  and  the  lymph-vessels  and  lymph- 
atic glands  are  inflamed.  Papules  that  become  pustules  may  also  develop 
in  the  neighborhood.  Such  an  eruption  has  been  mistaken  for  that  of 
smallpox,  but  is  soon  replaced  by  open  ulcers.  The  so-called /arcj'  huds  are 
nodular,  subcutaneous  enlargements  along  the  course  of  the  lymphatics,  and 
may  suppurate.     The  nose  is  not  involved. 

In  chronic  farcy  the  localized  tumors  form  under  the  skin,  especially  of 
the  extremities,  and  break  down,  but  the  process  is  more  slow,  and  there  is 
no  special  involvement  of  the  lymphatic  glands. 

Further  symptoms  in  both  forms  are:  chilliness,  fever  with  high  tem- 
perature, intense  prostration  and  depression,  muscular  and  joint  pain  and 
soreness,  abscess  formation,  and  finally  typhoid  symptoms  and  death. 

The  spleen  and  liver  may  be  enlarged,  albuminuria  may  be  present,  and 
it  is  said  even  leucin  and  tyro  sin  are  found  in  the  urine. 

Diagnosis. — The  diagnosis  in  the  acute  form  is  eas3^     It  has,  however. 


178  INFECTIOUS  DISEASES 

been  confounded  with  pyemia  and  smallpox.  Chronic  glanders  is  to  be 
distinguished  from  syphilis  and  tuberculosis.  The  history  of  exposure  is 
helpful.  In  doubtful  cases  cultures  should  be  made.  Especially  character- 
istic is  that  on  the  cooked  potato,  which  by  the  thrd  day  furnishes  an  amber- 
hued  film,  that  on  the  sixth  to  eighth  day  is  red  and  turbid,  surrounded  with 
a  pale-green  area.  Inoculation  with  "mallein,"  a  product  of  the  bacillus  of 
glanders,  comparable  to  the  tuberculin  of  tuberculosis,  should  be  made.  It 
causes  a  rise  of  temperature  in  affected  cases  as  do  tuberculosis  cases  with 
tuberculin.  A  reaction  of  3.50°  F.  (2°  C.)  in  horses  is  regarded  as  positive 
proof  of  the  presence  of  the  disease;  a  rise  of  1.85°  F.  (1.50°  C.)  is  strong 
presumptive  proof,  and  1.25°  F.  (1°  C.)  suspicious.  The  absence  of  the 
Waserman  reaction  will  distinguish  an  uncomplicated  case  from  syphilis. 

Prognosis.-T-The  prognosis  in  the  acute  variety  is  invariably  fatal;  in 
the  chronic  form  50  per  cent,  recover. 

Treatment. — In  the  cutaneous  form  excision  and  cauterization  should 
be  practised  as  early  as  possible,  foUowed  by  antiseptic  dressings.  In  the 
nasal  variety  sprays  of  carbolic  acid,  bichlorid  of  mercury  and  peroxidof 
hydrogen  should  be  introduced  into  the  nose  and  throat.  "Mallein"  has 
also  been  used  internally  as  a  remedy,  but  its  value  is  not  as  yet  determined. 


ACTINOMYCOSIS. 

.Synonyms. — Big  Jaw;  Swelled  Head;  Bone  Tumor. 

Definition. — An  infectious  inflammatory  disease  of  cattle,  communicable 
also  to  man,  and  depending  for  its  existence  on  a  peculiar  fungus  named 
by  Hartz,  a  Munich  botanist,  actinomyces  or  ray-fungus. 

Etiology. — The  fungus  belongs  to  the  species  Streptothrix  Actinomyces, 
and  is  known  as  the  ray-fungus.  As  found  in  the  pus  from  man  and  cattle 
affected  mth  the  disease,  it  appears  as  a  small,  yellowdsh  granule  from  one 
to  two  millimeters  (1/25  to  1/12  inch)  in  diameter,  detectable  by  the  naked 
eye.  By  the  microscope  the  granule  is  resolvable  into  conical  threads, 
radiating  from  a  center  to  which  they  are  attached  by  their  small  ends,  the 
other  club-like  ends  being  outward.  This  gives  the  external  surface  a 
mulberry  appearance.  The  center  is  composed  of  a  granular  substance, 
containing  numerous  bodies  resembling  micrococci.  The  disease  has  been 
reproduced  by  inoculation  of  the  fungus  from  a  diseased  animal,  as  well  as 
by  the  inoculation  of  cultures.  It  is  thought  to  arise  primarily  in  animals 
in  the  coui'se  of  their  feeding  on  vegetable  matter.  This  is  the  more  reason- 
able, because  the  ray-fungus  has  been  isolated  from  vegetables.  A  similar 
origin  is  ascribed  to  it  in  man. 

The  effect  of  the  parasite  is  to  produce  granulomatous  and  fibromatous 
new  formations,  which  ultimately  become  the  seat  of  suppuration.  The 
former,  like  tubercle,  is  composed  of  small  round  cells,  epithelioid  cells,  and 
giant  cells.  The  fibrous  matter  consists  of  proliferated  connective  tissue 
about  the  granulation  growth,  expanding  and  enlarging  the  bones  imtil  it 
resembles  an  osteosarcoma,  for  which  it  was  for  a  time  mistaken. 

The  tendency  to  suppuration  is  more  marked  in  man  than  in  cattle, 
where  the  process  too  is  more  localized.     In  man  the  disease  runs  its  course 


ACTINOMYCOSIS  179 

with  the  formation  of  multiple  abscesses  and  chronic  pyemia.  vSuch  course 
is  supposed  to  be  due  to  an  admixture  of  pyogenic  organisms  with  the  true 
ray-fungus.  Associated  with  the  suppurative  process  in  man  is  a  tendency 
to  fatty  degeneration  of  the  cells  of  the  granulation  tissue. 

Morbid  Anatomy. — In  addition  to  the  lesions  presently  to  be  described 
about  the  jaw  and  head,  there  are  found  in  the  lungs,  when  the  latter  are 
invaded,  the  miliary  nodules  alluded  to,  made  up  of  groups  of  fungi,  sur- 
rounded by  granulation  tissue.  Bronchopneumonic  areas  and  abscesses 
large  enough  to  be  recognized  by  their  physical  signs  diuing  life  may  also  be 
present.     Erosion  of  the  vertebrae,  ribs,  and  sternum  may  also  occur. 

Symptoms. — The  route  of  infection  is  generally  the  mouth,  while  the 
special  seats  seized  upon  are  carious  teeth,  whence  the  jaw  is  invaded  and 
becomes  swollen.  The  swelling  may  extend  thence  to  the  face  and  temporal 
region,  and  even  to  the  neck,  producing  discharging  sinuses  like  those  asso- 
ciated with  dead  bone.  Alongside  of  these  are  cicatricial  marks  of  healing. 
More  rarely  the  tongue,  fauces,  and  even  the  intestines  (large  and  small), 
and  the  liver  are  invaded.  The  latter  organ  may  also  become  involved 
metastatically.  The  fungus  has  been  found  in  the  stools  first  by  Ransom, 
and  pericecal  abscess  has  been  found  due  to  it. 

The  lungs  are  also  favorite  seats  of  invasion  by  actinomycosis,  and  it 
was  in  these  organs  in  man  that  Israel  recognized  the  fungus  which  proved 
to  be  the  ray-fungus  also.  The  symptoms  produced  are  those  of  tuberculosis 
— fever,  cough,  and  more  or  less  fetid  expectoration,  in  which  the  fungus  is 
occasionally  found.  In  the  lungs  the  posterior  and  lateral  parts  are  affected 
rather  than  the  apices.  They  may  be  invaded  simultaneously  with  the 
jaws.  The  course  of  lung  actinomycosis  is  chronic,  and  resembles  that  of 
pulmonary  consumption,  the  average  duration  in  man  being  ten  months. 
The  physical  signs  are  those  of  consolidation,  often  of  a  pleural  effusion.. 

Actinomycosis  may  occur  in  connection  in  the  skin  alone,  and  even 
in  the  brain,  abscesses  may  occur  containing  the  mycelium.  BoUinger  has 
reported  a  case  of  the  primary  disease  in  the  brain  of  man,  while  Gamgee 
and  Delpine  and  0.  B.  Keller  have  found  it  in  the  brain  secondary  to  pleural 
invasion.  The  metastatic  abscesses  are  the  direct  result  of  the  transfer  of 
a  portion  of  the  fungus. 

Diagnosis. — Sarcoma  of  the  jaw  presents  a  macroscopic  picture  very 
like  that  of  actinomycosis,  but  its  cotnrse  is  more  rapid  and  there  is  less 
suppuration,  yet  these  signs  are  of  themselves  insufficient,  and  there  re- 
cognition of  the  fungus  is  necessary  to  a  diagnosis. 

More  frequent,  perhaps,  than  any  other  error  is  that  which  mistakes 
the  disease  for  pyemia,  of  which,  indeed,  as  it  occurs  in  man,  it  is  a  chronic 
variety.  There  are  the  same  sort  of  metastases  in  the  lungs  and  elsewhere; 
in  man  with  pus  formation,  in  animals  with  or  without  slight  suppuration. 

Treatment. — The  treatment  is  sirrgical,  consisting  in  thorough  extirpa- 
tion, the  opening  of  the  abscesses  and  removal  of  the  dead  bone,  followed  by 
thorough  drainage.  lodid  of  potassium  in  doses  of  40  to  60  grains  (3.66  to 
4  gm.)  was  recommended  by  Thomassen  in  1885,  and  cures  are  reported 
from  its  use.  DaCosta  also  reports  success  with  this  drug.^  In  Boston 
Med.  and  Stirg.  Jour.,  July  18,  1912,  Kinnicutt  and  Mixter  report  eight 

1  "Proceedings  of  the  Association  of  American  Physicians,"  1900. 


180  INFECTIOUS  DISEASES 

cases  treated  by  either  autogenous  or  stock  vaccines,  six  of  these  cases  re- 
covered.    Certainly  the  procedtore  should  be  tried. 


FOOT-AND-MOUTH  DISEASE. 

Synonym. — AphthcB  e pizoolicce . 

Definition. — An  acute  infectious  disease  of  lower  animals,  communi- 
cable to  man.  It  aflects  especially  cattle,  sheep,  swine,  more  rarely  the  goat 
and  horse,  and  still  more  rarely  of  fowls,  dogs,  and  cats.  The  disease  in 
cattle  spreads  rapidly  and  entails  often  serious  loss.  It  is  characterized  by 
fever  and  the  presence  of  vesicles  and  ulcers  in  the  mucous  membrane  of 
the  mouth  in  the  fiurows  and  clefts  about  the  feet,  and  on  the  teats  of 
animals.     It  is  communicable  to  man  especially  during  epidemics. 

Etiology. — The  microbe  responsible  for  foot-and-mouth  disease  has  not 
been  settled  upon,  though  a  streptococcus  has  been  isolated  from  the  fluid 
of  the  vesicle  by  Klein,  and  a  micrococcus  from  milk  by  Cnyrim  and  Lib- 
beritz;  the  specific  power  of  neither  has  as  yet  been  determined.  The 
contagion  bearer  is  especially  the  contents  of  the  vesicle  alluded  to,  but 
milk,  blood,  tuine  and  feces  are  also  media.  It  is  communicated  to  man 
through  the  ingestion  of  unboiled  milk,  butter,  and  cheese,  or  through 
contact  with  the  fluid  of  the  vesicles  on  the  teats  by  milkers.  It  is  said 
to  be  communicable  even  by  the  saliva  from  the  affected  animal. 

A  certain  relation  is  believed  to  exist  between  the  aphthous  sore  mouth 
of  children  and  the  foot-and-mouth  disease,  chiefly  because  it  has  been 
observed  that  aphthae  are  apt  to  prevail  in  children  at  the  same  time  with  the 
foot-and-mouth  disease  in  cattle. 

Morbid  Anatomy. — As  recovery  invariably  takes  place,  no  lesions  other 
than  those  to  be  noted  under  symptoms  have  as  yet  been  observed. 

Symptoms. — The  disease  has  a  period  of  incubation  of  from  three  to  five 
days.  At  this  time  there  is  a  febrile  movement  with  malaise  and  loss  of  appe- 
tite. On  the  mucous  membrane  of  the  lips  and  tongue,  and  sometimes  on 
the  hard  plate  and  pharynx,  come  vesicles  containing  a  yellowish  sertim. 
There  is  a  sensation  of  heat  and  burning  throughout  the  mouth,  and  the 
swelling  may  be  so  great  as  to  make  speech  difficult  and  swallowing  painful. 
There  is  copious  salivation.  Almost  simultaneously  appear  vesicles  be- 
tween the  fingers  and  toes  and  around  the  nails.  Vesicles  have  also  been 
noted  on  the  nipples  of  women.  Indeed,  they  have  been  found  scattered 
all  over  the  body,  so  that  the  case  resembles  smallpox.  The  hands,  espe- 
cially may  be  extensively  involved.  Gastrointestinal  sjinptoms  are  some- 
times present. 

Diagnosis. — This  must  depend  largely  upon  the  history  of  exposure  of 
the  patient  to  the  infective  disease  in  animals.  There  is  no  specific  way 
of  making  a  diagnosis  from  catarrhal  or  severe  aphthous  stomatitis. 

Prognosis. — The  prognosis  is  favorable  in  man,  recovery  being  the  rule. 
Very  young  children  may  perish.  The  suckling  young  of  animals  perish 
in  large  nmnbers,  because  of  the  infected  milk  on  which  they  subsist. 

Treatment. — The  disease  can  be  easily  avoided  bj'  simple  proph}'lactic 
measures  bv  those  in  contact  with  animals,  of  which  the  use  of  boiled  milk 


MILK-SICKNESS  181 

is  the  most  important.     Cleanliness  of  man  and  beast  conduce  to  the  same 
end. 

Curative  measures  of  a  simple  kind  generall}'  suffice.  Mouth-washes 
of  a  saturated  solution  of  chlorate  of  potassium  should  be  frequently  used. 
Powdered  borax  and  alum  may  be  directly  applied.  The  separate  ulcers 
or  vesicles  should  be  touched  with  the  solid  silver  nitrate.  The  skin  lesions 
should  be  washed  in  corrosive  sublimate  solution  and  dressed  in  sublimate 
cotton  or  salicylated  cotton.  The  fever  should  be  combated  with  suitable 
antifebrile  measures. 


MILK-SICKNESvS. 

Synonyms. — Trembles;  Puking  Fever;  Slows. 

Definition. — An  infectious  disease  prevailing  in  the  western  and  south- 
western parts  of  the  United  States,  characterized  especially  by  trembling, 
vomiting,  constipation,  and  a  peculiar  fetor  of  the  breath. 

Etiology. — A  like  disease  caUed  "trembles"  prevails  among  the  cattle 
of  the  infested  districts,  and  it  is  supposed  to  be  communicated  to  man 
through  the  milk  and  its  products — viz.,  cheese  and  butter,  and  also  flesh 
when  used  as  food.  It  is  more  common  in  summer  and  autumn  and  in  dry 
seasons.  Nothing  more  definite  is  known  as  to  its  cause.  Recently  E.  L. 
Moselyi  has  called  attention  to  Eupatoriimi  ageroteides  or  white  snake- 
root  as  a  cause  of  milk-sickness,  communicated  to  animals  while  grazing; 
this  he  attempts  to  prove  by  experiments  on  animals,  apparently  refuted 
by  Albert  C.  Crawford,  of  the  U.  S.  Agricultural  Dept. 

Morbid  Anatomy. — Our  knowledge  of  the  morbid  anatomy  of  milk- 
fever  is  chiefly  by  inference  from  that  obtained  by  necropsies  on  cattle, 
those  on  man  being  few  and  imperfect.  The  lesions  noted  by  Graff  under 
these  circumstances  are  as  follows:  Cerebral  sinuses,  meningeal  vessels  of 
the  brain  and  cord  distended  with  blood;  pia  mater  opaque  and  overlaid 
with  purulent  exudate ;  brain  soft ;  stomach  and  intestines  contracted  and 
mucous  membrane  injected;  lungs,  liver,  kidneys,  and  spleen  engorged 
with  blood,  the  liver  and  spleen  soft,  the  latter  enlarged  in  some  cases  to 
twice  the  normal  size,  the  blood  fluid. 

Symptoms. — There  is  usually  a  prodrome  of  two  or  three  days,  mani- 
fested by  simple  uneasiness  and  discomfort,  after  which  the  disease  is  usually 
ushered  in  suddenly  by  severe  epigastric  pain,  constipation,  nausea,  and 
vomiting.  Hence  the  term  "puking"  sickness.  There  is  also  moderate 
fever  and  disproportionate  thirst.  The  pulse  at  first  is  full;  later,  small  and 
rapid.  There  is  marked  tremor  or  muscular  twitching  on  attempt  at  motion. 
The  constipation  is  characteristic.  The  tongue  is  swollen  and  the  breath  is 
peculiarly  foul.  This  is  said  to  be  diagnostic.  A  typhoid  state  may  super- 
vene, preceded  by  restlessness,  irritability,  coma,  and  even  convulsions. 

Prognosis. — The  duration  of  the  disease  is  from  two  to  ten  days  or 
longer.  The  short  cases  are  the  fatal  ones.  When  recovery  takes  place, 
convalescence  may  be  protracted  three  to  four  weeks. 

1  Mosely,  The  Cause  of  Trembles  in  Cattle,  Sheep  and  Horses  and  of  Milk-sickness  in  People.  Ohio 
Naturalist,  vol.  vi,.  p.  463  and  477.  1906. 

Crawford.  The  Supposed  Relationship  of  White  Snake-root  to  Milk-sickness  or  Trembles.  Govern- 
ment Printing  Office,  1908. 


182  IXFECTIOUS  DISEASES 

Treatment. — The  treatment  is  symptomatic,  and  consists  chiefly  in 
combating  by  alcohol,  aromatic  spirits  of  ammonia,  and  food  the  tendency 
to  weakness.  Happily,  the  disease  appears  to  be  dying  out  as  land  is 
improved. 

Prophylaxis  may  be  secured  by  fencing  off  cattle  affected  and  carefully 
guarding  against  the  use  of  infected  food  and  milk. 


SYPHILIS. 

Synonyms. — Lues  venerea;  The  Pox. 

Definition.  —Syphilis  is  a  specific  constitutional  disease  acquired  by  con- 
tact with  the  lesions  of  the  disease  or  their  excretions,  and  by  hereditj-. 
Under  the  former  condition  it  is  known  as  acquired  syphilis;  under  the 
latter,  as  hereditary  syphilis.  It  is  apparently  confined  to  the  human  race 
and  to  monkeys. 

Etiology. — The  infecting  organism  is  the  Treponema  pallidum  of  Schau- 
dinn  first  described  in  1905.  This  is  a  delicate  spiral,  4  to  10  microms  long, 
averaging  7  microns  (about  that  of  the  red  corpuscle  of  man)  and  in  width 
may  be  of  unmeasiu-able  thinness  to  1/2  micron.'  It  is  found  with  striking 
constancy  in  the  primary  and  secondary-  local  lesions  of  acquired  syphilis, 
whether  the  lesions  are  on  the  surface  or  interior  of  the  body.  It  was  found 
in  the  pharyngeal  secretions  of  a  congenitally  syphilitic  child  and  in  the 
conjunctival  secretions,  but  rarely  in  the  general  blood  stream,  explaining 
the  difficulty  in  producing  syphilis  by  inoculating  the  blood  of  syphiHtics. 
The  e\adence  in  favor  of  the  important  role  assigned  to  this  organism  is 
derived  from  its  presence  in  syphiHtic  lesions  and  from  experiments  on  the 
anthropoid  apes  which  are  susceptible  to  syphilis  which  is  communicable 
from  one  ape  to  another. 

Among  the  most  important  papers  upon  this  subject  those  by  Flexner, 
and  Uhle  and  Mackinnej--  appear  to  confirm  fully  pre-\aous  observations 
which  go  to  show  that  the  Treponema  pallidum  is  the  cause  of  syphilis. 

Syphilis  is  one  of  the  most  highly  contagious  diseases.  In  the  first 
place,  the  blood  of  the  syphilitic  is  inoculable  though  with  difficulty  and 
capable  of  producing  the  disease.  Further,  the  secretions  of  all  primary 
and  secondary  lesions  of  the  skin  and  mucous  membranes  are  similarly 
potent.  The  products  of  the  third  or  gummatous  stage  are  not  so  regarded, 
although  opinions  are  not  imanimous  on  this  point.  A  raw  or  abraded  sur- 
face is  a  necessary  condition  of  inoculation.  The  physiological  secretions, 
such  as  the  tears,  miUc,  nasal  and  bronchial  mucus,  do  not  communicate 
the  disease  when  inoculated,  although  they  may  become  virulent  by  con- 
tamination with  the  poisonous  secretions.  Exceptions  to  this  law  are  the 
spermatozoid  of  man  and  the  ovule  of  woman. 

The  acquired  disease  has  three  stages — a  primary,  secondary,  and  tertiary. 
The  primary  is  characterized  by  a  primary  sore  associated  with  glandular 


>  See  papers  by  Schaudinn  and  Hoffmann.  "Deutsche  med.  Wochenschrift,"  1905.     Numerous  other 

gapers  have  been  written  since  the  original  of  Schaudinn  and  Hoffmann,  by  Neisse^,^Ietschnikoff  and  Rou.^, 
.ekzet.  NeORgerath  and  Straehlen.  Simon  Fleiiner  and  others.     For  a  good  bibliography  see  Flexner' s 
paper,  "Medical  News."  1905. 

'  The  Demonstration  of  Spirocheta  Pallida  in  Lesions  of  Acquired  Syphilis.     "Journal  of  the  American 
Medical  Association."  February  16,  1907. 


SYPHILIS  183 

enlargement  in  the  neighborhood  of  the  seat  of  inoculation.  The  secondary 
stage  furnishes  general  lymph  node  enlargement,  lesions  of  the  skin  and 
mucous  membranes,  etc.,  among  which  sore  throat  is  especially  conspicuous. 
The  tertiary  is  characterized  by  the  affections  of  deep-seated  structiures,  the 
osseous  and  nen^ous  systems,  the  liver,  spleen,  kidney,  and  testicle ;  also  the 
subcutaneous  and  submucous  tissues. 

The  initial  sore  makes  its  appearance  within  six  weeks  after  exposure, 
usually  in  two  or  three  weeks.  The  phenomena  of  the  second  stage  usually 
show  themselves  about  six  weeks  after  the  appearance  of  the  initial  lesion. 
Rarely  this  period  may  be  somewhat  longer.  The  third  stage  is  more 
difficult  to  define  by  temporal  limits.  It  is  by  years  rather  than  months, 
and  is  characterized,  as  stated,  by  the  involvement  of  the  deeper-seated 
organs. 

In  the  vast  majority  of  cases,  acquired  syphilis  comes  from  sexual  inter- 
course, but  it  may  be  the  result  of  any  contact  such  as  kissing.  Drinking- 
cups,  utensils,  and  other  articles  used  bj-  the  infected  in  common  with  others 
sometimes  convej^  the  infection.  Phj^sicians  are  not  infrequently  infected 
in  midwifer^^  practice,  the  initial  lesion  making  its  appearance  around  the 
nail  or  in  the  web  between  the  first  and  second  fingers.  Wet-nurses  acquire 
the  disease  from  syphilitic  nurslings,  the  chancre  occurring  in  a  fissure  or 
abrasion  of  the  nipple. 

Hereditary  syphilis  may  be  transmitted  through  the  father  or  mother. 
In  the  former  instance  it  is  called  sperm  inheritance;  in  the  latter,  germ 
inheritance.  Syphilis  may  be  communicated  by  the  father  while  the  subject 
of  the  active  disease  or  after  all  signs  of  it  have  disappeared.  On  the  other 
hand,  a  syphilitic  father  Tn&y  beget  healthy  children. 

Syphilis  and  Marriage. — The  question  has  sometimes  to  be  decided  by  a 
physician  as  to  whether  a  sjrphihtic,  apparently  recovered,  may  martyr 
with  safety  to  offspring.  It  wiU  be  seen  from  the  above  that  an  absolute 
answer  dare  not  yet  be  _given;  but  this  much  may  be  said,  that  the  longer 
the  interval  since  the  primarj'  attack  the  less  likely  is  the  offspring  to  be 
tainted,  and  it  is  generally  acknowledged  that  sj-stematic  and  continuous 
treatment  may  eliminate  the  disease  altogether.  Since  the  discovery  of 
the  complement  reaction  and  its  application  to  syphilis  bj-  Wassermann 
the  question  maj^  be  more  definitely  answered.  An  individual  whose  blood 
gives  a  Wassermann  reaction  should  not  marry.  If  the  Wassermann  is 
negative  a  second  test  should  be  made.  If  both  tests  are  negative  the 
patient  may  safely  enter  into  marriage  provided  an  interval  of  not  less 
than  three  years  be  insisted  upon  between  the  disappearance  of  the  last 
symptom  and  the  patient's  marriage.  It  is  to  be  remembered  also  that 
each  successive  child  of  syphilitic  parents  shows  less  signs  of  the  disease, 
until  finally  healthy  offspring  results. 

A  syphilitic  mother  nxay,  of  course,  bear  syphilitic  children  from  germ 
infection,  producing  thus  true  hereditary  syphilis;  but  a  child  may  also  be 
infected  at  the  moment  of  its  birth,  when  the  syphilis  is  congenital  but  not 
inherited.  On  the  other  hand,  a  woman  may  bear  a  syphihtic  child,  and, 
though  herself  without  signs  of  the  disease,  will  not,  according  to  CoUes' 
law,  be  infected  by  her  child  should  she  suckle  it  while  it  has  syphilitic  ulcers 
of  the  Ups  and  tongue.     Such  women,  however,    show  the  Wassermann 


184  INFECTIOUS  DISEASES 

reaction.  Yet  a  healthy  nurse  who  suckles  this  same  child  or  merely 
handles  and  dresses  it  may  be  infected.  Such  a  mother  is  supposed  to  have 
received  protective  inoculation  without  evident  signs  of  the  disease ;  and  we 
may  have  here  an  example  of  protection  through  a  natural  immunity  of 
a  nonsyphilitic  mother. 

According  to  Prof  eta's  law  in  contrast  with  Colics',  a  child  born  of  a 
syphilitic  mother  may  suckle  the  mother  without  being  infected  even  if 
there  be  lesions  on  the  nipple,  immunity  having  been  acquired,  but  such 
children  show  the  Wassermann  reaction. 

A  woman  may  be  infected  after  conception,  when  the  child  ma\-  be  bom 
nonsyphilitic  or  syphilitic  by  placental  transmission. 

Of  course,  when  both  father  and  mother  are  infected,  the  chances  of 
the  offspring  being  infected  are  doubled. 

Morbid  Anatomy.  I.  Of  Acquired  Syphilis. — At  least  five  sets  of  lesions 
may  be  traced  to  acquired  syphilis.  The_^?'5/  is  the  initial  lesion,  the  chancre 
or  primary  sore  at  the  point  of  inoculation  making  its  appearance  two  or 
three  weeks  after  exposure.  This  constitutes  primary  syphilis.  Beginning 
as  an  abraded  spot,  a  vesicle  or  papule  develops,  forms  an  ulcer  with  a  hard, 
gristly  base  and  edge,  constituting  the  hard  of  indurated  chancre.  It  is 
found  to  consist  in  a  dense  infiltration  of  small  cells,  some  of  which  develop 
into  large  formative  (epithelioid)  cells  and  others  even  into  giant  cells,  but 
no  further  differentiation  takes  place ;  for  the  most  part  the  infiltration  breaks 
down  and  is  absorbed,  a  few  of  the  cells  going  to  form  the  cicatrix.  In  the 
lesion  is  found  the  trj'ponema  pallidum.  The  chancre  is  found  usually 
in  males  on  some  part  of  the  penis,  especially  on  the  prepuce,  and  in  females 
on  the  labia  or  vaginal  part  of  the  cervix.  '  It  may  be  so  small  as  to  escape 
notice,  especially  when  within  the  urethra.  The  sore  lasts  from  three  or 
four  weeks  to  as  many  months.  Its  peculiar  induration  is  easily  recognized 
by  taking  it  up  and  pinching  it  between  the  fingers,  though  it  is  often  not 
characteristic  on  the  flat  mucous  membranes  of  the  genitalia  of  women. 

Along  with  the  chancre  there  is  a  second  lesion,  an  adenitis  of  the  ad- 
jacent h'mph  glands,  forming  a  bubo,  or  there  may  be  a  hyperplasia  of 
connective  tissue,  terminating  in  persistent  induration  of  the  gland.  It 
usually  appears  soon  after  the  induration.  Buboes  may  be  long  stationary 
and  are  then  said  to  be  indolent.  They  may  be  multiple.  They  belong  to 
the  symptoms  of  primarv'  syphilis. 

The  third  lesion  is  the  mucous  patch,  soft  papule  or  condyloma  latum, 
which  is  one  of  the  events  of  the  secondary  stage  of  syphilis.  It  has  its  seat 
on  mucous  membrane  of  the  pharynx,  tonsil,  or  on  soft,  moist  skin,  as  in 
the  perimeun,  groins,  between  the  toes,  at  the  junction  between  the  skin 
and  mucous  membrane  at  the  angle  of  the  mouth,  and  about  the  anus. 
It  consists  of  an  inflammaton-  infiltration  of  the  epidermis  and  corium  with 
small  cells.  A  more  highly  differentiated  infiltration  of  the  papillae  of  the 
mucous  membrane  is  the  acuminate  condj'loma,  or  venereal  wart,  especially 
common  about  the  vulva  and  anus. 

The  fourth  lesion  is  the  cutaneous  affection,  or  syphilid,  of  which  there 
is  a  roseolar  or  macular,  a  papular,  a  pustular,  a  squamous,  and  a  tubercular 
variety.  All  are  characterized  by  a  copper-colored  hue,  especially  perma- 
nent after  the  other  features  have  subsided,  and  a  tendency  to  symmetrical 


SYPHILIS  185 

distribution.  The  macular  or  roseolar  syphilid  affects  more  particularly 
the  abdomen,  the  chest,  and  the  front  of  the  arms,  while  the  face  is  exempt. 
This  syphilid  persists  a  week  or  two.  The  papular  eruption  is  in  groups  on 
the  face  and  trunk.  The  pustular  eruption  often  closely  resembles  that  of 
small-pox.  The  squamous  syphilid  resembles  other  squamas,  but  it  is 
especially  distinguished  by  its  coppery  hue.  It  involves  perferably  the 
backs  of  the  arms  and  the  front  of  the  thighs — the  extensor  surfaces — 
and  is,  moreover,  rare.  The  skin  syphilids  are  symmetrical  in  the  earh- 
stages,  but  in  the  latest  stages  become  irregiilar  and  unilateral  in  their 
distribution. 

The  fifth  or  remaining  set  of  lesions  constitutes  the  tertiary  manifesta- 
tion, and  involves  the  deeper  tissues,  such  as  the  subcutaneous  tissues,  the 
osseous  and  the  nervous  systems,  the  liver,  lung  and  kidney.  They  include 
especially  the  tubercular  and  fibroid  induration.  The  first  occur  in  single 
nodtdes  or  may  coalesce  to  form  a  solid  tubercular  patch,  or  serpigi- 
nous patches  or  segments  of  circles.  They  are  confined  to  certain  regions, 
as  a  rule,  face,  back,  and  more  rarely  extremities,  and  are  usually  unilateral. 
The  most  widespread  is  the  fibroid  induration,  consisting  in  a  development 
of  fibroid  tissue  like  that  of  chronic  inflammation.  The  new  tissue  thus 
formed  arises  around  the  blood-vessels,  and  consists,  at  first,  of  a  small- 
celled  infiltration,  which  later  is  converted  into  fibroid  tissue.  It  is  found 
also  in  the  periosteum,  the  sheaths  of  the  nerve  trunks,  the  capsules,  and 
interstitial  tissue  of  organs  and  muscles.  It  occupies,  for  the  most  part, 
small  areas  surrounded  by  normal,  unaffected  structures.  When  in  the 
capsules  of  organs  it  sends  prolongations  into  their  interior,  which  partition 
off  the  organ  and  by  their  subsequent  contraction  give  rise  to  irregidar  thick- 
ening and  cicatricial  puckering. 

A  differentiation  of  this  fibroid  change,  a  most  characteristic  lesion  of 
syphilis,  is  the  gumma,  a  yellowish  white  fibrous  nodule,  closely  continuous 
by  its  outer  laj^er  with  the  connective  tissue  of  the  organ  in  which  it  is 
imbedded.  It  varies  in  size  from  that  of  a  pin  point  to  three  to  five  centi- 
meters (i  to  2  inches)  in  diameter.  Histologically,  it  is  with  tolerable  ease 
separated  into  three  parts — a  central  or  oldest  part  in  a  state  of  atrophic 
cheesy  degeneration,  an  intermediate  layer  of  imperfect  fibrous  tissue,  and  an 
external  layer  of  vascular  granulation-tissue  rich  in  cells.  It  is  frequently 
associated  with  the  fibroid  change  above  described.  In  the  degenerative 
changes  to  which  the  gumma  is  subject  it  may  produce  extreme  destruction 
of  the  organ  in  which  it  is  imbedded. 

The  seats  of  the  gumma  are  the  subcutaneous  and  submucous  tissues, 
muscles,  fasciae,  bone,  where  it  forms  the  syphilitic  node,  the  connective 
tissue  of  organs,  especially  the  liver,  brain,  testicle,  and  kidney,  less  com- 
monly the  lungs.  When  in  submucous  tissues,  it  may  give  rise  to  deep- 
seated  ulceration  and  supptu-ative  processes,  leading  to  destruction,  not 
only  of  soft  tissues,  but  also  of  bone.  Especially  frequent  and  repulsive 
in  its  result  is  the  destruction  of  the  nasal  bones  with  perforation  of  the 
palate. 

Another  variety  of  deep-seated  syphilids,  syphilitic  rupia,  consists  pri- 
marily of  large  pustules,  which  dry  and  crust  over  with  laminated  scabs, 
while  beneath  is  a  deep  ulcer.     This  may  subsequently  heal,  leaving  a  scar. 


186  INFECTIOUS  DISEASES 

Large  pustular  lesions  and  tubercular  syphiloderms  occur  especially  in  the 
neighborhood  of  the  sacrum. 

Another  tertiary  lesion  of  syphilis,  although  probably  not  peculiar  to  it, 
is  syphilitic  arteritis,  which  consists  in  a  cellular  thickening  of  the  vessel-walls, 
beginning  in  the  intima  and  intruding  thence  on  the  lumen  of  the  vessels. 
The  outer  coat  is  abnormally  vascular  and  infiltrated  with  small  cells  that 
also  invade  the  muscular  coat.  These  are  the  phenomena  of  obliterative 
endarteritis,  which  have  thus  far  been  studied  only  in  the  vessels  of  the  brain 
by  Greenfield  and  Huebner. 

Symptoms. — The  symptoms  of  acquired  syphilis  are  so  largely  the 
morbid  states  described  under  the  head  of  morbid  anatomy  that  most  of 
them  need  only  be  enumerated  in  connection  mth  the  date  of  their  appear- 
ance. The  chancre  or  primary  sore  and  the  bubo,  which  together  constitute 
primary  syphilis,  have  been  sufficiently  described. 

The  secondary  symptoms  manifest  themselves  usually  from  the  sixth 
to  the  1 2th  week,  beginning  with  general  lymphadenitis  followed  by  sore 
throat  commonly  associated  with,  fever,  which  rarety  exceeds  ioi°  F.  (38.3° 
C).  It  may  be  remittent  and  even  strikingly  intermittent,  and  in  rare 
instances  rises  much  higher  than  101°  F.  (38.3°  C),  reaching  104°  F.  (40° 
C),  and  even  105°  F.  (40.5°  C).  The  sore  throat  alluded  to  is  associated 
with  hyperemia  of  the  fauces,  often  with  intractable,  gray-based  ulcers,  and 
less  frequently  with  mucous  patches.  The  inflammation  may  extend  from 
the  throat  into  the  Eustachian  tube  and  middle  ear,  producing  impaired 
hearing.  The  larynx  is  especially  liable  to  become  the  seat  of  ulceration, 
which  may  heal  and  produce  marked  deformity. 

Then  there  are  the  syphilids  named.  Along  with  these,  a  very  common 
symptom  is  the  falling  out  of  the  hair,  and  especiallj^  from  the  eyebrows, 
giving  rise  to  a  striking  change  in  the  facial  expression.  An  inflammatory 
condition  at  the  root  of  the  nails,  syphilitic  onychia,  causes  them  to  become 
brittle  and  distorted.  Other  secondary  symptoms  not  mentioned  are 
iritis,  and  more  rarely  choroiditis  and  retinitis.  The  former  presents  itself 
in  from  three  to  six  months  after  the  primary  chancre,  and  is  one  of  the 
most  painful  and  trying  of  symptoms,  requiring  prompt  and  energetic 
treatment.  Involvement  of  the  ear  ossicles  is  rare  but  possible,  producing 
deafness. 

Joint  affections  are  sometimes  associated  with  tertiarj'  syphilis.  These 
may,  of  course,  result  from  the  invasion  of  the  joint  ends  of  the  bones  by  the 
gtunmatous  syphilitic  disease,  to  which  they  are  subject,  but  there  may  also 
be  direct  involvement  of  the  serous  tissues  themselves  by  inflammatory  and 
gummatous  processes  that  give  rise  to  pain  and  interfere  with  motion.  The 
bone  affections  of  syphilis  are  characterized  by  nocturnal  pains. 

The  involvement  of  internal  glandular  organs  occurs  later,  ten  or  more 
vears  after  the  primary  lesion,  though  precocious  tertiary  lesions  of  this  kind 
have  been  reported  much  earlier.  Amyloid  disease  is  a  very  common 
tertiary  affection,  involving  liver  and  spleen  and  producing  some  of  the  most 
striking  enlargements  of  the  former.  But  cirrhosis  and  cicatricial  markings 
are  also  common.  Syphilitic  lesions  of  the  liver  are  of  such  a  degree  and 
importance  as  to  demand  separate  consideration  under  the  diseases  of  that 
organ. 


SYPHILIS  187 

An  atrophy  of  the  follicular  glands  at  the  base  of  the  tongue — smooth 
atrophy  of  the  base  of  the  tongue — was  early  (at  least  as  early  as  1863) 
pointed  out  by  Virchow  as  a  symptom  of  late  syphilis.  Lewin  and  Heller' 
made  a  special  study  of  it.  They  ascribed  it  to  an  interstitial  inflammation 
and  probably  irreparable.  Sixty-two  per  cent,  of  cases  investigated  were 
over  40  years  old,  more  frequently  found  in  men. 

A  sarcocele  involving  the  whole  testicle  is  among  the  tertiary  affections 
often  mistaken  for  tuberculosis,  from  which  it  may  be  distingviished  by  the 
fact  that  the  latter  is  accompanied  by  tuberculosis  elsewhere,  and  involves 
the  proper  structure  of  the  testicle  instead  of  the  whole  organ.  Sclerosis  of 
the  spinal  cord  is  frequently  associated  with  syphilitic  history,  and  it  is  often 
ascribed  to  it.  A  special  condition  is  an  involvement  of  the  nervous  system 
of  such  importance  as  to  require  a  separate  section.  Gumma  of  the  brain 
occur,  producing  pressure  symptoms;  a  similar  association  is  true  of  ar- 
teriosclerosis as  well  as.  the  arteritis  obliterans  alluded  to. 

Sooner  or  later  the  syphilitic  becomes  anemic  and  an  examination  of  the 
blood  recognizes  a  reduction  in  the  number  of  red  corpuscles,  in  the  hemo- 
globin and  an  increase  in  the  white  cells.  Repeated  abortion  is  a  common 
symptom  of  syphilis  in  a  married  woman.  Frequently  four,  five  or  even 
more  abortions  occur,  while  each  successive  one  usually  takes  place  longer 
after  conception  until  finally  a  living  child  may  be  born. 

II.  Of  Hereditary  Syphilis. — Except  the  primary  chancre  all  the  symp- 
toms described  as  occurring  in  acquired  syphilis  may  be  present  in  the 
congenital  form.  It  may  be  said,  in  a  word,  that  visceral  alterations  are 
more  prominent,  especially  those  involving  abdominal  organs.  It  is  nec- 
essary, therefore,  to  mention  here  onl}'  those  that  may  be  regarded  as 
additional. 

Among  the  most  important  of  these  is  premature  birth.  Such  aborted 
products  are  shriveled,  the  skin  exfoliates,  and  there  is  often  reason  to 
believe  they  have  been  some  time  dead.  Syphilitic  children  bom  at  term 
have  evidently  been  arrested  in  development,  are  shriveled  and  wizen- 
faced,  and  may  suffer  from  cutaneous  syphilids. 

The  so-called  pemphigus  neonatorum,  with  blebs  occurring  about  the 
wrists,  hands,  ankles  and  feet,  is  characteristic.  There  is  also  apt  to  be 
enlarged  liver  and  spleen.  Or  a  child  may  be  born  apparently  healthy  and 
take  on  these  symptoms  after  three  or  four  weeks.  This  is,  however, 
unusual.  Rhinitis,  or  nasal  catarrh  with  snuffles,  is  one  of  the  earliest 
symptoms,  often  followed  by  cutaneous  lesions,  particularly  about  the 
nates.  Fissures  about  the  lips  and  ulcerations  on  the  muco-cutaneous 
surface  may  be  present,  and  the  discharges  from  these  are  inoculable. 

Disease  of  the  epiphyseal  cartilages  of  long  bones  and  of  the  cartilages 
of  the  ribs  is  a  very  common  symptom  of  hereditary  syphilis.  The  zone 
of  the  cartilage  adjacent  to  the  bone  exhibits  proliferated  cartilage  cells  and 
prolongations  over  the  end  into  the  diaphysis  instead  of  being  sharply  sepa- 
rated.    There  is  tendency  to  hemorrhage.     A  syphilitic  cry,  high  pitched 


1- Lewin  &  Heller,  "Die  glatte  Atrophie  der  Zungenwurzel  und  chr^Verhaltniss  zur  Syphilis."  "Vir- 
'chow's  Archive,"  138  p.,  1894.  The  latest  paper  which  also  reviews  the  literature  is  by  Nathaniel 
Sowditch  Potter  entitled  "The  Value  of  Virchow's  Smooth  Atrophy  of  the  Base  of  the  Tongue  in  the 
Diagnoses  of  Syphilis,"  published  in  the  "  Boston  Medical  and  Surgical  Journal,"  March  8,  190G. 


188  TXFECriOUS  DISEASES 

and  harsh,  is  described.  To  these  may  be  added  any  of  the  symptoms 
already  mentioned  imder  acqtiired  syphilis. 

A  later  symptom  is  "notched  teeth,"  first  described  by  Jonathan 
Hutchinson  as  characteristic  and  distinctive  of  hereditary  syphilis.  The 
teeth  affected  are  the  permanent  incisors  of  the  upper  and  lower  jaws.  The 
appearances  are  not  uniform,  and  are  better  appreciated  by  examining  the 
accompanying  drawings  than  from  descriptions.  Other  late  symptoms  are 
keratitis,  iritis,  impaired  hearing  from  ear  aifections,  periostitis,  and  splenic 
and  hepatic  enlargement. 

If  it  survive  the  earlier  lesions  or  escape  them,  the  syphilitic  child 
remains  undeveloped  and  stunted  in  its  growth,  and  in  consequence  of 
arrest  of  development  a  singular  reversal  of  the  appearance  of  premature  age. 


■m^ 


mm 


Fig.  20. — The  lower  incisors  of 
a  girl,  aged  fifteen,  the  subject  of 
inherited  syphilis.  The  teeth  are 
very  short,  rounded  and  peglike, 
with  wide  interspaces.  This  set 
shows  the  most  typical  condition 
ever  exhibited  by  the  lower  set — 
(after  Hulchinson). 


Fig.  21. — The  two  upper  and  four  lower  incisors 
(permanent)  of  a  girl,  the  subject  of  inherited  syphilis, 
all  recently  cut.  The  upper  teeth  are  narrow  from  side 
to  side,  at  their  edges,  and  show  a  thin  middle  lobe, 
bounded  above  by  a  crescentic  line.  The  lower  teeth 
are  rounded  and  show  foliated  extremities.  All  the 
teeth  are  small  and  spaces  occur  between  the  adjacent 
ones.  In  the  upper  ones  the  crescentic  thin  mid-lobe, 
and  in  the  lower  ones  the  foliated  extremities  will, 
before  long,  break  away — {after  Hutchinson). 


described  as  characteristic  of  the  syphihtic  child  at  birth,  takes  place.  The 
new-bom  syphilitic  cliild  looks  prematurely  old.  A  popular  novelist  has 
aptly  described  the  appearance  of  the  syphilitic  child  in  the  terse  phrase, 
"a  little  old  man  with  a  cold  in  his  head."  The  syphilitic  who  outlives  his 
childhood  remains,  however,  younger  looking  than  he  actually  is,  insomuch 
that  a  young  man  of  20  may  appear  as  though  he  were  but  12,  a  condition 
to  which  Foumier  applies  the  name  infantilism.  In  such  the  forehead 
is  prominent,  the  frontal  bosses  are  marked,  the  bridge  of  the  nose  is  de- 
pressed, its  tip  turned  up.     The  head  may  be  asymmetrical. 

Diagnosis. — The  recognition  of  general  syphilis  is  not  usually  difficult. 
The  s}-mptoms  described  are  of  themselves  distinctive,  but  the  complement 
de\'iation  test  of  Wzssermann  or  Nagouchi's  modification  shoidd  always  be 
made  use  of  when  the  diagnosis  is  the  least  doubtful.  According  to  Ricketts 
and  Dick,  it  is  present  in  from  64  to  100  per  cent,  of  cases  in  the  various 
stages  of  syphilis.  A  positive  reaction  may  be  misleading  in  from  0.3  to 
3.6  per  cent,  of  positive  findings.  This  test  is  time  consuming  and  requires 
much  experience  for  accuracy.  It  therefore  should  be  gi-\-en  into  the  hands 
of  a  trained  laboratory  worker. 

Prognosis. — The  prognosis  of  acquired  syphilis  depends  wholly  on  the 
treatment.  With  earl}-  treatment  properly  conducted  it  is  favorable;  with- 
out treatment  or  with  defective  treatment  the  most  serious  consequences 


SYPHILIS  189 

result,  while  the  physical  inconvenience  and  suffering  scarcely  exceed  the 
mental  misery  which  the  knowledge  of  the  presence  of  so  loathsome  a  disease 
entails.  In  congenital  syphilis  treatment  is  less  satisfactory  for  the  severer 
manifestations,  and  it  is  perhaps  fortunate  that  so  many  perish  in  infancy 
or  early  childhood.  Even  those  most  fortunate  remain  delicate  and  vul- 
nerable to  disease  through  life,  and  too  often  fall  victims  to  causes  which 
but  slightly  affect  the  healthy  man  and  woman. 

Treatment.  Prophylaxis. — Against  sexual  syphilis  the  only  prophy- 
lactic measure  to  be  relied  upon  is  sexual  purity.  The  duty  of  the  physician 
is  plain  in  respect  to  this,  and  the  medical  man  who  advises  illicit  sexual 
intercourse  for  any  reason  degrades  his  calling.  Medical  men  should  be 
exceedingly  cautious  in  their  necessary  professional  contact  with  all  sus- 
pected of  having  syphilis  and  protect  themselves  against  accidental 
infection.  It  is  to  be  remembered  that  the  secretions  of  all  primary 
and  secondary  lesions,  as  well  as  the  blood  of  syphilitics,  may  transmit  the 
disease. 

Treatment  of  the  Primary  Sore. — With  the  appearance  of  a  suspicious  sore 
the  exudate  from  the  lesion  should  at  once  be  examined  for  the  tr\^ponema 
pallidum,  and  a  Wassermann  test  should  be  made.  If  the  organisms  are 
found  or  if  the  Wassermann  reaction  is  positive,  the  seat  of  the  primary  sore 
should  at  once  be  excised,  if  such  excision  is  not  mutilating,  and  the  con- 
stitutional treatment  recommended  below  at  once  be  carried  out. 

The  Constitutional  Treatment. — This  should  begin  at  once.  All  syphil- 
ologists  are  agreed  that  Ehrlich's  neo-salvarsan  should  be  used  in  practically 
all  cases  of  syphilis  of  whatever  stage.  The  drug  is  best  given  intravenously 
with  every  asceptic  precaution,  and  should  only  be  given  by  one  accustomed 
to  such  sufgical  procedures.  If  given  very  early  it  controls  the  disease 
better  than  any  other  drug.  If  given  on  the  appearance  of  secondary  or 
tertiary  lesions,  these  lesions  usually  disappear  magically.  It,  however, 
does  not  effect  a  cure  in  one  dose.  The  neo-salvarsan  should  be  followed  by 
some  form  of  mercurial  medication  described  below.  After  about  three 
months  a  Wassermann's  reaction  should  be  taken,  if  this  is  positive  another 
dose  of  neo-salvarsan  should  be  given  to  be  again  followed  by  mercurial 
medication,  after  another  interval  of  three  months  a  second  Wassermann 
should  be  done.  A  third  Wassermann  reaction  should  be  done  at  the  end  of 
a  year  after  infection.  The  occurrence  of  three  negative  Wassermann  reac- 
tions indicates  a  cure.  Mercury  is  the  remedy  par  excellence  of  the  second 
stage.  The  best  method  of  administration  for  mercury  is  undoubtedly  by 
inunction.  The  following  is  the  plan  to  be  piursued:  A  warm  bath  is  taken, 
if  possible,  each  day,  and  immediately  thereafter  i  dram  (4  gm.)  of  mercurial 
ointment  is  spread  between  the  hands  and  rubbed,  one  day  on  the  inside  of 
one  thigh,  the  next  on  the  inside  of  the  other;  again,  under  the  arm,  on  the 
chest,  and  so  on  until  each  part  of  the  body  covered  by  softer  skin  is  treated, 
after  which  the  same  coiu-se  can  be  repeated.  The  friction  is  to  be  kept  up 
until  the  skin  is  thoroughly  dry,  half  an  hour  being  usually  necessarj^  The 
part  rubbed  should  be  washed  off  the  following  day.  Parts  covered  with 
hair  are  to  be  avoided,  because  mercurial  eczema,  characterized  by  pustides 
starting  from  the  hair  follicles,  is  more  apt  to  be  produced  in  these  localities. 
During  this  time  the  patient  should  not  smoke,  and  the  teeth  should  be 


190  INFECTIOUS  DISEASES 

frequently  and  carefully  cleansed  and  the  mouth  washed  wth  solution  of 
chlorate  of  potash  with  a  view  of  averting  mercurial  sore  mouth.  Sooner 
or  later,  however,  sore  mouth  may  manifest  itself  by  a  fetid  odor,  swollen 
gimnis,  and  a  sensation  as  though  the  teeth  were  loose,  when  the  treatment 
should  be  suspended  for  a  week  or  ten  days,  or  until  the  signs  of  ptyalism 
have  disappeared.  The  inunctions  may  then  be  resumed,  this  should  be 
continued  until  the  Wassermann  reactions  are  negative. 

The  inunctions  may  be  substituted  by  the  use  of  hydrarg\'ri  iodidum 
flavum  (protiodide  of  merctuy)  1/4  grain  (0.016  gm.)  three  times  a  day,  or  the 
biniodid,  1/16  grain  (0.004  gm.)  three  times  a  day.  The  former  is  usually 
]:)referred  because  less  irritating.  This  last  addition  to  the  treatment  should 
be  kept  up  until  a  cure  is  indicated  by  a  negative  Wassermann  reaction. 
By  such  means  as  these  tertiary  symptoms  can  be  averted  if  the  patient  is 
but  willing  to  continue  the  treatment.  The  great  difficulty  is  to  secure  this. 
He  tires  of  the  monotony  and  the  trouble  involved  in  a  faithful  adherence  to 
the  directions,  and  sj'mptoms  sooner  or  later  return.  Should  secondary 
symptoms  recur  a  course  of  inunctions  may  be  repeated. 

Most  recently  mercury  has  been  administered  by  direct  injection  into 
the  muscles.  One-third  grain  (0.0216  gm.)  of  bichlorid  dissolved  in  20 
minims  (1.333  ^■^■)  of  water  is  injected  once  a  week,  or  from  i  to  2  grains 
(0.066  to  0.132  gm.)  of  calomel  in  20  minims  (1.333  c.c.)  of  glycerin  and 
water.  The  salicylate  of  mercury  may  also  be  used.  The  injection  is  made 
deep  into  the  muscles,  and  not  in  the  subcutaneous  tissue,  through  silver 
canidae.  The  points  selected  are  the  sides  of  the  thorax  and  back,  where 
abscesses  are  said  to  be  less  likely  to  occiar.  Great  care  should  be  taken  in 
sterilizing  instruments.  The  nicest  attention  to  these  points  is,  however, 
still  followed  at  times  by  abscesses.  Many  experts  use  this  method  almost 
exclusively. 

In  the  treatment  of  the  third  stage  the  iodids  are  especially  useful.  It 
is  here  that  large  doses  of  iodid  of  potassium  are  indicated  and  often  pro- 
duce such  magical  results.  The  most  convenient  mode  of  administration  is 
the  solution,  of  which  i  drop  contains  one-half  a  grain  (o  .033  gm.)  Starting 
with  10  drops,  a  drop  may  be  added  each  day  to  the  dose  until  the  symptoms 
>'ield,  that  is,  until  the  tumors  disappear.  Pressure  symptoms  and  head  and 
bone  pains  are  relieved.  The  iodid  is  well  administered  in  milk.  The 
indications  for  its  discontinuance  or  reduction  in  the  dose  are  the  erythe- 
matous rash,  coryza,  and  salivation  and  constriction  about  the  throat  due 
to  swelling  of  the  salivary  glands. 

Diseases  Due  to  Anim.\l  Parasites 

Out  of  the  vast  number  of  animals  which  in  one  or  other  period  of  the 
life  cycle  are  parasitic  upon  some  higher  form  of  life,  the  group  which  in- 
fests man  either  as  the  defiiiitive  host  or  as  host  of  some  inermediate 
stage  is  comparatively  small ;  and  that  which  includes  onlj^  the  more  impor- 
tant forms  capable  of  actually  working  harm  to  the  human  host  is  much 
smaller.  Representatives  of  the  animal  parasites  of  sufficient  importance 
to  be  here  considered  are  distributed  among  the  protozoa,  the  worms  and 
arthropods. 


PARASITES 


191 


Fig.  22. — Amoebae  coli  in  fecal  matter; 
several  of  the  parasites  show  included  red 
blood  cells.  In  the  fecal  matter  in  addi- 
tion to  the  granular  (largely  bacterial) 
matter,  one  may  note  red  corpuscles, 
muscle  and  elastic  tissue,  a  vegetable  spiral 
duct  and  numerous  crystalline  bodies. 


I    Class:  RHIZOPODA; 

Order:  Amcebina; 

Genus:  Ammba. 

Amoeba  Coli,  Losch. 

{Amoeba  dysenterice;  enlamceba  coli,  Schaud.;  entamosba  histolytica,  Schaud.;  entamoeba 

hominis,  Casagrandi.) 

The  amoeba  coli  is  commonly  observed  in  the  stools  and  in  the  wall 
of  the  colon  of  human  beings  subjects 
of  so-called  amebic  dysentery.  Its 
demonstration  in  the  dejecta  is  to  be 
made  by  placing  a  bit  of  fresh  warm 
material  upon  a  slide,  and  covering 
with  slip  without  further  precaution 
than  to  obtain  a  thin  and  even  layer. 
The  blood-stained  mucus  in  the  dysen- 
teric stool  is  especially  suitable  for  the 
purpose.  The  parasite  may  be  recog- 
nized by  obtaining  the  cells  in  active 
motion.  They  are  very  susceptible  to 
the  influence  of  cold  and  then  quickly 
become  quiescent;  it  is  therefore  best 
to  insist  that  the  stool  should  be  quite 

fresh  and  warm  from  the  body  or  with  its  warmth  artificially  maintained, 
and  that  the  observation  be  made  in  a  warm  room  or  with  the  aid  of  a  warm 
stage.  In  such  case  the  movements  are  usually 
quite  active  and  readily  draw  attention  to  the 
parasites;  but  even  if  slow  and  uncertain  they 
may  be  surely  determined  by  making  outline 
drawings  of  a  cell  at  frequent  intervals  for  a  few 
minutes  and  comparing  these.  It  is  difficult  to 
reinduce  movement  when  the  animals  have  be- 
come chilled.  In  such  preparations  of  dejecta, 
especially  after  they  have  become  cold,  encysted 
forms  (spherical  and  with  an  apparent  ceU-wall) 
are  often  to  be  observed;  this  condition  being 
apparently  assumed  as  more  resistant  to  the 
influences  of  heat,  cold,  drying,  etc.,  and  believed 
to  be  that  most  favorable  for  prolongation  of  life 
and  the  usual  condition  of  amoebse  in  trans- 
mission from  one  to  a  second  host.  In  the  walls 
of  the  colon  the  amoeba  are  found  in  the  necrotic 
matter  of  dysenteric  ulcerations  and  in  the  sur- 
rounding tissues  of  the  mucosa  and  submucosa, 
often  being  seen  in  great  numbers  in  the  lymph 
spaces  of  the  latter  layer,  even  at  some  distance 
from  the  base  of  the  ulcer.  (For  the  general 
description  of  the  pathological  changes,  symp- 
toms, and  treatment  of  amebic  dysentery  reference  should  be  made  to  the 
special  section  dealing  with  this  disease  (p.  88). 


Fig.  23. — Section  of  waU  of 
colon  at  border  of  dysenteric 
ulcer;  showing  loss  of  sub- 
stance of  mucosa,  thickening 
of  submucosa  from  inflamma- 
tory changes  and  in  the  latter 
large  numbers  of  amoebae  coli. 


192  IXFECTIOU.S  DISEASES 

Errant  examples  of  the  parasite  arc  most  frequently  met  in  the  pus  of 
secondary  hepatic  abscesses  in  dysenteric  subjects  and  in  the  bordering 
hepatic  tissue,  and  in  the  lung  and  expectoration  where  such  abscesses  have 
perforated  the  diaphragm  and  penetrated  the  lung.  Thej^  have  been  found 
rarely  in  other  positions.  The  transmission  of  amoeba  coli  is  b\''  no  means 
clear.  It  is  thought  that  the  parasites  when  passed  from  the  intestine  of  the 
original  host  assume  an  encysted  condition  and  are  carried  to  the  alimentary 
canal  of  the  second  individual  in  impure  water,  or  perhaps  by  foods  tainted 
by  such  water  or  by  contact  with  insects  carrj'ing  the  amoeba;  from  the  de- 
jecta in  which  they  originally  existed.  Arrived  in  the  large  intestine  the 
parasite  multiplies  by  division;  Grassi  believes,  too,  that  he  has  seen  en- 
dogenous formation  of  small  amoebEe  within  the  encysted  form. 

A  remedial  measure  of  considerable  value  which  should  be  mentioned 
in  addition  to  the  procedures  recommended  in  the  section  upon  amebic 
dysentery  (p.  88)  is  the  use  of  infusions  or  the  fluid  extract  of  the  chaparra 
amargosa,  a  simarubacea  growing  in  Mexico  and  Texas,  given  preferabh^ 
by  the  mouth  but  also  employed  in  enemata.  The  infusions  of  the  entire 
plant  seem  to  be  more  valuable  than  the  fluid  extracts  of  the  pharmaceutical 
houses;  and,  given  in  wineglassful  measure  three  or  four  times  daily. 

II.  Class:  FLAGELLATA;  Subclass;  FLAGELLIDIA; 

Order:  Polymastigida;  Monostomea; 

Genus:   Trichomonas. 

Trichomonas  vaginalis  (Donn6), 

Trichomonas  intestinalis   (Leuckart,  etc.). 

Originally  it  was  believed  that  trichomonas  vaginalis  was  to  be  met 
solely  as  a  parasite  of  the  vaginal  canal,  in  women  with  an  add,  spumous 
type  of  vaginal  secretion,  occurring  mainly  in  young  females, 
but  possible  at  any  time  of  life  and  irrespective  of  conditions 
of  pregnancy  or  of  actual  menstruation  at  the  time  of  ex- 
amination. A  number  of  instances  of  its  occurrence  in  the 
urinary  bladder  and  urethra  of  the  male  have,  however,  been 
recorded;  and  at  present  it  is  generally  accepted  that  the 
organism  described  under  the  name  trichomonas  intestinalis 
is  identical.  It  is  believed,  too,  that  similar  organisms  met 
in  the  mouth,  stomach,  and  in  piilmonary  cavnties  and  de- 
scribed as  separate  species  are  really  of  the  same  nature.  It 
may  be  accepted,  however,  that  it  most  frequently  occurs  in 
the  vaginal  secretions.  It  is  apparently  unproductive  of  any 
important  results.  There  need  be  no  definite  vaginal  dis- 
charge or  anj^  recognizable  degree  of  vaginal  catarrh;  doubt- 
less in  the  existence  of  such  condition  the  parasite  may  have 
some  minor  influence  in  maintaining  the  irritative  state,  but 
is  apparently  unable  or  unlikely  to  initiate  it.  So,  too,  while  symptoms 
of  cystitis  coexisted  with  the  presence  of  the  parasite  in  the  bladder  and 
lu-ine  in  certain  cases,  it  is  not  to  be  held  as  the  essentially  influential  agency 
in  their  production.  In  the  intestine  it  is  present  along  with  other  protozoa, 
either  with  diarrheal  symptoms  or  entirely  without  any  symptoms. 

As  to  its  origin  in  the  human  host  practically  nothing  is  known.     For 


PARASITES 


193 


the  intestinal  occurrence  it  is  natural  that  unfiltered  water  should  have  been 
suspected  and  several  instances  suggestive  of  this  mode  of  acquirement  have 
been  published;  perhaps  females  may  by  the  use  of  similarly  unclean  water  in 
bathing  the  genitals  transmit  it  to  the  vaginal  mucous  membrane;  and  it 
has  been  suggested  that  it  may  be  air-borne  to  explain  its  occasional  occur- 
rence in  the  lung.  Experiments  seeking  to  transmit  the  organism  by  the 
mouth  to  lower  mammals  have  failed.  Its  persistence  is  variable.  Often 
in  young  females  it  would  appear  that  the  menstrual  discharge  mechanically 
rids  the  canal  of  the  parasites,  yet  it  may  in  instances  not  infrequently  be 
found  persisting  over  months  and  years.  It  is  not  difficult  of  destruction 
by  the  use  of  alkaline  vaginal  douches  or  douches  of  very  hot  water.  In 
the  intestinal  occurrence  it  often  disappears  without  treatment  of  any 
kind ;  and  generally  the  use  of  calomel  and  intestinal  antiseptics  is  followed 
by  the  early  disappearance  of  the  organism. 

Family:  Rhizomastigida; 

Genus:   Trypanosoma. 

Trypanosoma  gambiense  (Dutton),  {Sleeping  Sickness). 

Elongate  flagellates,  two  to  four  times  the  length  of  a  human  red  blood-corpuscle: 

with  an  undulatory  membrane  extending  the  length  of   the  more  or  less  curved  and 

slightly  spirally  twisted,  delicately  fusiform  body,  and  prolonged  into  a  long,   single 

flagellum  at  one  end;  at  base  of  undulatory  membrane  at  nonflagellate  end  is  a  small 

refractile  body  regarded  as  a  centrosome  or  by  others  as  a  micronucleus;  an  oval  nucleus 

near  middle  of  body;  reproduction  by  cell  division  (believed  to  take  place  after  sexual 

fertilization  and  ookinet  formation  in  the  intestine  and  body  of  the  human  tse-tse  fly, 

the  definitive  host) ;  parasitic  in  human  blood  and  cerebrospinal  fluid  (human  beings 

regarded  as  the  intermediate  hosts). 

Trypanosomes  of  different  species  have  been  discovered  in  the  blood 
of  frogs,  birds,  rats,  rabbits,  guinea-pigs,  of  horses  suffering  from  diseases 
known  as  surra,  douraine,  mal  de 
caderas,  of  cattle  with  tse-tse  fly  dis- 
ease; and  within  recent  years  the  form 
above  outlined  has  been  encountered  in 
the  human  blood  by  Nepveu,  Dutton, 
and  Mason.  Quite  recently  Castel- 
lani  has  demonstrated  with  much  uni- 
formity the  presence  of  the  same  species 
in  the  cerebrospinal  fluid  of  individ- 
uals, almost  invariably  negroes,  pre- 
senting the  symptoms  of  the  African 
sleeping  disease;  and  has  apparently 
led  to  the  solution  of  this  mysterious  and  fatal  affection,  the  etiology  of 
which  has  hitherto  been  entirely  a  fleld  for  surmise.  This  malady  is  prati- 
caUy  unknown  save  in  Africa;  and  is  but  infrequently  met  in  Europeans  in 
the  locations  where  it  is  endemic.  It  runs  a  rather  long  course,  the  period 
of  incubation  being  of  months  or  even  a  year  or  two  in  duration,  the  period 
of  the  active  manifestations  extending  over  three,  four  or  five  months  in 
addition  before  the  fatal  termination.  When  fully  developed  the  disease  is 
essentially  a  meningoencephalo-myelitis  and  is  characterized  by  progressive 
lassitude  and  mental  dullness,  deepening  into  somnolence  and  coma,  by 
tremors  and  uncertainty  of  gait  and  eventually  inability  to  progress,  edema 
of  moderate  degree,  especially  about  the  face,  irregular  temperature,  rapid 


Fig.  25. — Trypanosomes;  showing  ordi- 
nary structural  appearance  on  left;  in  middle 
a  trypanosorae  undergoing  division;  on  the 
right  an  agglutinated  group. 


194  INFECTIOUS  DISEASES 

pulse,  emaciation,  glandular  enlargements,  a  papulovesicular  eruption  be- 
coming superficial  ulcers,  and  eventually  death.  L.  Lorand  ascribes  the 
malady  to  a  degeneration  of  the  thyroid  consequent  on  the  action  of  the 
toxins  generated  by  the  trypanosome. 

The  parasites  are  readily  found  in  the  cerebrospinal  fluid  and  at  times 
also  in  the  blood.  They  may  also  be  obtained  in  the  juices  removed  by  a 
hypodermic  syringe  from  the  enlarged  lymph  nodes.  They  are  to  be  sought 
for  in  ordinary  fresh  moist  films  or  in  dried  preparations  just  as  one  examines 
the  blood  for  malarial  hematozoa;  and  in  dried  and  fixed  films  are  stained 
in  the  same  manner  as  are  the  malarial  organisms.  In  the  moist  film  the 
trypanosomes  may  be  seen  winding  their  way  among  the  corpuscles,  im- 
parting a  slight  motion  to  the  cells.  There  can  be  little  doubt  from  the 
symptomatic  picture  of  the  disease  and  from  the  experimentally  discovered 
fact  that  the  pathogenic  power  of  an  allied  species  (T.  evansi,  of  the  rat, 
cultivated  by  Novy  on  agar  with  defibrinated  rabbit  blood  added — the 
first  successful  artificial  cultivation  of  a  protozoon)  may  be  lost  by  prolonged 
artificial  culture,  that  the  efTects  of  the  parasite  are  largelj^  the  result  of  some 
toxin  in  some  way  elaborated  by  it.  It  has  been  shown  both  by  clinical 
studies  and  by  experiments  upon  monkeys  that  this  species  is  transmitted 
by  the  human  tse-tse  fly  (glossina  palpalis),  thus  closely  following  the 
transmission  of  t.  hrucei  in  cattle  which  is  conveyed  by  glossina  morsitans, 
the  tse-tse  fly  of  cattle.  It  is  of  interest  to  know  that  Schaudinn  has 
recently  suggested  that  spirochaetae,  regarded  as  of  bacterial  nature,  and 
known  best  in  connection  with  relapsing  fever,  are  in  reality  trypanosomes. 
Treatment. — In  the  treatment  of  sleeping  sickness  a  number  of  try- 
panocides  are  available,  as  members  of  the  benzidin  group  such  as  trypan 
red,  various  arsenical  compounds,  among  which  atoxjd  (an  ardline  compound 
of  arsenic  acid)  has  attained  especial  prominence,  and  various  basic  anilines, 
as  well  as  mercurial.  Salvarsan,  0.4  or  0.5  gm.,  has  been  widely  used  with 
marked  benefit,  but  cannot  be  employed  with  impunity  because  of  serious 
complications  to  which  it  may  give  rise.  The  method  best  suited  to  escape 
such  consequences  is  to  administer  the  chemical  in  the  dose  mentioned  for 
two  daj's,  then  to  permit  an  interval  of  ten  or  1 5  days  for  the  elimination  of 
the  drug,  repeating  this  plan  for  months.  In  the  inter\^als  mercurials  may 
be  given  or  some  of  the  anilines.  The  combination  of  trypanocides  in  this 
fashion  is  further  sustained  by  the  fact  that  Ehrlich  has  shown  in  experimen- 
tations that  trypanosomes  may  attain  immunity  against  the  various  chemi- 
cals used  for  their  destruction  and  that  such  resistance  may  be  carried 
forward  for  many  generations;  but  that  where  a  strain  of  trypanosomes  is 
encountered  which  is  resistant  to  a  given  chemical  it  may  be  readily  de- 
stroyed by  some  other  type  of  trypanocide.  After  administration  of  atoxyl 
the  parasites  are  soon  diminished  or  even  lost  from  the  fluids  used  for  ex- 
amination, but  improvement  of  the  general  conchtion  of  the  patients  is  not 
likely  to  be  recognized  until  after  some  weeks  of  persistence  of  treatment. 
Prophylaxis  must  of  course  be  of  great  importance.  It  contemplates 
the  destruction  of  herbage  about  the  damp  places  where  the  himian  tse-tse 
flies  abound,  the  careful  screening  of  all  dwellings,  the  proper  protection 
of  those  exposed  to  their  bites  by  suitable  clothing,  the  removal  of  all 
infected  individuals  and  animals  from  districts  where  the  disease  does  not 


PARASITES  195 

ordinarily  prevail  to  situations  where  the  disease  is  endemic,  and  the  destruc- 
tion of  such  animals  (crocodiles)  from  which  the  flies  seem  ordinarily  to 
obtain  the  blood  which  seems  necessary  for  their  life  and  reproductive 
ability. 

II— VERMES  OR  WORMS. 

Worms  are  bilaterally  symmetrical,  more  or  less  elongate  animals,  with- 
out articulated  members,  with  the  body  usually  showing  a  number  of 
apparent  rings  or  segments  (metameres),  and  are  either  flat  or  cj'lindrical 
in  transverse  section.  Excluding  a  number  of  classes  as  of  no  interest  in  the 
present  connection,  there  remains  the  classes  of  Flat  worms  and  Round 
worms  as  including  various  genera  and  species  in  which  occur  human 
parasites. 

Family:  FASClOHDiE; 

Genus:  Fasciola. 

Fasciola  hepatica  (Lamb6), 

(Distomum  hepaticum;  d.  cavicB;  fasciola  humana;  cladocmlium  hepaticum;  the 

common  liver  fluke). 

A  comparatively  large  fluke,   measuring  20. —50.   mm.  long  and  8.-13.  mm.  wide, 
of  leaf  shape,  with  anterior  extremity  prolonged  into  a  small  cone;  greatest  width^  of 
body  about  anterior  third  of  length;  light  brown  color;  cuticle  provided  with  alternating 
transverse  rows  of  spines,  extending  on  ventral  surface  to  the 
posterior  level  of  testes,  but  not  as  far  posteriorly  on  dorsal  sur- 
face; oral  sucker  at  anterior  end  of  cephalic  cone,  inclining  to 
ventral  surface  (i.  mm.  in  diameter);  ventral  sucker  near  ante- 
rior  end    behind   cephalic   cone   (1.6  mm.  in  diameter);   well- 
developed   pharynx   and   short   esophagus;   intestinal  branches 
extending  nearly  to  posterior  extremity  of  worm,  approaching  the 
median  line  posteriorly,  with  few  median  and  numerous  lateral 
branches;   excretory  pore  at  posterior  extremity,  with  well-de- 
veloped system  of  excretory  tubes;  genital  pore  in  median  line 
anterior  to  ventral  sucker;  two  large,  highly  branched  testes, 
mostly  posterior  to  the  transverse  vitelline  duct;  ovary  single,  Fig.  26. — Fasciola 

branched,  lying  in  front  of  testes  and  to  one  side  of  median  line;       hepatica:  natural  size; 
uterus  coiled  into  a  rosette,  showing  as  a  brown  spot  (from  ova       cleared  in  oil.     [Gould 
contained)  just  back  of  ventral  sucker  on  ventral  surface;  vitel-      '^Z'^''  Leuckart.) 
line  glands  numerous,  ranging  along  each  lateral  border  from  the 

level  of  the  ventral  sucker  to  the  posterior  extremity  of  the  worm ;  vitelline  ducts  running 
transversely  at  about  the  end  of  the  anterior  third  of  body;  ova  yellowish-brown,  oval, 
operculated,  measuring  130.-145.  microm.  long  and  70.-90.  microm.  wide. 

This  parasite  is  a  common  one  in  sheep;  and  is  also  found  in  cattle, 
deer,  goats,  hogs,  horses,  asses,  camels,  rabbits,  guinea-pigs,  and  other 
mammals.  It  is  occasionally  (23  cases  recorded  according  to  Braun)  met 
in  man.  It  has  a  wide  geographical  distribution  over  the  world,  and  is 
not  infrequently  found  in  this  country.  Its  usual  habitat  is  the  gall  ducts; 
but  it  has  been  encountered  ("errant  flukes")  in  the  gall-bladder,  intestines, 
in  the  portal  and  other  venous  channels,  and  rarely  in  subcutaneous  cysts. 
The  life-history  has  been  unusually  well  followed  out  and  may  be  outlined 
as  follows.  The  ova  after  oviposition  are  carried  by  route  of  the  gall- 
passages  and  intestines  to  the  exterior  where,  if  fortune  favors,  they  are 
deposited  in  water.  Here  the  embryo  develops  and  escapes  through  the 
operculum,  swimming  about  as  the  free  miracidium  until  it  can  gain  entrance 
to  the  tissues  of  a  snail  (some  form  of  Limnwa),  in  which  the  sporocyst  is 
formed  and  the  rediae  (half  a  dozen  or  more)  develop;  these  presently 
emerge  from  the  parent  cyst  and  wander  further  into  the  tissues  of  the  snail. 


196 


INF  EC  no  US  DISEA  SES 


each  then  again  encysting  and  dividing  into  a  number  of  cercarise.  By 
this  time  probably  the  snail  has  died  from  the  effects  of  the  parasites;  and 
its  tissues  disintegrating,  the  tadpole-like  cercarife  escape  in  the  water  and 
for  a  time  swim  free.  These  later  become  attached  to  a  blade  of  grass  or 
other  similar  object,  lose  their  tails,  and  become  covered  with  a  hard  cover- 
ing, a  product  of  their  cuticular  glands,  and  thus  remain  protected  for  a 
variable  time.  Later  the  definitive  host,  probably  a  sheep,  devours  the 
grass  and  with  it  the  cercaria,  which  on  arrival  in  the  alimentary  tract 


Fig.  27. — Showing  the  sexual  organs  of 
fasciola  hepatica;  5X1.  0.  oral  sucker; 
D,  intestinal  ceca;  Do,  viteUine  glands;  Dr, 
ovary;  Ov,  uterine  canal;  T,  testicles;  Sg., 
"shell  gland,"  V,  transverse  viteUine  duct; 
Gp,  genital  pore;  S,  ventral  sucker.    {Braiin.) 


Fig.  28. — Showing  the  alimentary  system 
oi  fasciola  hcpalica,  other  parts  suppressed; 
5X1.  (From  a  fluke  as  yet  undeveloped  in 
its  sexual  organs.)     [Braiin.) 


has  its  covering  removed  through  the  action  of  the  digestive  juices  and  in 
some  manner  (whether  by  the  common  duct  into  the  hepatic  duct  and  its 
radicals,  or  by  boring  through  the  intestinal  wall  into  the  portal  vein  and 
thus  carried  to  the  liver,  is  unknown)  finds  its  way  into  the  bile  ducts, 
where  it  grows  into  the  adult  wonh.  Doubtless  in  the  occasional  cases  of 
htunan  acquirement  it  is  similarly  conveyed  upon  some  water  vegetables, 
as  cress,  to  the  stomach.  In  the  lower  animals  there  are  often  found 
large  ntunbers  (from  dozens  to  hundreds)  of  the  flukes  in  the  bile  ducts 
of  a  single  host ;  but  in  man,  while  this  is  possible,  ordinarily  one  finds  but 
very  few. 

The  effects  as  seen  in  the  lower  animals — quite  similar  in  general  char- 


PARASITES 


197 


Fig.  2g. — Miracidium  of 
fasciola  hepatica.  {Gould 
after  Leiickarl.) 


acter  in  case  of  man — are  of  little  severity  and  may  well  be  overlooked 
in  case  the  parasites  are  but  few;  but  when  the  parasitism  is  of  serious 
grade  a  condition  often  proving  fatal,  and  known  in  sheep  as  "liver-rot," 
is  induced.  The  worms  are  well  anchored  in  the  small  tubes  by  their 
suckers  and  posteriorly  inclined  cuticular  spines,  and  the  ducts  are  often  at 
site  of  the  parasites  distended  into  small  cysts.  The  flukes  suck  blood 
from  the  walls  of  the  ducts,  and  cause  considerable  biliary  and  peribiliary 
irritation  with  fibrous  thickening  of  the  walls  and  a  cirrhotic  extension 
into  the  surrounding  hepatic  tissue,  which  undergoes  atrophic  and  degenera- 
tive changes  in  some  degree.  Hemorrhages  into 
the  ducts  often  occur,  constituting  one  of  the  influ- 
ences producing  the  more  or  less  severe  anemia 
characterizing  the  affection.  Gallstone  formation 
is  quite  common,  mixed  concretions  of  biliary 
matter,  mucus,  and  blood  remnants  sometimes 
forming  complete  casts  of  greater  or  less  length  of 
the  infested  ducts.  Thus  biliary  obstruction  with 
the  development  of  icterus,  and  portal  interference 
with  the  production  of  ascites,  are  common.  At 
first,  the  liver  is  enlarged,  but  eventually  becomes 
atrophic  from  the  cirrhosis  and  tissue  degeneration. 
Digestive  disturbances  with  anemia,  loss  of  flesh  and 

enfeeblement  appear,  and  eventually  death  is  apt  to  take  place  from  exhaus- 
tion. These  symptoms,  usually  first  appearing  in  a  month  or  two  after 
the  parasites  gain  access  to  the  liver,  are  evidence  of  an  active  but  definite 
inflammatory  and  degenerative  hepatic  affection;  and  for  the  absolute 
diagnosis  of  the  nature  of  the  case  recourse  must  be  had  to  the  microscopic 
examination  of  the  dejecta  for  the  ova  of  the  parasites.  The  majority 
of  instances  encountered  in  man  have  been  met  at  autopsy,  without  pre'vdous 
suspicion  of  their  existence. 

It  is  probable  that  the  cases  of  flukes  in  the  eye  and  described  under 
the  names  Distomum  oculi  humani   (Ammon,    1833),  Monostomum  lentis 
(v.     Nordmann,     1832)     and    d.    ophthalmobium 
(Diesing,    1850),   were  but  errant  and  immature 
examples  of  the  worm  under  discussion. 

Treatment. — But  little  of  value  can  be  said  in 
connection  with  treatment  of  the  condition,  the 
most  important  measures  being  prophjdactic  and 
looking  to  the  restriction  of  the  flocks  and  herds 
from  pastures  on  badly  drained  land  where  the 
common  grass  snails  are  known  to  be  present. 
In  active  treatment  it  must  be  clear,  because  of  the  position  of  the  flukes, 
that  difficulty  exists  to  reach  the  parasites  with  medicaments  capable  of 
destroying  them.  Numerous  remedies  have  been  suggested  for  the  affection 
in  sheep  and  the  same  substances  may  be  tried  in  human  cases.  Salol  is 
said  to  have  lethal  effects  upon  the  trematodes  in  the  liver,  but  must  be 
given  in  comparatively  large  doses  and  persistently;  the  ethereal  extract 
of  male  fern  is  sometimes  employed,  as  well  as  naphthalin,  various  salts 
of  iron,  sodium  chlorid,  and  a  number  of  other  substances.     In  addition 


Fig.  30. — Ovum  of  fasciola 
hepatica. 


198 


INFECTIOUS  DISEASES 


measures  may  be  indicated  to  combat  the  digestive  and  nutritive  symp- 
toms, but  these  are  in  no  wise  peculiar. 

The  Asiatic  lung  fluke  inhabits  the  bronchial  tubes  of  man,  cat,  dog, 


Fig.    31. — Paragonimus    wcstermanni    (ventral  Fig.     32.  —  Paragonhnus     wester- 

view).  loXi.     4,  oral  sucker;  S,  ceca;  Z>,  acetab-  manni;  photograph  from  a  sexually 

ulura;  E,  genital  pore;  F,  uterus;  G,  ovary;  //,  immature  specimen, 

testicles;  /,  vitelline  glands;  K,  excretory  canal; 
L,  e.-scretory  pore.     (Braitn,  ajler  Leuckart.) 

hog,  and  mouse;  it  has  also  been  recorded  from  the  bronchial  tubes  of  a 
tiger  in  the  zoological  gardens  of  Amsterdam;  the  worm  has  also  been 
found  in  the  brain  and  a  few  other  situations  in  the  bodv.     Usuallv  there 


i 


Fig  3;^. — Paragonimus 
westermanni:  natural  size;  to 
left  showing  ventral  surface; 
to  right  showing  dorsal  surface. 
{Braun,  ajler  Katsurada.) 


Fig.  34. — Ovum  of  para- 
gonimiis  wcslcrmatini,  from 
sputum;  looox I.  (Braun, 
aflcr  Katsurada.) 


Fig.  35. — Ovum  of  para- 
gonimus wcstermanni,  from 
sputum. 


are  small  bronchiectatic  cysts  in  the  lungs,  in  which  in  the  midst  of  a 
reddish-brown  mass  of  blood  and  mucus  the. worms  are  found,  generally 
two  in  each  such  cyst;  the  ptilmonary  tissue  about  these  cysts,  fibroid  or 


SCHISTOSOMUM 


199 


otherwise  changed,  and  the  bronchial  mucous  membrane  in  the  vicinity  of 
the  cyst  more  or  less  inflamed.  From  tissue  destruction  in  the  cyst-wall 
bronchial  hemorrhages  from  time  to  time  are  apt  to  take  place,  constituting 
the  most  pronounced  evidence  of  the  afl:ection  and  leading  to  some  degree 
of  anemia.  As  a  rule,  the  patient  suffers  but  little  inconvenience  beyond 
a  slight  cough,  and  the  hemoptysis  rarely  requires  special  attention.  In 
the  sputtma  the  ova  are  readily  found,  their  recognition  establishing  the 
diagnosis.  These  are  known  to  develop  in  from  six  to  eight  weeks  in  water 
into  a  cUiated  miracidium ;  but  all  further  knowledge  as  to  the  intermediate 
stages  and  their  hosts  is  lacking.  The  parasite  has  been  encountered  most 
frequently  in  Japan,  Formosa,  Korea,  and  China;  in  the  hog,  dog  and  cat, 
it  is  known  to  exist  in  this  country,  and  one  im- 
ported case  in  man  has  been  reported  from  Port- 
land, Oregon. 

The  condition  is  not  incurable;  inhalations  of 
balsamic  material,  of  chloroform  short  of  anes- 
thesia,   and    similar   measures    holding    out   some 


Fig.  37. — Miracidium  of  dicro- 
cwlium  lanceatum:  A ,  lateral  and 
B,  flat  view.  (Braun,  after 
Leuckart.) 


Fig.  38. — Ovum  of 
dicrociBtium  lanceatum. 
X600. 


Fig.  36.  —  Dicrocalium 
lanceatum:  on  left  natural 
size;  on  right  enlarged  10 
times  (ventral  view);  ph, 
pharynx;  m,  oesophagus,  i, 
cecum;  t  and  t' ,  testicles;  cd 
and  cd' ,  vasa  differentia; 
'  pc,  cirrus  pouch;  0,  ovary; 
ga,  vitelline  glands;  u, 
uterus; »,  vagina;  w,  acetab- 
ulum.    (Railliet.) 


promise  of  success  in  destroying  the  parasites  and 
allowing  them  to  be  dislodged  by  coughing  efforts, 
providing  they  are  not  too  deeply  encysted  in  the 
bronchial  pockets.  Nothing  is  known  of  the  modes 
of  acquirement  of  the  worm  and  hence  no  known 
prophylactic  measures  exist  at  present. 

Family:  Schistosomid^; 

Genus  r     Schislosomum. 

I.    Schistosomum  haematobium  (Bilharz). 


(Distomum  hcBmatobium;  d.  capense;  Bilharzia  hcematobia;  gynecophorus  hcematobius; 
thecosoma  hamatobium;  African  blood  fluke.) 

Sexes  separate.  Male:  whitish,  12.-14.  mm.  long  (often  less),  with  margins  back 
of  ventral  sucker  folded  on  ventral  surface  so  as  to  form  a  long  groove  (gynecophorous 
groove)  and  when  thus  folded  the  thickness  is  about  half  a  millimeter;  oral  and  ventral 
suckers  close  together  in  the  attenuated  anterior  end  of  the  worm  on  ventral  surface, 
prominent;  esophagus  short,  dividing  into  two  simple  intestinal  tubes  which  back  of  the 
testes  reunite  to  form  a  single  cecum;  numerous  gland  cells  about  esophagus;  excretory 
pore  opening  at  posterior  extremity  slightly  dorsally;  genital  opening  in  median  line  back 
of  ventral  sucker;  no  cirrus  pouch;  testes  iive  or  six  in  number,  vesicular;  cuticle  of 
dorsal  surface  covered  with  small  spinulated  tubercles,  of  ventral  surface  bearing  spines 
except  along  the  median  line.  Female:  whitish  to  reddish-brown;  filiform;  length  1 5.-20. 
mm.;  suckers  as  in  male,  prominent;  cuticle  with  spines;  digestive  tube  as  in  male  (single 
cecum  from  reunion  of  intestinal  tubes  posterior  to  ovary) ;  ovary  oblong,  lobate,  lying 
in"posterior  fork  of  intestine;  vitelline  follicles  extend  posteriorly  to  extremity  of  body 


200 


INFECTIOUS  DISEASES 


from  just  back  of  ovary;  oviduct  and  longitudinal  vitelline  duct  run  forward  to  unite  at 
" shcU-gland "  with  the  uterus  in  a  dilated  obtype;  uterus  straight,  tubular,  extending 
forward  to  the  genital  pore,  which  opens  at  posterior  border  of  ventral  sucker.  The  two 
sexes  lie  constantly  together,  ventral  surfaces  in  contact,  the  female  in  the  gynccophorous 
groove  of  the  male.  Ova  oval  in  shape,  thin-walled,  without  operculum,  with  a  spine 
at  one  end  or  along  the  side  of  one  end,  135. -l8o.  microm.  long,  55.-60.  microm.  broad. 

The  blood  fluke  is  found  in  the  veins,  commonly  the  portal  veins  and 
its  branches,  and  the  plexuses  about  the  bladder  and  rectum,  in  man  and  a 
few  species  of  monkeys.  It  is  met  mainly  in  Africa  (Egypt,  Abyssinia, 
Sudan,  Mozambique,  Natal,  Tunis,  Algeria,  etc.);  but  has  been  reported 
in  imported  cases  from  this  country  and  elsewhere.  It  is  said  also  to  occur 
in  Cuba  and  Porto  Rico.     It  is  more  common  in  the  young  than  in  adidts. 

The  presence  of  the  adult  worm  is  not  the  serious  feature  of  the  in- 
fection, the  fatilt  depending  rather  upon  the  fact  that  the  ova  are  liable  to 
obstruct  the  vessels  and  give  rise  to  important  pathological  results.  Lodged 
for  example  in  the  small  veins  of  the  vesical  plexus,  an  inflammation  of  the 


Fig.    39. — Ova  and  miracidium  of  schistosomum    hmmalobium,   X300;    A,  ovum  as  seen  in 
urine;  B,  the  same  after  addition  of  water;  C,  miracidium.     (RaHlict.) 

bladder  and  rupttire  of  the  occluded  vessel  with  appearance  of  blood  in  the 
urine  are  apt  to  result;  or  if  in  the  wall  of  the  lower  bowel,  a  proctitis  or 
colitis  with  dysenteric  hemorrhages.  The  vesical  symptoms  are  not  infre- 
quently marked,  pain  and  tenderness  in  the  hypogastrium,  a  burning  pain 
in  the  urethra,  especially  on  micturition,  diffictilty  of  micturition,  sometimes 
evidence  of  prostatic  swelling,  with  the  urine  containing  blood,  pus,  and 
mucus  as  well  as  the  ova  of  the  parasite.  Sometimes  the  inflammatory 
disturbances  may  extend  along  the  ureter  to  the  pelvis  of  the  k-idney  and 
the  latter  organ  itself,  inducing  the  symptoms  of  a  more  or  less  grave 
nephritis.  Occasionally  from  convection  of  the  ova  into  the  liver  or  lungs 
symptoms  referable  to  these  organs  may  also  be  met.  Fatal  results  are 
to  be  apprehended  after  a  variable  period  of  such  s>Tnptoms,  with  secondary 
anemia,  debility,  and  exhaustion. 

No  knowledge  is  had  of  the  intermediate  stages  beyond  the  miracidium, 
which  is  not  infrequently  seen  in  the  ova  in  the  urine  or  feces.     It  is  suspected 


DI  BOTH  RIOCEPH  ALUS 


201 


that  the  infection  is  carried  through  unfiltered  drinking-water,  and  as  a  meas- 
ure of  prophylaxis  this  should  be  strictly  cared  for  in  infested  districts. 
No  plan  of  successful  medication  is  known;  but  all  means  of  ordinary 
character  for  conservation  of  nutrition  and  repair  of  blood  loss  should  of 
course  be  undertaken  as  well  as  the  usual  methods  of  overcoming  the  actual 
hemorrhage,  as  the  use  of  ergot,  etc. 

This  fluke  has  been  met  in  cats  and  in  man  in  Japan  and  China.  It  is 
believed  to'  be  responsible  for  an  endemic  affection  known  in  Japan  as 
Katayama,  characterized  by  enlarged  liver  and  spleen,  disturbances  of 
appetite,  diarrhea  (the  dejecta  often 
containing  blood  and  mucus),  and 
in  severe  cases  anemia,  fever, 
ascites,  and  edemas,  and  occasion- 
ally death  from  exhaustion.  The 
worms  inhabit  the  vena  porta  and 
its  mesenteric  branches,  and  the 
ova  are  found  in  the  liver  and  in 
the  walls  of  the  intestine,  especially 
the  large  intestine.  Unlike  5.  heni- 
atobium,  these  ova  are  not  apt  to 
be  met  in  the  urine  but  are  found 
in  the  intestinal  dejecta.  In  the 
liver  and  wall  of  the  bowel,  as  well 
as  in  mesenteric  lymph-glands,  in 
the  pancreas  and  other  situations 
into  which  the  ova  are  carried, 
there  ensue  either  from  the  me- 
chanical irritation  of  these  objects 
or  possibly  partly  from  toxic  factors 
produced  by  the  worms  and  simi- 
larly disseminated  (or  from  both  of 
these  influences)  chronic  hyper- 
plastic and  indurative  changes 
which  may  be  of  serious  impor- 
tance. Anemic  symptoms  are  best 
seen  in  heavy  infestments,  and  are 
thought  to  be  partly  due  to  the 
blood  destruction  and  partly  to 
toxic  influences.  Yamagiwa,  according  to  Katsurada,  believes  that  a  case 
of  epilepsy  which  he  originally  attributed  to  lodgment  of  ova  of  paragonimus 
westermanni  in  the  brain  of  the  patient  was  due  in  reality  to  ova  of  the  para- 
site here  mentioned. 


Fig  40. — Schistosomiim  hatnatobium:  male 
vnth  female  in  gynecophorous  groove.  (Braun, 
after  Loos.) 


I.  Dibothriocephalus  latus  (Leuckart). 

(Tcenia  lata;  bothriocephatus  latus;  dibothrium  latum;  bothriocephalus  latissimus;  fish 
tapeworm;  etc.) 
Description. — Strobile  two  to  ten  meters  or  more  in  length  (reported  20  in  one  or 
two  cases);  strobile  yellowish;  marked  in  ripe  segments  by  brownish  central  rosette 
(uterus  with  ova)  when  specimen  is  soaked  in  water;  head  elongated  almond-shape 
(2.-5.  mm.  long,  and  0.71  mm.  transversely),  with  two  lateral  grooves  or  bothridia  as 
suckers;  neck  variable  according  to  degree  of  contraction;  3000-4000  segments;  the 


202 


INFECTIOUS  DISEASES 


anterior  links  poorly  defined,  in  their  growth  increasing  slowly  in  length  but  markedly 
in  breadth;  ripe  links  back  of  middle  of  strobile  measure  2.-4.  mm.  long  and  lo.-l 2.-20. 
mm.  wide,  with  opaque  brownish  rosette  in  middle  line;  terminal  links  shrunken  and 
narrower  than  above  in  proportion  to  the  length  after  discharge  of  ova;  vagina  and 
cirrus  open  in  small  prominence  in  midventral  line  near  anterior  border  of  link  and  just 
back  of  this  a  third  opening  (uterine);  testes  numerous,  best  seen  toward  the  margins; 
uterus  of  a  number  of  plicated  tubes  in  form  of  rosette;  ova  brownish,  ellipsoidal  (68.-71. 
microm.  long,  44.-45.  microm.  transversely),  operculated. 

This  parasite  in  its  adult  stage  is  most  commonly 
met  in  the  human  intestine,  but  has  been  fencotmtered 
also  in  dogs  and  cats.  It  is  most  common  in  parts  of 
central  Europe  (Switzerland,  northern  part  of  Italy, 
southern  Germany  and  this  vicinity),  along  the  Baltic 
borders,  occasionally  in  Denmark  and  in  the  Nether- 
lands, and  British  Islands.  In  Asia  it  has  been  met  a 
few  times  in  Turkestan  and  in  Japan.  The  few  examples 
which  from  time  to  time  are  reported  from  this  country 
occtu-  invariably  in  foreigners. 

The  strobile,  the  longest  met  in  man,  is  generally 
found  singly,  the  head  attached  in  the  upper  part  of 
the  small  intestine  and  the  length  trailing  through  the 
gut  in  a  somewhat  plicated  fashion  and  not  infrequently 
extending  bej'ond  the  Ueo-cecal  valve.  Unlike  other 
large  tapeworms  of  the  human  intestine  ovulation  takes 
place  in  this  form,  the  eggs  being  discharged  through  the 
uterine  opening  without  the  necessity  of  destruction  of 
the  link,  and  large  numbers  are  usually  encountered  in 
the  fecal  matter,  where  they  are  readily  recognized  on 
microscopic  inspection.  In  the  Hfe-history  of  the  para- 
site, these  ova,  being  carried  out  with  the  fecal  matter, 
require  for  their  further  development  immersion  in 
water.  If  thus  favored,  in  about  two  weeks  at  a  temperature  of  about 
30°  C.  (longer  time  in  cooler  water)  the  operculimi  at  the  end  of  the 
eggs   opens  and  permits  the  escape  of  a  minute  hexacanthous  embryo, 


Fig.  41.  —  Dibo- 
Ihriocephalus  latiis 
(Leuckart.) 


Fig.  42. — Ova.  ol  dibolhrioccphaUis  latiis:  Fic.    43.  —  Free 

A,  after  treatment  with  sulphuric  acid  so  swimming  embryo  of 
as  to  render  lid  apparent;  B,  natural  appear-  dibollirioccplialtis  la- 
ance  in  fecal  matter.  liis.  Xsoo.     {Leuck- 

art.) 


Fig.  44.  —  Plero- 
cercoid  of  dibothri- 
occphalus  lalus:  A, 
with  head  projected; 
B,  head  retracted. 
(Brami.) 


which  is  surrounded  by  a  ciliated  membrane  and  which  lives  a  free 
existence  in  the  water  for  a  time.  It  is  not  known  how  this  embryo 
passes   to   the   intermediate    host,    one    or    other   of   several   fresh-water 


DIBO  TIIRIOCEPHA  L  US 


203 


fishes,  but  it  is  probably  swallowed;  in  event  of  failure  to  attain  this 
secondary  host,  it  dies  after  some  days.  Within  the  fish  it  develops 
into  a  small  worm-like  larva  (8.  mm.  long,  3.  mm.  thick),  known  as  a 
plerocercoid,  which,  without  a  surrounding  (adventitious)  capsule,  is  found  in 
the  ovary,  wall  of  the  intestine,  liver  and  other  viscera,  and  in  the  muscular 
system.  It  possesses  a  slight  vermicular  movement.  Essentially  it  is  the 
anterior  end  of  the  future  adult  tapeworm.  The  head  is  generally  in- 
vaginated,  but  may  be  caused  to  protrude  if  the  specimen  is  placed  for  a 
time  in  warm  water,  when  it  will  be  found  to  present  the  characteristics 
above  outlined  for  the  adult  head;  unlike  the  common  bladder- worms  of 
many  tapeworms  the  posterior  part  of  this  larva  is  not  cystic.  From  ex- 
periments it  has  been  found  that  under  ordinary  conditions  these  plerocer- 
coids  will  retain  their  vitality  in  the  flesh  of  the  dead  fish  for  about  18  days, 
that  they  are  quickly  killed  in  a  saturated  sodiiim  chlorid  solution,  that  they 
are  comparatively  resistant  to  cold  but  are  soon  destroyed  by  a  heat  above 
50°  C.-S3°  C.  Transmission  of  the  parasite  to  man  is  believed  to  be  con- 
fined to  the  swallowing  of  the  plerocercoid  in  the  flesh  of  the  infested  fish 
imperfectly  salted  or  cooked;  although  formerly  it  was  believed  if  the  cili- 
ated embryo  were  taken  into  the  human  alimentary  canal  with  unfiltered 
water,  it  was  able  to  develop  directly  into  the  strobile.  The  fish  most  liable 
to  contain  the  larval  worms  are  fresh-water  fish,  as 
pike,  turbot,  perch,  tench,  grayling,  etc.  In  covui- 
tries  where  these  fish  abound 
it  not  infrequently  happens 
that  certain  parts,  as  the  roe 
or  liver,  are  eaten  as  delica- 
cies very  imperfectly  cooked, 
such  habits  distinctly  favor- 
ing the  acquirement  of  the 
parasite,  should  the  fish  be 
infested. 


Fig.  45. — Dihothrio- 
cephalus  cordatus:  adult. 
(Leuckart.) 


Fig.  46. — Young  speci- 
mens ol  diothrioce pha- 
lus  cordatus;  natural  size. 
(Leuckart.) 


Fig.  47. — Head  and  anterior 
segments  of  dibothriocephalus 
cordatus:  A,  seen  from  margin 
of  strobile;  B,  seen  from  sur- 
face of  strobile.     {Leuckart.) 


The  symptoms  of  parasitism  by  dibothriocephalus  latus  are  for  the  most 
part  quite  similar  to  those  occasioned  by  other  tapeworms,  alimentary  and 
nutritive  and  reflex  nervous.  Usually  the  alimentary  or  local  symptoms  are 
the  most  pronounced,  and  proportionately  more  marked  than  in  the  case  of 


204 


INFECTIOUS  DISEASES 


infestment  by  the  beef  and  the  pork  tapeworms.  These  may  be  very  trivial 
and  be  entirely  neglected,  however,  although  there  is  commonly  some  degree 
of  abdominal  discomfort,  fullness,  and  a  sense  of  weight,  with  now  and 
again  some  little  pain.  Often  the  pains,  irregularly  intermittent  in  occur- 
rence, are  severe.  Diarrhea  alternating  with  constipa- 
tion is  common,  and  occasionally  nausea  and  vomiting 
are  noted.  The  appetite  is  apt  to  be  capricious.  In 
time  some  loss  of  weight  and  strength  and  a  more  or 
less  striking  and  notable  anemia  may  be  expected  which 
resembles  in  every  particular  so  far  as  blood-findings  are 
concerned  the  progressive  pernicious  anemia,  the  latter 
being  supposed  to  be  due  to  the  absorption  of  some  toxic 
principle  elaborated  by  the  parasite  or  developing  under 
conditions  of  its  presence  in  the  alimentary  tract.  The 
nervous  phenomena  are  generally  of  little  moment,  but 
may  exceptionally  be  pronounced.  There  may  be  nasal 
and  anal  pruritis,  ocular  disturbances,  sometimes  a  func- 
tional and  transitory  strabismus,  choreiform  twitching, 
epileptiform  seizures,  headaches,  mental  hebetude,  tin- 
nitis,  etc. 

Treatment  rests  upon  the  general  principles  and  meas- 
ures detailed  in  the  section  devoted  to  treatment  of  tape- 
worm disease  in  general  (p.  211).  For  personal  prophy- 
laxis the  individual  should  not  be  permitted  to  eat  of  the 
flesh  of  fish  from  infected  districts  except  it  be  well  cooked ;  and  as  a  general 
measure  to  prevent  the  infestment  of  the  fish,  human  excreta  should  be  kept 
from  the  drainage  into  lakes  and  rivers  inhabited  by  fishes  suitable  for 
the  plerocercoid  stage. 


Fig.  4S.—Boll!rio- 
cephatus     mansoni : 

A,  after  Leuckart; 

B,  after  Cobbold. 


Genus:  Hymenolepis. 
I.   Hymenolepis  nana  (von  Sicbold). 
{Txnia    nana;   t.   cegyptica;  diplacanthus  nana;  hymenolepis  muria;  dwarf   tapeworm.) 

Description. — Average  length  of  strobile  10.-15.  mm.  (may'  reach  25.  mm.);  head 
subglobular,  measuring  0.25-0.30  mm.  in  transverse  diameter;  head  provided  with  four 
large  rounded  suckers  and  a  large  rostellum  retractile  into  an  infundibulum;  rostellum 
surrounded  by  a  single  crown  of  booklets  (24-30);  neck  rather  long  and  slender;  about 
.150  proglottids,  very  small,  broader  than  long;  the  largest,  near  the  posterior  end  of 
strobile,  measure  0.14-0.30  mm.  long  by  0.4-0.9  mm.  broad,  while  the  terminal  links 


^(*lilili^lP*^ 


Fig.  49. — Hymcnolepsis  nana:     Xio.     {Gould,  after  Leuckart.) 

narrow  slightly  and  lengthen,  so  as  to  give  a  rounded  posterior  extremity  to  the  strobile. 
Genital  pores  all  on  the  same  (left)  margin,  near  anterior  end  of  margin  of  links;  three 
spherical  testes,  in  posterior  part  of  segment  near  dorsal  waU;  vas  deferens  small,  straight, 
sUghtly  distended  before  reaching  cirrus  pouch;  cirrus  pouch  club-shaped,  near  anterior 
end  of  segment.  Vagina  distended  into  prominent  receptaculum  seminis,  in  anterior 
part  of  segment;  ovary  bUobed,  extending  transversely  just  anterior  to  middle  of  seg- 
ment; back  of  it  the  yolk-gland  and  between  the  two  the  "shell-gland";  uterus  distended 
with  ova  occupies  nearly  the  whole  segment,  obscuring  the  other  parts  (ova  often  free  in 


HYMENOLEPIS  NANA 


205 


parenchyma  of  segment).  Ova  round  or  oval,  double-walled;  outer  diameter  averaging 
40.  microm.,  but  variable  (36.  :  32.  microm.  to  56.  :  42.  microm.) ;  inner  wall  showing  meas- 
urements ranging  from  20.  :  18.  to  32.  :  24.  microm.;  at  each  pole  of  inner  membrane  a 
small  protuberance  from  which  spring  a  number  of  clear,  refractile  threads  which  are 
distributed  in  a  waving  fashion  through  the  substance  intermediate  to  the  outer  and  inner 
walls;  within  the  egg  a  hexacanthous  embryo  sUghtly  separated  from  the  inner  membrane. 


Fig.  50. — Head  of  hy- 
moiotcpis  nana:  with  rostel- 
lum  retracted,  X75;  A,  an 
isolated  hooklet,  X300. 
{Gould,  after  Leuckarl.) 


This  parasite,  now  regarded  by  most  authorities  as  identical  with  hy- 
menolepis  murina  of  rats  and  mice,  is  an  intestinal  parasite  of  these  animals 
and  of  man.  It  has  a  wide  geographical  distribution,  being  perhaps  best 
known  in  Italy  and  neighboring  parts  of  southern  Europe.  Recently  a 
number  of  cases  have  been  encountered  in  the 
eastern  and  southern  states  of  this  country,  and 
there  is  some  reason  in  the  supposition  that  it  will 
come  to  be  regarded  as  one  of  the  most  common 
tapeworms  of  this  portion  of  the  world.  It  is  most 
frequently  met  in  children,  especially  in  those  of  the 
poor  and  those  living  in  poorly  cared-for  homes. 
The  parasite  inhabits  the  ileum,  usually  from  the 
middle  toward  the  ileo-cecal  valve,  and  is  com- 
monly met  in  large  numbers  in  the  indi\adual 
infested  (sometimes  a  thousand  or  more.)  The 
tisual  life-history  is  not  finally  established.  For  a 
long  time  certain  cysticercoids  met  in  the  common 
meal-worm  were  suspected  as  representing  the  inter- 
mediate stage,  but  the  evidence  now  held  would  refer  these  to  another 
tapeworm;  although  it  is  not  excluded  that  some  such  intermediate  host 
may  perhaps  at  times  serve  as  a  connecting  link.  However,  it  has  been 
shown  by  Grassi  that  if  the  ova  be  fed  to  rats  (best  from  one  to  three 
months  old)  the  adult  worm  will  develop  in  the  intestine  of  the  rat;  and  it 
has  been  found  in  such  cases  that  the  embryos  having  had  the  shell  removed 
by  the  action  of  the  upper  digestive  juices  penetrate  into  the  villi  of  the 
mucous  membrane,  and  there  become  encysted  as  minute  cj^sticercoids, 
which  later  drop  into  the  intestinal  lumen  and  develop  the  adult  worms. 
This  would  suggest  the  possibility  of  direct  multiplication  within  the  in- 
testine of  the  definitive  host,  but  this  is  a  mistake.  The 
ova  are  not  affected  by  the  juices  of  the  lower  intestinal 
canal  and  are  passed  from  the  original  host  without 
change  and  for  their  further  progression  must  gain  access 
to  a  second  suitable  host  (rat,  mouse,  man)  or  perhaps  to 
the  original  host  of  reinfecting  himself  with  ova  from  his 
own  intestine.  The  means  of  convection  to  the  second 
host  probably  include  unfiltered  water  tainted  with  human 
or  murine  dejecta,  food  to  which  rats  or  mice  have  had  access,  or  in  case 
of  man  the  fingers  soiled  with  fecal  matter  after  scratching  about  the  anus. 
The  symptoms  caused  by  the  parasite  are  of  the  same  general  nature  as 
those  induced  by  the  common  larger  tapeworms ;  but  in  children,  and  when 
in  large  numbers,  may  be  of  marked  severity  and  even  terminate  fatally. 
When  present  in  but  small  ntunbers  and  in  resistant  individuals,  the  symp- 
toms may  be  trivial  and  overlooked.  In  their  severer  manifestations,  in 
addition  to  the  intestinal  discomfort  and  pain   (sometimes  severe)    and 


Fig.  5 1 . — Ovum  of 
hymenolepis  nana, 
X300.  {Gould,  afler 
Leuckarl.) 


206 


INFECTIOUS  DISEASES 


irregular  diarrhea,  there  may  be  marked  nutritive  disturbances  with  more 
or  less  severe  anemia ;  and  the  nervous  phenomena,  as  epileptiform  convul- 
sions, may  be  a  marked  feature  of  the  case,  continuing  for  j^ears  until  the 
parasites  are  gotten  rid  of  or  perhaps  untU  death.  The  presence  of  the 
parasite  being  suspected,  the  diagnosis  may  readily  be  confirmed  by  the 
discovery  of  the  ova  by  microscopic  examination  of  the  fecal  matter,  large 
numbers  being  usuall}^  fovmd  where  the  parasites  are  present  in  any  marked 
degree  of  infection. 

The  treatment  is  much  as  in  other  types  of  tapeworm  disease;  but  male 
fern  has  proved  most  satisfactory  among  the  common  anthelmintics  (p. 

2Il). 

Subfamily:  T^NiiN«;  Genus:  T^Ni.\. 

I.  Taenia  saginata  (Goeze). 

{Tcenia  mediocanellala;  t.  inermis;  beef  tapeworm.) 

Average  length,  3.-8.  meters  (in  relaxed  condition  often  reaching  10.  meters),  head 

tetragonal,  pyriform,  without  hooklets  or  rostellum  (in  place  of  latter  a  central  depression 

in  center  of  frontal  face,  often  slightly  pigmented),  with  four  cup-shaped  suckers  placed 

at  the  corners  of  frontal  face,  these  provided  with  rather  thick  lips  and  often  slightly 

pigmented  at  the  borders;  head  measuring  two  milUmeters  in  transverse  diameter  at 

frontal  face;  neck  rather  long  and  slender;  first  segments  very  short  and  broader  than 

long;  the  segments  increasing  in  their  development  so  as  to 

become  much  longer  than  broad  (almost  cord-like  at  posterior 

extremity)   and  when  fvdly  ripe  (near  posterior  extremity)  of 

long  quadrate  shape,   1 8.-20.  mm.  long  and  5.-7.  mm.  broad; 

genital  pores  in  adjacent  segments  irregularly  alternating  upon 

opposite  margins  and  situated  a  little  back  of  the  middle  of  the 

margin  of  each;  gravid  uterus  showing  a  median  longitudinal 

trunk  with  lateral  single  or  dichotomously  branching  and  slender 

diverticula  (25-35  on  each  side);   embrj^ophore   ovoid,    nearly 

spherical,  slightly  brownish,  30.-40.  microm.  long  and  20.-30. 

microm.   transversely,   with   thick  radially  striated  shell  and 

containing  granular  hexacanthous  embryo. 

Habitat  and  Transmission. — Tliis  tapeworm,  in  its 
adult  stage  almost  solely  foimd  in  the  small  intestine 
of  man,  is  widely  disseminated  over  the  world, 
especially  in  districts  where  beef  is  largely  consimied, 
particularly  when  by  habit  of  populace  the  flesh  is 
not  well  preserved  or  thoroughly  cooked.  At  present 
it  is  by  far  the  most  frequent  tapeworm  of  man  in 
this  country,  and  is  also  the  most  common  cestode 
of  man  in  western  Europe.  It  is  a  mistake  to  trust 
in  the  popular  idea  prevailing  in  the  United  States 
that  of  the  large  tapeworms  met  in  man,  most  are 
derived  from  pork.  The  late  Professor  Leidy,  to 
^TGoiuTaJiTuuckartT  ^^om  large  numbers  of  worms  were  constantly  being 
sent  for  opinion,  informed  the  author  of  this  work 
that  all  specimens  sent  him  for  examination  diuing  a  period  of  1 5  years  were 
tcBnim  saginatcB;  and  while  in  central  Germany  tmiia  solium  has  in  previous 
periods  been  comparatively  common.  Heller  has  found  in  Holstein  the 
beef  tapeworm  four  times  as  prevalent  as  the  pork  worm. 

The  parasite  is  obtained  from  eating  improperly  cooked  fresh  beef 
containing  the  bladder-worm  of  the  cestode.  This,  the  cysticerus  bovis, 
is  a  small  spherical  or  ovoid  vesicle,  colorless  and  glistening,  usually  about 
half  a  centimeter  in  diameter   (occasionally  reaching  or  exceeding   one 


TAENIA  S  AGIN  ATA 


207 


Fig.  53. — Head  and 
neck  of  tcenia  saginata: 
A,  retracted.  B,  ex- 
tended. {Gould,  after 
Leuckart.) 


centimeter),  and  surrounded  by  a  thin  connective-tissue  capsule  formed 
at  the  expense  of  the  host.  After  separating  the  bladder  from  this  envelope 
one  may  note  a  small,  opaque,  whitish  point  on  one  side  of  the  cyst.  This 
is  the  invaginated  head  of  the  future  tapeworm,  which  can  be  expelled 
from  the  cyst  by  careful  pressure  of  the  latter  between  the  thumb  and 
finger  or  may  be  caused  to  protrude  by  immersion  in 
slightly  warmed  water;  thus  exposed,  the  head  will  be 
found  to  possess  the  characters  of  the  future  head  of 
the  adult  tapeworm,  with  its  neck  faintly  striated 
transversely  (future  segments)  and  with  its  posterior 
end  distended  into  the  cyst  into  which  the  head  was 
invaginated.  This  bladder-worm  because  of  its  small 
size  and  small  numbers  (usually)  is  often  missed  in 
inspections  of  slaughtered  beef ;  it  may  be  found  in  any 
part  of  the  striated  muscular  system  and  sometimes  in 
the  solid  viscera,  but  Hertwig  has  pointed  out  its 
special  frequence  in  the  muscles  of  the  masseteric 
region,  in  the  internal  and  external  pterj'goid  muscles. 
It  develops  from  the  ingested  ovum  apparently  in  a 
period  of  about  three  or  four  weeks ;  as  a  rule,  is  not 
of  long  life  in  this  stage,  as  experimentalh^  produced 
cysticercosis  of  but  a  few  months'  duration  has  re- 
peatedly shown  numbers  of  dead  and  calcified  speci- 
mens in  the  muscles  of  the  experiment  animals.  There  is  no  doubt  of  the 
statement  that  transmission  of  the  parasite  to  man  follows  only  when  the 
meat  eaten  is  imperfectlj^  cooked,  as  it  has  been  shown  that  brief  periods 
of  exposure  (several  minutes)  to  temperatures  of  4S°-48°  C.  will  kill  the 
larval  parasite,  and  it  is  safe  to  say  that  well-roasted  meat  (70°  C.)  cannot 
transmit  the  worm  in  vital  condition.  Moreover,  while  temporarj^  drying 
of  the  flesh  is  by  no  means  lethal  to  the  bladder-worm  (which  while  thus 
shrunken  will  again  assume  its  vesicular  appearance  on 
soaking  in  water).  Perroncito  has  found  all  cj'sticerci 
dead  at  the  end  of  two  weeks  in  a  well  dried  and  salted 
piece  of  veal.  After  eating  infected  beef  the  subject 
requires  from  seven  to  ten  weeks  before  manifesting  evi- 
dence of  the  presence  of  a  full}^  developed  ttsnia  sagi- 
nata by  the  passage  from  the  anus  of  ripe  segments  of 
the  worm. 

These  separated  segments,  usually  single,  may  be 
found  in  the  dejecta  or  may  be  passed  in  the  interval 
between  stools;  they  were  formerly  regarded  as  special 
intestinal  parasites  and  spoken  of  as  "cucumber-worms," 
water- worms,"  etc.;  they  are  yellowish- white  in  color,  range  up  to  about 
two  centimeters  in  length,  and  are  either  distinctly  quadrate  and  flat  or  are 
shrunken  into  nearly  a  cylindrical  shape;  they  are  usually  quite  active, 
having  a  mode  of  motion  not  unlike  that  of  "measuring  worms,"  and  in 
this  country  among  the  ignorant  there  is  a  superstition  that  they  will, 
if  tmdisturbed,  always  crawl  toward  the  nearest  water  (whence  the  name 
"water- worms").     Quite   commonl}^  they   do  gain    access   to  water,    but 


Fig.  54. — Proglot- 
tid of  tcBnia  saginata. 
X2.     (Braun.) 


208  IM'ECTIOUS  DISEASES 

only  in  a  passive  convection  with  ordinary  drainage,  and  when  immersed 
may  retain  their  vitaHty  and  activity  for  a  number  of  days.  Ferdinand 
Herff,  of  San  Antonio,  speaks  of  having  found  a  number  of  actively  moving 
proglottids  of  this  parasite  in  the  water  of  a  well  into  which  surface  drainage 
carried  the  contents  of  a  cesspool.  If  deposited  on  a  dry  surface  they  soon 
die  and  are  disintegrated  and  the  ova  are  scattered  over  the  herbage,  these 
not  losing  vitality  for  some  time  because  of  the  protection  which  their  thick 
shells  afford  against  drying  and  the  elements.  Cattle  eating  the  blades 
of  grass  thus  acquire  the  embryos  within  their  alimentary  tubes,  and  later 
these  penetrate  the  intestinal  walls  and  gain  access  to  suitable  parts, 
where  they  are  encysted  as  larvae  or  bladder- worms. 

The  adult  tapeworm  in  the. human  intestine  has  an  undetermined  dura- 
tion of  life;  it  is  well  known  to  persist  for  years,  and  Railliet  quotes  Wawurch 
in  connection  with  a  case  known  to  have  passed  segments  over  a  period 
of  35  years.  The  parasite  is  found  invariably  in  the  small  intestine  when 
discovered  at  autopsy;  usually  the  head  is  fixed  a  short  distance  below  the 
pylorus  among  the  villi,  the  strobile  ranging  loosely  through  the  extent 
of  the  small  bowel  and  only  rarely  found  extending  beyond  the  ileo-cecal 
valve.  (Recently  Fussell,  Phila.  Path.  Soc.  Repts.,  found  several  segments 
in  the  lumen  of  an  appendix  veriformis  which  was  removed  from  a  case 
with  symptoms  of  appendicitis.)  Although  not  provided  with  booklets  as 
is  the  pork  tapeworm,  it  is  apparently  more  firmly  fixed  than  the  latter 
to  the  mucous  membrane.^  Usually  but  a  single  example  of  the  beef  tape- 
worm exists  in  one  host,  but  cases  are  reported  furnishing  as  many  as  five 
or  six. 

But  little  difiiciilty  can  be  experienced  in  attempting  to  distinguish  be- 
tween this  worm  and  the  tcenia  solium,  with  which  alone  it  is  likely  to  be 
confused  at  first.  As  a  rule,  the  strobile  is  considerably  larger  and  longer; 
the  segments  are  larger  and  more  active  in  their  movements,  and  are 
more  likely  to  be  discharged  from  the  anus  in  the  intervals  between  the 
stools;  the  uterus  in  each  link  is  more  highly  branched  than  in  case  of  the 
tapeworm  of  the  hog;  the  head  is  not  provided  with  booklets;  the  ova 
are  somewhat  larger  than  those  of  the  latter  and  a  little  less  spherical.  In 
examining  a  link  for  study  of  the  arrangement  of  the  uterus,  it  is  usual  to 
compress  it  between  two  glass  slides  in  a  small  amount  of  a  i  per  cent, 
solution  of  caustic  potash, or  in  a  20  per  cent,  solution  of  acetic  acid. 

Symptoms. — The  symptoms  occasioned  by  the  parasite  are  partly 
local  and  partly  of  a  reflex  nervous  type,  and  are  both  often  so  tri\'ial  as  to 
pass  unnoted.  The  former  are  generally  of  the  nature  of  an  indefinite 
abdominal  discomfort,  of  weight  and  fullness,  of  occasional  indistinct  pain, 
usually  most  marked  at  meal-times,  capricious  appetite,  irregular  periods 
of  diarrhea  alternating  with  constipation,  occasional  nausea  and  vomiting, 
slow  loss  of  flesh  and  strength,  and  eventually  a  moderate  degree  of  anemia. 
The  nervous  phenomena  are  also  very  variable  and  indefinite,  such  as  nasal 
pruritus,  slight  vertigo,  choreiform  twitching  and  occasionally  epileptiform 
convulsions,  visual  disturbances  and  restless  sleep.    When  the  parasite  is 

'  At  least  this  is  the  opinion  of  Railliet.  page  239  of  his  "Treatise  on  Medical  Zoology,"  although  it 
does  not  seem  reasonable  that  the  worm  armed  with  suckers  only  should  be  more  difficult  to  dislodge 
than  the  worm  armed  with  suckers  and  hooklets.  I  cannot  speak  from  my  own  experience,  for  I  have 
never  had  a  case  of  pork  tapeworm. 


TMNIA  SOLIUM  209 

suspected,  the  stools  should  be  carefully  watched  for  discharged  i^roglottids 
and  the  patient  instructed  as  to  the  appearance  of  these  should  they  pass 
in  the  intervals  from  the  anus  upon  the  clothing.  By  microscopic  examina- 
tion occasionally  the  ova  may  be  discovered,  but  probably  the  safer  and 
almost  as  quick  a  recognition  will  be  obtained  by  noting  the  links  them- 
selves as  they  appear. 

The  treatment  of  parasitism  by  this  worm  presents  no  special  features 
differing  from  the  treatment  of  tapeworms  generally  and  will  be  discussed 
(p.  2i'i)  in  the  latter  connection. 

2.  Taenia  Solium  (Leuckart). 

[Tcenia  cucurbitina;  t.  dentala;  cystotcenia  solium;  pork  tapeworm.) 

Description. — Average  length  of  strobile,  2.-3.  meters,  occasionally  reaching  twice 
this  measurement;  head  more  spherical  than  that  of  the  tania  mediocanellata,  but  with 
a  somewhat  tetragonal  shape  given  by  the  four  rather  prominent  cup-like  suckers  with 
thick  lips;  head  provided  with  a  short  thick  rostellum  bearing  a  double  crown  of  hooklets 
(22-32  in  number,  usually  28) ;  transverse  diameter  of  head  0.6-1.  mm.;  neck  rather  thin 
and  approaching  one  centimeter  in  length;  about  800-900  proglottids;  fairly  developed 
links  found  unusually  close  to  head;  fully  grown  and  ripe  segments  measure  10.-12. 
mm.  long  and  5.-6.  mm.  broad;  regular  alternation  of  genital  pore  on  opposite  margins 
of  adjacent  links,  back  of  middle  of  margin;  uterus  consisting  of  a  median  longitudinal 
trunk  with  from  seven  to  ten  coarsely  dendritic  branches  on  each  side;  embryophore 
nearly  spherical,  light  brownish,  with  thick  radially  marked  shell  and  containing  a  granu- 
lar hexacanthous  embryo,  measures_'3i.-36.  microm. 

Habitat  and  Transmission. — This  parasite  in  its  adult  stage  is  practically 
limited  to  the  small  intestine  of  man  in  its  occurrence.  It  is  extremely 
rare  in  this  country,  popular  impressions  to  the  contrary  notwithstanding; 
and  is  most  frequently  met  with  in  Germany,  France,  Italy,  and  the  British 
Islands.  Because  of  the  more  careful  meat  in- 
spection prevailing  at  present  it  is,  however, 
decidedly  less  frequently  met  with  than  formerly. 
That  it  does  occur  occasionally  among  us  is 
strongly  indicated  by  the  fact  that  the  bladder- 
worm  in  pork  is  occasionally  found  in  America; 
although  the  above  statement  as  to  its  rarity  is 
the  experience  of  practically  all  American 
helminthologists.  While  the  bladder-worm  is 
occasionally  encountered  in  other  animals  than 

the   hog    (and  rarely  in  man),    htiman   beings         „  ,,     ,       ,        ■ 

.       ,       .  .      /  .  .  f  Fig.  55. — Head   and  neck, 

obtain  the  mtestmal  parasites  practically  solely     and   ovum    X300,  of   imnia 

from  eating  improperly  cooked  pork  containing     sohum.      Enibryophore    sur- 
.  ^  roundedbv    viteUus.      {Gould, 

the  cysticerci.      The  encysted  larva,  known  as     ajter  Leuckart.) 

cysticercus  celluloscB,  is  generally  when  found  in 

pork  encountered  in  large  numbers,  commonly  in  the  muscles  and 
especially  in  those  of  the  shoulder,  neck,  tongue,  diaphragm,  and  loins, 
but  often  in  any  part  of  the  muscular  system  and  sometimes  in  the 
solid  viscera  and  even  in  the  central  nervous  system.  It  is  somewhat 
larger  than  that  of  the  beef  tapeworm,  is  a  pale,  shining  cyst  of  ovoid 
shape,  measuring  from  one-half  to  two  centimeters  in  length,  and  from 
three  to  ten  millimeters  in  transverse  diameter;  and  as  above  described 
for  cysticerci  in  general  is  surrounded  by  an  additional  thin  connective- 
tissue   wall  derived  from  the  surrounding  tissues  through  inflammatory 


210 


INFECTIOUS  DISEASES 


reaction.  When  picked  out  of  such  a  situation  there  may  be  noted  on  one 
side  of  the  cyst  a  small,  slightly  elevated  spot  of  opaque  white  color,  with  a 
minute  opening  at  the  tip  of  the  prominence.  The  white  mass  is  the 
invaginated  head,  the  tiny  opening  the  outer  end  of  the  canal  of  invagination ; 
and  by  careful  pressure  or  by  immersion  in  warm  water  the  head  may  be 
caused  to  protrude  from  its  bed  through  the  opening  referred  to,  showing 
the  characters  belonging  to  the  scolex  of  the  adult  worm.  The  actual 
relationship  between  the  cysticercus  and  the  developed  tenia  solium  has 
frequently  been  demonstrated  by  feeding  experiments.  In  pork  there  are 
usually  large  numbers  of  these  cysticerci,  the  muscles  of  favored  parts 
being  literally  riddled  with  the  bladder- worms ;  many  of  which  are  usually 
found  in  a  shrunken  and  calcified  condition  (dead).  The  duration  of  life 
in  this  lan,'al   stage  encj'sted  in  pork  is  unknown,   but  probably  varies 


Fig.  56.  —  Cysticercus 
celliilosce:  A,  \vith  invagi- 
nated head,  B,  with  evagi- 
nated  head.     (Leuckart.) 


Fig.  57.  —  Cysliccnis 
ceUuloscE,  X12.  (Coplin 
and  Bevan,  after  Leuckarl.) 


Fig.  58.  —  Cysticcriis 
cellulosa:  after  digestion  of 
the  bladder,  Xio.  (Leuck- 
art.) 


between  several  months  to  several  years.  Young  hogs  (less  than  six  months 
of  age)  are  more  apt  to  be  infested  than  older  ones,  which  seem  to  possess 
some  degree  of  immunity  against  the  lar^^al  worms ;  and  as  would  readUy  be 
supposed,  hogs  which  are  not  carefully  stalled  and  fed,  but  which  are  allowed 
to  roam  about,  often  rooting  about  manure-heaps  (in  which  in  country  dis- 
tricts human  fecal  material  is  apt  to  be  deposited),  are  most  likely  to 
show  infested  flesh.  As  in  case  of  the  cysticercus  bovis  above  mentioned, 
careful  cooking  and  prolonged  and  thorough  salting  and  drying  of  the 
meat  will  destroy  the  vitality  of  the  bladder- worms ;  but  they  seem  slightly 
more  resistant  to  such  influences  than  the  cysticerci  of  beef.  About  two 
and  one-half  months  or  over  are  required  for  the  development  of  the  adtilt 
worm  after  the  infested  pork  has  been  devoured;  after  wliich  the  ripe  links 
may  be  found  in  the  stools  of  the  patients.  They  are  readily  known  from 
those  of  the  beef  tapeworm  by  their  smaller  size,  their  less  active  movement, 
and  by  the  coarser  and  less  highly  branched  appearance  of  the  uterus 
as  seen  in  compressed  links  cleared  with  acetic  acid,  caustic  potash  solu- 
tion, or  glycerin.  The  ova  are  less  frequently  encoimtered  in  the  stools 
than  those  of  the  beef  tapeworm,  being  more  apt  to  be  retained  in  the  ripe 
segment  until  after  its  discharge  and   disintegration. 

The  habitat  of  the  strobile  in  the  human  intestine,  as  seen  in  cases 
discovered  at  autopsy,  is  similar  to  that  noted  for  the  tcenia  saginata; 
usually  but  a  single  specimen  is  fotmd  (whene  the  name  "solium,"  "the 
solitary  worm"),  but  occasionally  several  are  encountered  in  the  single  host. 


TMNIASIS  211 

The  duration  of  its  existence  in  the  intestine  is  tinknown,  but  instances  of 
infested  persons  who  passed  links  for  years  are  common. 

Treatment  of  Tapeworm  Diseases. — There  is,  perhaps,  no  morbid 
condition  which  has  brought  more  opprobrium  upon  the  regiilar  profes- 
sion and  more  "grist  to  the  mill"  for  advertisers  and  those  who  use  secret 
remedies  than  tapeworm,  and  to  our  humiliation  it  must  be  said  that  these 
persons  do  seem  to  have  more  success  in  getting  rid  of  tapeworm  promptly 
than  we  do.  There  are,  I  think,  two  reasons  why  this  is  so.  In  the  first 
place,  it  is  certain  that  they  do  not  use  different  remedies  from  those  com- 
monly in  use  by  the  profession,  but  they  give  larger  doses.  In  the  second 
place,  they  see  a  larger  number  of  cases  and  develop  a  sort  of  specialty 
which,  like  all  specialties,  produces  greater  skill  in  treatment.  In  order 
that  a  tapeworm  may  be  successfully  removed  it  is  necessary  that  it  shall 
be  of  a  certain  size;  so  that,  if  a  large  part  of  the  worm  has  been  brought 
away  by  medicine,  it  is  useless  to  give  anylihing  more  untU  the  remaining 
part  increases  sufficiently  in  size. 

It  is  sometimes  useful  to  know  the  exact  coiu"se  pursued  in  a  given 
successful  case.  Thus,  in  such  a  case  the  patient  was  fasted  for  29  hours. 
Twelve  hours  after  fasting  began  he  was  given  one  ounce  of  castor  oil. 
Twenty-four  hours  after  fasting  began  he  was  given  i  1/2  drams  (5.55  c.c.) 
of  oleoresin  of  male  fern.  In  5  hours  more  he  was  given  another  ounce  of 
oil.     The  worm  came  away  entire  in  a  mass. 

There  are  half  a  dozen  remedies  for  tapeworm,  and  they  are  all  good. 
The  two  best  are  probably  the  ethereal  extract  of  male  fern  and  kousso 
flowers.  Some  prefer  the  first  of  these,  while  others  prefer  the  second. 
The  ethereal  extract  of  male  fern  is  prefered  by  us. 

Patients  reqmre  some  preparation  before  any  remedy  is  employed. 
In  all  cases  they  should  be  kept  absolutely  quiet  during  treatment.  They 
should  eat  nothing  from  breakfast  time  of  one  day  until  the  next  morning, 
during  which  time  the  bowels  should  be  moved  by  a  saline  cathartic;  when 

1  dram  (4  c.c.)  or  2  drams  (8  c.c.)  of  the  extract  of  male  fern  either  in  several 
capsules  or  in  an  electuary  is  to  be  taken.  If  at  the  end  of  six  hours  no 
movement  of  the  bowels  has  taken  place,  a  promptly  acting  aperient,  as  a 
dose  of  oil,  compound  jalap  powder,  or  elatritim,  is  taken.  The  worm  is 
usually  discharged  entire.  Of  course,  one  is  never  certain  that  this  is  the 
case  imless  the  head  is  found.  At  the  same  time,  it  does  not  follow  because 
the  head  cannot  be  found  that  it  has  not  been  passed,  for  it  is  ver\-  small,  and 
may  be  lost  in  the  discharges.  In  the  tcBnia  solium  the  head  is  about  the 
size  of  a  small  pin's  head;  in  the  mediocaneUata  it  is  a  little  larger,  and  in 
the  bothriocephalus  it  is  still  larger.  If  the  head  has  not  been  removed,  it 
is  certain  that  in  from  10  to  16  weeks  the  worm  -will  grow  out  again  and  begin 
to  discharge  links. 

The  third  remedy,  in  order  of  efficiency,  is  the  bark  of  the  root  of  the 
pomegranate.     This  has  been  given  in  the  shape  of  a  decoction,  from 

2  to  4  ounces  (60  to  120  c.c.)  to  the  pint  (0.5  liter).  Boil  the  bark  half 
an  hour,  strain,  and  drink.  The  fluid  extract  is  more  convenient  in  the 
dose  of  from  45  minims  to  2  fluidrams  (3  to  8  c.c).  Two  hours  later  a 
purgative  should  be  given.  An  alkaloid  is  obtained  from  pomegranate, 
named  pelletierine,  in  honor  of  the  chemist,  Pelletier.     This  is  given  in  a 


212  INFECTIOUS  DISEASES 

single  dose  from  8  to  25  grains  (0.5  to  1.6  gm.)-  When  first  introduced 
it  was  vaunted  as  a  "sure  cure,"  but  the  experience  of  practitioners  has  not 
been  uniform,  and  success  has  been  by  no  means  invariable.  I  have  been 
successful  with  it. 

Kamala,  the  hair  of  the  rottlera  tinctoria,  is  said  to  be  very  efficient 
in  tapeworm  and  may  be  used.  It  is  given  in  doses  of  from  1  to  2  drams 
(4  to  8  gm.)  suspended  in  syrup,  repeated  in  from  eight  to  ten  hours  if  it 
does  not  purge.  The  fluid  extract  is  also  given  in  doses  of  1/2  a  dram  to  i 
dram  (2  to  4  c.c).  It  is  piu^gative,  sometimes  drastically  so.  It  may  also 
cause  nausea  and  vomiting. 

Another  efficient  remedy  is  the  oil  of  turpentine.  It  is,  however,  apt 
to  produce  symptoms  so  unpleasant  that  it  shovdd  be  last  used.  The 
dose  is  from  i  oimce  to  2  ounces  (30  to  60  c.c.),  mixed  with  twice  that 
amount  of  castor  oil — a  horrid  dose;  but  if  others  fail,  it  may  be  tried. 

Still  another  is  ptimpkin-seed.  There  are  two  ways  in  which  it  may 
be  given.  Three  or  4  ounces  (30  to  120  gm.)  of  the  seeds  may  be  crushed 
in  a  mortar  with  water,  then  strained,  and  the  emulsion  taken  fasting, 
after  a  day's  dieting.  A  few  hours  later  a  brisk  purge  should  be  taken. 
Second,  the  seeds  may  be  made  into  an  electuary  which  is  almost  as  pleasant 
as  sugar  candy,  and  often  is  about  as  effectual.  These  different  remedies 
in  the  order  of  their  efficiency  are  about  as  follows :  male  fern,  kusso,  pome- 
granate, kamala,  turpentine,  and  lastly,  pumpkin-seed. 

Combinations  are  sometimes  very  efficient.  The  following  is  recom- 
mended by  Striimpell : 

ISf      Granati  corticis  radicis,  5  iv-v  (120  to  150  gm.) 

Aquae,  Oij  (1000  c.c.) 

Macerate  for  24  hours  and  boil  until  it 

is  reduced  to  five  fluid-ounces  (150 

c.c). 
Add: 

Oleoresinae  filicis,  gr.  l.x.w  (5  gm.). 

The  whole  amount  is  to  be  taken  in  three  or  fotir  doses  as  close  together 
as  possible. 

Thymol,  in  doses  of  10  grains  (0.66  gm.)  three  times  a  day  in  a  wafer, 
has  been  recommended.  Another  method  is  to  give  five  grains  (0.33  gm.) 
every  hour  with  or  without  preparation.  Papain,,  juice  of  carica  papaya, 
is  given  in  doses  of  from  i  to  10  grains  (0.066  to  0.66  gm.).  If  thymol  is 
given  the  purgative  should  not  he  oil  but  some  saline. 

Prophylaxis  is  of  the  greatest  importance.  Great  attention  should 
be  paid  to  the  cooking  of  meats,  especially  of  large  joints,  in  order  that 
they  may  be  thoroughly  "done."     Rare  meats  should  not  be  eaten. 

Family:  Angiostomid^; 

Genus:  Slrongytoides. 

Strongyloides  intestinalis  (Grassi). 

(Anguillula  intestinalis  et  stcrcoralis;  leplodcra  intestinalis  et  stercoralis;  pscudorhabditis 

stercoralis;  rliabdonema  strongyloides;  rhabdonema  intestinale.) 

Living  as  two  different  (heterogonous)  generations;  the  first  dioic  and  free;  the  second 
parasitic  as  parthenogenetic  females.  The  parasitic  form  lives  in  the  upper  intestinal 
tract  of  man;  2.5  mm.  long;  cylindrical,  with  pointed  tail  end;  smooth  cuticle;  simple 
mouth  with  four  (3?)  lips;  long,  slender  cylindrical  esophagus,  reaching  one-quarter  of 
the  length  of  the  worm;  anus  close  to  tail;  vulva  at  posterior  third;  containing  yellowish- 
green  oval  ova  (50.-58.  :  30.-34.  microm.);  larvae  develop  in  intestine  (at  first  200.-240. 


STRONGYLOIDES 


213 


miorom.,  in  length,  but  increase  to  two  or  three  times  this  length)  and  are  passed  in  the 
fecal  material.  The  larvse  differ  essentially  from  the  parent  in  having  an  esophagus  with 
two  bulbs  (rhabditiform).  In  the  discharged  feces  at  suitable  temperature  (about  30°  C.) 
these  develop  with  one  moulting  of  the  cuticle  to  a  free-living  generation  with  separate 
sexes  (at  lower  temperature  are  apt  to  remain  at  least  in  part  asexual).  In  this  free 
sexual  generation  the  worms  are  smooth,  cylindrical,  and  tapering,  with  pointed  tail 
end;  mouth  as  in  parasitic  form;  esophagus  rhabditiform  (two  bulbs)  with  its  anterior 
portion  long  and  with  the  posterior  pyriform  and  containing  a  Y-shaped  chitinous 
armature;  anus  at  base  of  tail;  male  with  tail  curved  and  two  spicules,  body  length  0.7 
mm.;  female  I.  mm.  long,  with  straight  pointed  tail,  vulva  a  little  back  of  middle;  ova 
few,  yellowish,  ellipsoid,  thin-shelled,  70.  145.  microm.,  sometimes  hatching  in  uterus. 
The  larvas  of  this  generation  look  much  as  their  free  parents,  are  at  first  0.22  mm.  in 
length,  but  grow  to  0.55  mm.,  then  moult  and  assume  a  filariform  or  strongyloid  char- 
acter like  that  of  the  parasitic  grandparent.  In  unknown  manner  these  gain  access  to 
the  intestine  of  a  new  host  or  shortly  die. 


The  above  outline  follows  that  known  for  the  tropical  strongyloides; 
it  is  said  that  in  the  European  examples  the  intermediate  generation  with 
separate  sexes  fails,  that  the 
rhabditiform  larvte  of  the 
parasitic  worms  pass  with 
moulting  to  the  condition  of 
the  strongyloid  larvae  and 
these,  if  introduced  into  the 
intestine  of  the  next  host, 
directly  develop  into  the  para- 
sitic females  as  above. 

The  worm  is  commonly 
spoken  of  as  strongyloides  in- 
testinalis  when  one  refers  to 
the  parasitic  parthenogenetic 
females  and  their  larval  off- 
spring; as  strongyloides  ster- 
coralis  in  the  free  form  having 
separate  sexes.  The  parasite 
was  first  met  in  the  stools  of 
persons  suffering  from  Cochin- 
China  diarrhea,  and  was  sup- 
posed to  be  the  cause  of  this 
affection;  and  at  one  time, 
too,  was  suspected  of  being  in 
causal  relation  to  Asiatic 
cholera.  Both  these  views 
are  erroneous,  the  worm  prob- 
ably having  no  direct  patho- 
logical significance;  although 
perhaps,  when  present  in  large 
numbers,  it  is  capable  of  aid- 
ing in  keeping  up  the  intes- 
tinal irritation  of  a  diarrheal 

affection  caused  by  some  other  original  influence.  The  parthenogenetic 
females  are  found  in  the  upper  part  of  the  small  intestine,  burrowed  in  the 
crypts  or  a  little  way  in  thernucous  membrane.  Here  they  deposit  their 
ova.     These  retained  in  the  crypts  or  between  the  folds  rapidly  incu- 


FiG.  59. — Strongyloides  intestinalis:  on  the  left  a 
gravid  female  from  human  intestine  (natural  size,  2.5 
mm.).  In  the  middle  a  rhabditiform  larva  from  fresh 
fecal  matter,  X 120;  to  the  right  a  filariform  larva  from 
culture,  X120.     {Braun.) 


214  INFECTIOVS  DISEASES 

bate  and  give  origin  to  the  larvre  found  in  the  stools.  These  arc  usually 
found  in  great  numbers,  scarcely  a  bit  of  the  fecal  matter  but  contains  at 
least  two  or  three  of  the  young  worms  in  ordinary  cases.  They  are  readily 
observed  with  low  powers  of  magnification  in  thin  layers  of  the  fecal  matter, 
actively  wriggling.  In  autopsies  there  are  occasionally  found  a  few  sexuall}' 
developed  examples  of  the  intermediate  generation  [s.  stercoralis)  in  the 
intestine  of  the  cadaver;  but  it  is  probable  that  these  develop  after  the  death 
of  the  host  from  the  intestinal  larvae  in  the  same  manner  that  they  usually' 
follow  after  ordinary  discharge  to  the  exterior. 

Nothing  is  known  as  to  the  mode  of  transmission  to  the  second  host, 
but.  presumably  unfiltered  water  or  unclean  vegetables  (uncooked)  which 
may  have  been  grown  in  soil  watered  with  fecal  infusions  (as  is  rather 
common  in  China,  Japan,  and  elsewhere)  may  bear  the  second  generation 
of  larvae  to  the  intestine  of  the  next  person.  The  worm  is  found  widely 
distributed  in  Indo-China,  the  East  Indies,  Africa,  Europe,  and  in  both 
North  and  South  America.  Few  cases  have  been  reported  from  this  country, 
but  it  is  not  an  infrequent  parasite,  at  least  in  our  Southern  States,  where 
the  writer  has  encountered  it  a  number  of  times,  invariably  without  notable 
symptoms. 

It  may  be  expelled  without  much  difficulty  by  the  use  of  the  ethereal 
extract  of  male  fern;  and  in  case  of  infested  persons  who  for  some  reason 
decline  treatment,  or  in  whom  perhaps  treatment  temporarily  fails,  the 
stools  should  as  a  matter  of  precaution  be  disinfected  to  prevent  the  dis- 
semination of  the  parasite. 

Family:  Filariid.E; 

Genus:  Filaria. 

I — Filaria  bancrofti  (Cobbold). 

{Trichina  cystica; filaria  sanguinis  hominis ; filaria  sanguinis  hominis  csgy plica; f.  wuchereri; 
f.  sanguinis  hominum;  f.  sanguinis  hominis  nocturna;  f.  nocturna.) 

Male:  colorless;  40.  mm.  long,  o.i  mm.  thick;  filiform;  anterior  end  .slightly  clubbed, 
the  head  being  a  little  thicker  than  the  neck;  posterior  end  curved,  but  not  spiral;  anus 
close  to  tail  on  ventral  side,  with  three  pairs  of  small  preanal  papilla;  and  same  number 
of  postanal  papillae;  unequal  spicules.  Female:  brownish;  76.-80.  mm.  long,  o.  2-0.3 
mm.  thick;  extremities  rounded;  vulva  1.27  mm.  back  of  anterior  extremity,  anus  0.28 
mm.  anterior  to  posterior  extremity;  nearly  the  whole  of  the  body  is  occupied  by  the  two 
uterine  tubes  in  which  may  be  seen  the  ova  and  already  developed  larval  filarial.  Larva; 
covered  by  a  delicate  sheath-like  membrane,  130.-300.  microm.  in  length,  7. -11.  microm. 
thick. 

Bancroft's  filaria,  the  common  form  of  htiman  blood  filaria,  is  met 
in  most  tropical  countries.  It  occurs  in  the  West  Indian  islands,  in  our 
own  Southern  States  (where  it  was  first  demonstrated  by  Dr.  John  Guit^ras, 
and  later  by  a  ntrmber  of  observers),  and  in  South  America.  It  is  encoun- 
tered frequently  in  India,  China,  and  Japan,  in  the  East  Indian  islands  and 
the  South  Sea  islands,  in  Australia,  commonly  in  Africa,  and  has  even 
been  met  in  southern  Europe  (Spain).  The  worm  was  first  known  only 
as  the  larva  fotmd  in  the  circulating  blood,  no  recognition  being  made  of 
the  species  /.  diurna,  f.  perstans  and  others  later  described  as  separate 
species  by  Manson.  From  tha  fact  that  these  larva?  were  met  in  the  blood 
of  infested  indi\'iduals,  the  name _;?/ana  sanguinis  hominis  was  first  attached; 
but  later,  when  the  adults  were  recognized,  it  was  found  that  the  proper 


FILIARlASrS  215 

habitat  of  the  worm  in  man  is  in  one  of  the  lymph  passages,  usually  one  of 
the  large  lymph  vessels  of  the  trunk,  as  in  the  groins,  the  pelvis,  or  thoracic 
duct;  although  as  errant  forms  they  are  also  to  be  found  in  subcutaneous 
lymph  vessels,  and  even  in  the  heart  and  blood-vessels.  In  such  situation 
are  visually  found  two  worms,  male  and  female,  intimately  coiled  together 
and  probably  living  thus  for  long  periods  and  producing  their  larvag.  The 
female  generally  gives  birth  to  the  larvae  (occasionally  ova) ,  in  large  numbers, 
each  inclosed  in  a  so-called  "sheath"  (the  shell-membrane).  These  are 
carried  along  the  lymph  vessels  by  the  current  and  eventually  are  poured 
into  the  blood-vessels,  each  larva  being  probabl}^  capable  of  several  months 
of    life    in    the    blood.      The  ^a, 

establishment    of    a    positive  .jfeo  ^ 

diagnosis  of  filariasis  is  made  (IX  ^v    j 

by  the  discovery  of  these  larvag  S|^e^  ^^^ 

in  the  blood  of  the  subject  ex- 
amined.      They    are   readily    ^^ 

detected  with  ordinary  labor-       An  qQ     ®   O  O  qqqq    q8q 

atory    powers    of  the  micro-      ^'^^^-^P        *^^3yi       ^^^T^sS^ij^-^^ 
scope  in  thin  moist  films   of  ©^h^P^^^^gg^  ^  A^  gP 

the    fresh    blood    made    just  ©®©     ^^^^^  ^  '    '  (it'^eiie 

as  in  examination  for  malarial  ^^^  6o.-Larval  !Uaria  bancrofti  in  blood.  (Coplin.) 
parasites,    each    larva    being 

about  as  thick  as  the  diameter  of  a  red  blood  cell,  and  about  forty  times 
as  long.  They  are  nicely  demonstrated  with  the  sheath  stained  by 
drying  a  film  of  blood  over  the  fumes  of  acetic  or  osmic  acid  and  then 
staining  with  hematoxylin  and  eosin  or  carmine  and  methylene  blue.  In 
the  fresh  blood  they  are  seen  to  have  an  active,  wriggling  movement, 
but  because  of  their  inclosure  in  the  sac-like  sheath  they  accomplish 
but  little  progression  by  their  activity.  They  may  be  obtained  at  any 
hoiu-  from  the  interior  blood;  but  show  a  peculiar  periodicity  in  the 
peripheral  blood,  that  drawn  as  in  ordinary  clinical  examinations  from  the 
subcutaneous  tissues  only  showing  their  presence  when  taken  at  night 
(best  between  dusk  and  midnight).  WhUe  no  certain  knowledge  is  had 
explanatory  of  this  periodicity  it  probably  does  not  rest  with  periodicity 
in  the  life  of  the  worm,  but  is  rather  due  to  a  variation  in  caliber  of  the 
peripheral  capillaries  at  night  and  in  day.  From  the  tonicity  of  the  walls 
of  the  capillaries ,  and  their  surrounding  tissues  in  the  waking  hours  of  the 
subject,  probably  the  capillary  lumen  is  too  narrow  for  the  easy  progres- 
sion of  these  larvae;  while  in  the  relaxation  from  fatigue,  and  in  sleep,  it 
may  become  sufficiently  wide  to  allow  the  worm  fair  opportunity  to  be 
borne  along  with  the  blood.  In  support  of  such  an  idea  stands  the  fact 
that  if  the  habits  of  the  infested  individual  be  changed  so  that  he  sleep  in 
day  and  be  awake  and  active  at  night,  after  a  short  period  of  indifference 
the  larvae  are  to  be  found  in  the  peripheral  blood  only  in  the  day.  While 
in  the  blood  the  larvae  retain  their  sheaths  and  are  only  passively  carried 
in  the  blood  stream;  were  it  otherwise  they  could  probably  actively  pro- 
gress at  any  hour  through  the  finest  blood  channels,  and  could  in  all  likeli- 
hood be  found  in  the  peripheral  blood  at  all  hours,  and  perhaps  might 
penetrate  the  vessel  walls  and  tissues  of  the  host.     It  has  repeatedly  been 


216  I M' EC  no  US  DISEASES 

noted  that  in  blood  preparations  after  the  cells  disintegrate  and  give  off 
their  hemoglobin,  the  plasma  thus  becoming  thicker  (although  not  coagu- 
lated), the  larvsE  are  able  by  their  active  movements  to  break  through  the 
sheath  (which  is  somewhat  fixed  by  the  denser  plasma)  and  then  arc  actively 
progressive,  each  showing  on  close  examination  a  small  boring  apparatus 
at  the  head  end. 

The  further  life-history  of  these  larvae  is  not  certainly  established; 
but  it  is  known  that  at  least  some  are  removed  from  the  infested  subject 
by  mosquitoes  of  the  genus  culex  in  withdrawal  of  blood  by  these  insects. 
It  has  been  observed  that  in  the  stomach  of  the  mosquito,  as  the  blood 
disintegrates  and  the  plasma  thickens,  the  larvae,  just  as  in  the  blood- 
film  alluded  to,  escape  from  their  sheaths  and  penetrate  the  walls  of  the 
stomach  to  bore  into  the  thoracic  muscles  of  the  gnat.  Here  they  grow 
to  an  intermediate  size,  reaching  as  much  as  1.5  mm.  in  length.  It  was 
generally  believed  that  the  larvee  are  next,  with  the  death  of  the  infested 
gnat,  freed  into  the  water  upon  which  commonly  the  mosquito  has  died, 
and  that  they  are  transferred  with  this  to  the  alimentary  canal  of  the 
next  host,  boring  through  the  walls  of  the  digestive  tube  and  attaining 
one  of  the  abdominal  or  pelvic  lymphatics.  This  idea  is  by  no  means  aban- 
doned ;  but  it  is  known  that  larvae  experimentally  kept  in  water  die  in  the 
course  of  a  few  days,  and  attempts  to  infect  monkeys  with  water  contain- 
ing the  larvae  have  failed.  On  the  other  hand,  it  is  well  established  that 
the  larvae  after  growth  in  the  muscles  of  the  gnat,  may  travel  and  get  into 
the  proboscis ;  and  it  is  thought  quite  possible  that  if  the  culex  at  such  times 
should  bite  a  fresh  human  subject  these  larv^ae  may  readily  gain  access  to  the 
wound  and  thus  enter  the  new  host.  Strong  analogy  exists  in  the  es- 
tablished similar  mode  of  transmission  of  /.  immitis  of  the  dog  by  mo- 
squitoes shown  by  Noe;  and  the  ])resent  attitude  favors  this  view. 

Pathology  and  Symptomatology. — The  symptoms  of  filariasis,  aside 
from  the  presence  of  the  larvae  in  the  blood,  vary  much  in  individual  cases. 
It  is  well  known  that  the  iixfested  persons,  with  numerous  larval  filariae 
in  their  blood,  may  for  years  show  no  symptoms  and  be  apparently  in 
excellent  health.  Doubtless  in  such  cases  the  parent  worms  are  located 
in  some  portion  of  the  lymphatic  circulation  which  they  do  not  occlude 
(as  the  receptaculum  chyli)  or  in  such  part  where  free  anastomosis  prevents 
serious  fault  in  the  lymph  flow.  If,  however,  the  parasites  should  occasion 
obstruction  and  cause  stoppage  of  the  lymph  circulation,  then  in  a  limited 
or  extensive  portion  of  the  body,  according  to  the  lymphatic  area  affected, 
there  follows  dilatation  of  the  lymph  vessels.  This  may  result  in  rupture 
of  the  distended  vessels  and  lymph  edema;  or  a  lymph  fistula  may  develop 
to  the  external  surface  of  the  body  or  into  one  of  the  body  cavities  or  hollow 
viscera.  Not  infrequentl}'  such  fistula  opens  into  a  ureter  or  the  urinary 
bladder,  the  urine  becoming  milky  from  the  lymph  admixture  (chyluria) ; 
and  at  times  in  the  development  of  the  fistula  some  of  the  small  blood-vessels 
may  also  be  broken  into  and  blood  is  added  (hematochyluria) .  The  dis- 
tention of  the  lymphatics  may  involve  the  Ij'mph  glands;  thus  those  of  the 
inguinal  region  sometimes  form  tumor-like  masses  of  a  peculiar  boggy 
quality  ("varicose  glands"),  giving  on  palpation  the  sensation  of  interior 
small  solid  areas,  occasionally  growing  to  half  the  size  of  a  fist,  and  re- 


F I  LI  ARIA  SIS  217 

quiring  to  be  differentiated  from  hernia.  Along  with  such  conditions  the 
tissues  about  the  dilated  lymph  vessels  and  passages  become  hyperplastic, 
especially  in  the  skin,  where  the  sometimes  enormous  thickening  of  the 
corium  known  as  elephantiasis  (the  possibility  of  a  combined  or  secondary 
bacterial  infection  in  the  production  of  which  should  be  held  in  mind)  is 
occasioned.  This  last  is  usually  met  in  the  skin  of  the  lower  members  and 
about  the  genitals,  but  is  occasionally  seen  elsewhere.  These  changes  are 
essentially  permanent,  and  for  this  reason  not  every  case  showing  elephan- 
tiasis, lymph  edema,  varicose  glands,  lymph-fistula,  or  chyluria  need  neces- 
sarily show  the  presence  of  the  filarial  larvse  in  the  blood,  all  of  the  parent 
and  larval  parasites  having  perhaps  died — moreover,  lymph  obstruction 
with  any  of  the  above  secondary  results  may  arise,  of  course,  from  other 
than  parasite  cause;  yet  it  is  safe  to  say  that  in  infested  districts  the 
majority  of  such  conditions  as  above  mentioned  should  be  regarded  as 
due  to  existing  or  previous  presence  of  filarial  parasites.  In  addition,  there 
are  likely  to  develop  some  blood  changes,  eosinophilia  and  more  or  less  re- 
duction in  the  number  of  red  cells,  enlargement  of  the  general  lymphatics 
and  of  the  spleen,  some  indefinite  febrile  disturbances,  more  or  less  altera- 
tion of  nutrition,  together  with  possible  inflammatory  changes  of  the  peri- 
toneum, bladder,  pelvis  of  the  kidney  or  of  the  latter  organ  itself. 

The  mechanism  of  the  obstructive  phenomena  and  their  results  are 
thus  outlined  by  Manson : 

"A  parent  filaria  is  lodged  in  the  left  thoracic  duct.  In  some  way  not  yet  under- 
stood it  injures  the  walls  of  the  vessel,  causing  ulceration  or  inflammatory  thickening. 
In  time  this  lesion  leads  to  stenosis  of  the  duct.  Pari  passu  with  the  development  of 
the  stenosis  the  thoracic  duct  on  the  distal  side  of  the  stricture  dilates  owing  to  the 
rising  lymph.  After  a  time  the  stricture  becomes  so  narrow  that  the  lymph  and  chyle 
no  longer  find  their  way  past  it  to  the  left  subclavian  vein.  They  seek,  however,  to 
reach  the  blood  by  another  route;  a  retrograde  movement  down  the  thoracic  duct  sets 
in,  and  so,  by  way  of  the  pelvic  lymphatics  in  the  walls  of  the  abdomen  and  the  anasto- 
mosis between  these  and  the  lymphatics  of  the  upper  part  of  the  body,  the  chjde  from 
the  intestines  and  the  lymph  from  the  lower  extremities  find  their  way  into  the  circu- 
lation by  the  right  thoracic  duct.  Possibly  there  are  other  routes,  as  by  the  lymphatics 
of  the  esophagus,  diaphragm,  and  back.  It  is  certain,  however,  that  a  frequent  course 
pursued  is  that  described,  which  is  much  the  same  as  that  pursued  by  the  blood  in  the 
case  of  observed  portal  circulation.  To  accommodate  this  diverted  chyle  and  lymph, 
the  lymphatics  by  which  they  pass  become  enlarged  and  in  many  places  varicose.  The 
tendency  to  varicosity  is  very  evident  in  such  places  as  the  scrotum,  mucous  membrane 
of  the  bladder,  or  wherever  the  lymphatics  are  abundant  and  feebly  supported.  In 
many  instances  these  varices,  when  superficial,  can  be  seen  or  felt  and  their  nature  readily 
recognized.  If  the  inguino-femoral  glands  are  involved,  the  varicose  groin  glands,  so 
characteristic  of  filaria  infection,  are  produced.  Sometimes  the  varix  is  apparent  on 
the  surface  of  the  abdomen  even,  as  in  a  case  related  by  Sir  William  Roberts  and  in  another 
by  Havelhing.  That  these  varices  are  really  part  of  an  anastomosis  conveying  chyle 
from  the  abdominal  viscera  to  the  blood  is  proved  by  the  nature  of  their  contents, 
which  are  usually  milky-white  or  slightly  red-tinted  chyle — not  clear  and  limpid  lymph, 
such  as  comes  from  the  legs.  As  the  lacteals  are  the  only  source  of  chyle,  these  chylous 
contents  of  the  varicose  lymphatics  must  have  come  from  that  source,  and  the  route 
followed  must  have  been  the  retrograde  one  described.  Now,  if  the  lymphatics  of  the 
bladder  happen  to  be  involved  in  the  compensatory  anastomosis,  and  if  they  give  way, 
as  the  lymphatics  of  the  scrotum  so  frequently  do  in  similar  circumstances,  the  result 
is  a  leakage  of  chyle  in  the  bladder,  and  chyluria.  It  is  evident  from  this  that  the  embryo 
filarias,  although  they  are  generally  present  in  the  blood  and  the  urine  in  chyluria,  have 
'nothing  whatever  to  do  with  its  production.  This  is  further  proved  by  the  fact  that  in 
some  few  cases  of  genuine  and  persistent  tropical  chyluria  no  embryo  filaria  can  be  found 
either  in  blood  or  urine.  Proper  treatment  of  chyluria  is  in  principle  the  same  as  the 
treatment  of  acquired  varix  in  any  accessible  region.  This  should  consist  of  rest,  eleva- 
tion, lowering  of  the  tension  in  the  lymphatic  vessels  by  the  use  of  saline  purgatives 
limited  and  appropriate  food,  and  abstinence  from  fluids  as  much  as  possible.  Cer- 
tain drugs  have  been  vaunted  as  specifics  for  chyluria.  Temporary  recovery  from  time 
to  time  is  the  rule,  and  the  drug  which  was  being  used  at  the  time  the  urine  cleared 
spontaneously  from  the  healing  of  the  rupture  in  the  varix  of  the  bladder  is  often  credited 


218  INFECTIOUS  DISEASES 

with  the  cure.     I  cannot  understand  how  a  drug  introduced  by  the  mouth  can  possibly 
cause  the  closure  of  a  gaping  varix  in  the  bladder." 

Besides  /.  bancrofti  reference  may  be  made  at  this  point  to  the  follow- 
ing species  of  filariac,  the  larvte  of  which  are  to  be  met  in  the  blood  and 
liable  to  be  confused  with  those  of  the  ordinary  form  of  human  blood 
filariae: 

2 — Filaria  diurna  (/.  sanguhiis  hominis,  var.  major):  a  larval  filaria  found  by  Manson  in 
the  blood  of  negroes  in  West  Africa,  and  differentiated  by  this  observer  from  the  larvas 
of  /.  bancrofti  by  its  presence  in  the  peripheral  blood  in  the  day  rather  than  at  night, 
and  by  the  fact  that  its  intestine  is  not  as  granular  as  that  of  /.  bancrofti.  It  is  of  the 
same  size  and  general  appearance  as  the  latter,  however.  Manson  has  suggested  this 
as  the  larval  form  of/,  loa.  In  the  few  cases  in  which  it  was  seen  it  presented  no  special 
symptomatology.  It  seems  quite  possible  that  this  species  is  identical  with  /.  bancrofti, 
the  time  of  appearance  in  the  peripheral  blood  being  perhaps  dependent  rather  upon 
conditions  of  the  host  than  of  the  parasite,  the  less  granular  condition  of  the  intestine 
being  scarcely  enough  to  justify  the  idea  of  specific  difference. 

3 — Filaria  Persians  (J.  sanguinis  hominis,  var  minor):  This  form  was  met  as  the 
larva  by  Manson  in  the  blood  of  negroes  along  the  west  coast  of  Africa  and  by  him 
erected  into  a  separate  species.  It  is  distinguished  from  the  ordinary  filaris  of  human 
blood  by  the  fact  that  it  is  present  in  the  peripheral  blood  at  all  times,  without  diurnal 
or  nocturnal  periodicity;  is  smaller;  as  seen  in  the  blood  has  no  sheath  and  is  actively 
progressive;  has  its  posterior  end  truncated  and  abruptly  rounded;  and  the  boring 
spicule  at  the  head  end  is  more  prominent  than  that  of/,  bancrofti.  The  adult  parasites, 
subsequently  recognized,  inhabit  the  mesenteric  and  retroperitoneal  tissues.  The  para- 
site is  apparently  of  little  or  no  pathogenic  importance,  as  the  hosts  present  no  symptoms 
or  important  lesions  thus  far  referable  to  the  worms  or  their  embryos.  The  male  reaches 
a  length  of  45.  mm.  and  is  0.06  mm.  in  thickness;  the  female  is  about  twice  as  long  and  as 
thick  as  the  male.  The  head  end  is  rounded.  The  tail  of  the  male  is  curled,  and  is 
marked  by  by  four  pairs  of  preanal  and  one  pair  of  postanal  papillae;  spicules  unequal; 
a  pair  of  small  cuticular  appendages  at  the  tip  of  the  tail.  Vagina  0.6  mm.  from  the  head 
end;  tail  with  cuticular  appendages  at  tip  as  in  male;  one  anal  papilla. 

The  intermediate  hosts  are  as  yet  unknown. 

6 — Filaria  magalhcBsi:  At  autopsy  in  the  heart  of  a  child  in  Rio  Janeiro  Magalhaes 
found  two  sexually  mature  filarial  worms,  male  and  female,  to  which  the  above  name 
has  been  applied.  Male:  83.  mm.  long  and  from  0.28  to  0.4  mm.  thick,  with  thick  finely 
transversely  striated  cuticle,  rounded  head  end  without  papillce,  posterior  end  with 
double  curl  and  four  large  pairs  of  preanal  and  of  postanal  papiUae,  with  one  (probably 
two  unequal)  spicule,  anus  o.  1 1  mm.  anterior  to  tail,  mouth  round  and  unarmed.  Female: 
155.  mm.  long,  0.6-0.8  mm.  thick,  with  cuticle  a  little  more  coarsely  striated  than  in  male; 
head-end  as  in  male;  tail  slender,  ending  buntly;  vulva  2.5  mm.  from  anterior  end; 
anus  0.13  mm.  in  front  of  tail;  two  ovaries,  with  the  ova  contained  measuring  38.  microm. 
long  and  14.  microm.  wide,  the  larvae  300.-350.  microm.  in  length. 

Treatment  of  Filariasis. — There  are  no  established  remedial  measures 
in  case  of  these  forms  of  filarial  infection.  Thjonol  has  been  lauded  as 
almost  a  specific  and  has  at  times  seemed  to  have  given  excellent  results, 
but  in  many  other  cases  it  has  been  apparently  of  no  value.  So,  too, 
benzoic  acid  and  benzoate  of  soda  have  been  recommended  for  the  de- 
struction of  the  parasites,  but  are  of  not  more  promise  than  the  thymol. 
At  best  treatment  has  most  to  deal  with  the  effects  of  the  parasites  in 
the  way  of  the  elephantiasis,  lymph  edema,  fistulae,  chyluria,  etc.,  and 
of  course,  the  above  drugs  can  have  no  value  in  such  relation.  Such 
conditions  must  be  met  indi\ddually  and  symptomatically.  Elephantiasis 
is  at  times  to  be  dealt  with  surgically,  as  in  case  of  elephantiasis  of  such 
restricted  regions  as  the  scrotum,  or  of  the  female  genitalia.  It  may 
be  dealt  with  in  cases  of  general  involvement  of  the  skin  of  the  limbs  by 
elevation  of  the  member,  application  of  pressiu-e  by  bandage  from  foot 
upward,  and  perhaps  some  value  may  be  realized  from  the  internal  ad- 
ministration of  iodid  of  potash.  Inasmuch  as  there  is  reason  to  believe 
that  the  dermal  thickening  of  elephantiasis  is,  at  least  in  the  early  stages 
of  the  inflammation,  in  part  due  to  associated  infection  of  the  skin  by 


FILIARIASIS  219 

various  common  bacteria  of  the  surface  of  the  body,  there  is  reason  in 
employing  internal  antiseptics  (as  methylene  blue  or  ichthyol)  or  appli- 
cations of  ichthyol  or  other  antiseptics  to  the  surface  beneath  the  bandages 
advised.  Treatment  of  chyluria  or  hematochyluria  demands  rest  in  the 
recumbent  position,  the  lowering  of  lymphatic  tension  by  saline  purgatives, 
appropriate  food,  and  limitation  of  fluids;  such  measures  being  appropriate 
also  in  connection  with  the  pressure  treatment  of  elephantiasis  and  in  that 
of  all  of  the  mechanically  induced  lesions. 

As  measures  of  prophylaxis  the  careful  screening  of  infested  individu- 
als from  mosquitoes,  particularly  at  night,  all  efforts  to  destroy  mos- 
quitoes and  prevent  their  breeding  and  entering  human  habitations,  and 
the  careful  filtration  and  boiling  of  water  used  by  inhabitants  of  infested 
districts  (in  recognition  of  the  possibility  of  correctness  of  the  old  theory 
of  water  transference  of  the  larvae)  should  all  be  practised — such  measures 
much  more  than  attempted  remedy  of  existing  cases  holding  out  promise 
of  valuable  results. 

7 — Filaria  medinensis  (Linneus). 

{Vena    medinensis;    dracunculus   Persariim;    gordius    medifiensis;    filaria     dracunculus; 
f.  cBthiopica;  dracunculus  medinensis,  Guinea-worm.) 

Only  the  female  certainly  known;  whitish  or  yellowish;  50.-80.  cm.  or  more  in 
length,  0.5-1.7  mm.  thick;  cylindrical;  anterior  end  rounded;  oral  orifice  terminal; 
small,  with  two  lips  back  of  which  are  two  lateral  and  four  submedian  papillae,  posterior 
extremity  curved  into  a  hook  and  terminating  in  a  blunt  point;  intestine  missing  (,prob- 
ably  atrophied  by  pressure  of  gravid  uterus)  up  to  esophagus;  vulva  and  vaginal  tube 
not  recognized ;  nearly  the  whole  body  occupied  by  the  double  uterus  full  of  larvae  and  ova 
in  various  stages  of  development.  Males  probably  represented  by  the  small  worms 
found  by  Charles  in  an  autopsy  on  a  native  in  Lahore,  in  whom  in  the  subperitoneal 
tissue  he  encountered  two  female  Guinea-worms  each  having  a  small  worm  about  four 
centimeters  in  length  attached  about  14  centimeters  back  of  the  head  end;  it  is  from  this 
believed  that  males  are  much  smaller  than  females  and  that  after  coition  they  perish 
and  are  lost.  LarvcB  in  uterus  measure  0.5-0.75  mm.  in  length,  slight  tapering  toward 
the  head  extremity  and  gradually  tapering  from  the  middle  to  a  long  fine  straight  posterior 
extremity,  finely  striated  transversely,  somewhat  flattened  laterally;  escaping  to  the 
exterior  of  host  through  the  mouth  of  the  parent  by  rupture  of  uterine  sac  when  the 
mother  worm  comes  to  the  surface  of  the  body  of  the  infested  individual. 

The  Guinea-worm,  known  of  old  as  the  "fiery  serpent"  of  the  chil- 
dren of  Israel  in  their  wandering  through  the  wilderness  and  mentioned 
in  the  ancient  writings  of  other  races,  occurs  in  India,  Persia,  Turkestan, 
in  Egypt,  and  in  fact  all  through  tropical  Africa,  especially  on  the  west 
coast.  It  has  been  introduced  with  negroes  from  Africa  into  this  country, 
but  has  not  taken  permanent  hold  in  the  western  hemisphere  save  in  a  few 
isolated  localities  in  South  America.  It  has  been  found  occasionally  in 
cattle,  horses,  the  dog,  jackal,  leopard,  and  wild  cat,  but  it  is  most  common 
in  man.  It  occurs  without  reference  to  race  or  age,  is  more  common  among 
males,  but  probably  only  because  of  some  difference  in  exposure  from  habits ; 
and  generally  is  most  frequently  seen  during  the  wet  season  and  in  the  suc- 
ceeding hot  months  of  the  year.  Its  usual  habitat  in  the  host  is  in  the 
subcutaneous  tissue  of  the  lower  extrem't'es,  down  near  the  ankles,  but  it  has 
been  found  in  the  trunk,  in  the  face,  and  about  the  eyes  and  in  the  tongue, 
and  elsewhere.  It  does  not  remain  in  one  locality,  but  wanders  through 
the  tissue,  usually  causing  some  minor  itching  as  it  travels;  and  after  matura- 
tion, which  is  reached  after  some  months  or  a  year  or  more  after  entrance  of 
the  larval  worm,  it  coils  itself  in  some  locality,  as  about  the  ankles,  and  there 


220 


JXFECTIOUS  DISEASES 


occasions  a  red  and  painful  tumefaction.  Probably,  as  above  suggested, 
in  the  original  infestment  both  a  male  and  a  female  larva  enter  the  host; 
after  coition  it  is  thought  the  male  dies  and  is  absorbed  and  the  female  con- 
tinues to  grow,  developing  an  enormous  number  of  larvae  in  the  uterus, 
pressure  from  the  distended  uterine  sac  causing  the  atrophy  of  the  other 
structures  internally  and  being  largely  responsible  for  the  size  of  the  mature 
worm.     After  several  days  the  swelling,  which  may  be  as  big  as  a  pigeon's 

egg,  becomes  vesicular  at  the  top  and 
breaks  down  into  an  tdcer.  When  moist- 
ure is  applied  over  this  ulcerated  tip 
(either  water  purposely  dripped  upon  it 
or  incidentally  applied  when  the  host  is 
wading)  the  worm  seems  to  be  stimulated 
to  discharge  the  larvae,  and  the  head  end 
is  slightly  protruded  through  a  small 
opening  in  the  midst  of  the  ulcer.  The 
uterine  sac  seems  to  be  forced  through 
the  oral  orifice,  breaks,  and  from  it 
escapes  a  milky  fluid  abounding  in 
actively  moving  larvas.  Some  days  may 
elapse  before  the  entire  discharge  of  the 
latter,  the  worm  coincidentally  shriveling 
and  eventually  spontaneously  passing  out 
from  the  tissue. 

Nothing  is  really  certainly  known  as 
to  the  life-histon^  of  the  larvae.  It  has 
been  definitely  shown  that  they  may  be 
directly  passed  with  the  water  into  which 
they  have  escaped  to  the  next  host  and 
reach  full  development  in  such  individ- 
ual; but  whether  this  is  the  rule  is  not 
established.  Manson  and  others  believe 
that,  having  escaped  from  the  host  into 
water,  thej^  enter  the  bodies  of  certain 
minute  water  arthropods  (cyclops) ,  therein 
moulting  several  times,  becoming  cylindrical,  losing  the  delicate  tail, 
and  developing  a  small  tripartite  tail  appendage.  Whether  the  larvae 
enter  the  next  human  host  ordinarily  with  the  water  into  the  intestine 
(either  free  or  inclosed  in  the  arthropods),  or  whether  they  penetrate  the 
skin  of  some  individual  who  may  be  wading  in  water  containing  them,  is 
not  known.  It  is  known  that  in  clean  water  they  are  not  of  long  life,  dying 
in  five  or  six  days;  in  muddy  water  they  live  for  several  months  as  free- 
swimming  lar\'£e;  and  when  parasitic  in  cyclops  are  still  more  enduring. 

There  is  rarely  more  than  one  parasite  of  the  species  in  one  host,  although 
there  have  been  placed  on  record  as  many  as  50.  The  symptoms  occasioned 
are  practically  entirely  localized  to  the  place  of  escape  of  the  worm  and  under 
conditions  of  cleanliness  after  the  removal  of  the  parasite  entirely  disap- 
pear. Occasionally,  in  the  height  of  the  local  inflammation,  there  may  be  a 
slight  febrile  general  state  induced,  but  this  is  not  of  importance;  however, 


Fig.  61. — Filaria  medinensis:  a,  ante- 
rior extremity;  0,  mouth;  P,  papiUse; 
b,  female,  reduced  to  less  than  half  normal 
adult  size;  c,  larvae,  enlarged.  {Braun, 
after  Clans.) 


FILIARIASIS  221 

should  the  worm  be  broken  in  an  endeavor  to  drag  it  out,  suppuration  and 
more  or  less  septic  absorption  with  general  symptoms  may  ensue. 

Treatment. — ^Attempts  to  destroy  the  worm  before  its  maturation 
and  pointing  are  practically  useless  with  means  at  present  known;  and 
the  treatment  is  limited  to  the  safe  withdrawal  of  the  worm  and  antiseptic 
dressing  of  the  sore  occasioned.  The  natives  are  in  the  habit  of  allowing 
water  to  drip  over  the  tilcerated  surface  to  cause  the  protrusion  of  the 
head  of  the  worm;  this  is  then  fastened  to  a  small  stick,  which  is  bound 
loosely  to  the  surface  by  a  well  moistened  bandage.  From  time  to  time 
several  times  daily,  a  turn  is  taken  upon  the  stick,  thus  winding  the  pro- 
truding part  upon  it  until  finally  the  entire  length  is  safely  and  without 
breakage  withdrawn.  A  more  excellent  method  has  been  suggested  by 
a  B'rench  surgeon,  Emily,  who  injects  vnXh.  a  fine  hypodermic  needle  a  lit- 
tle corrosive  sublimate  solution  into  the  head  end  of  the  worm,  which  kills 
the  parasite  and  allows  it  to  be  more  readily  withdrawn.  Or  if  this  can- 
not be  done  he  would  inject  a  small  amount  of  the  bichlorid  solution  into 
the  swollen  tissue  about  the  worm,  which  is  also  likely  to  destroy  the 
worm,  and  then  cuts  down  upon  it  and  carefully  extracts  it.  Faulkner 
has  said  that  he  has  been  able  to  expel  the  worm  entire  within  an  hour  by 
applying  one  pole  of  the  constant  current  over  the  tumefied  area. 

It  is  impossible  to  be  specific  as  to  prophylaxis;  but  at  least  with  our 
present  knowledge  it  is  advisable  to  refrain  from  the  use  of  water  for  drink- 
ing which  has  not  been  boiled  or  well  filtered,  and  lest  perhaps  the  larvae 
enter  the  host  through  the  skin  it  would  be  well  to  refrain  from  wading 
in  muddy  water  in  countries  where  the  parasite  is  known  to  exist. 

8— Filaria   loa  (Guyot). 

(Filaria  oculi;  dracunculus  oculi;  d.  loa;  f.  subconj unctivalis ;  f.  lachrymalis.) 

Male:  length,  20.-30.  mm.;  width,  03-0.4  mm.  whitish  or  yellowish;  cuticle  not 
striated  but,  except  at  extremities,  beset  with  numerous  irregularly  placed  protuberances; 
anterior  end  as  a  truncated  cone;  at  base  of  cone,  dorsally  and  ventrally,  a  small  papilla; 
posterior  end  slightly  curved  ventrally,  pointed;  mouth  unarmed;  anus  82.  microm.  in 
front  of  tail;  three  pairs  of  prominent  preanal  papillse,  two  pairs  of  smaller  postanal 
papillae;  two  unequal  sexual  spicules.  Female:  30-40.  mm.  or  more  long,  0.5  mm. 
thick;  surface  and  anterior  end  as  in  male;  posterior  end  straight  and  tapering,  round  at 
tip;  vulva  at  end  of  first  fourth  of  body;  double  uterine  tube  nearly  filling  the  body, 
the  ends  of  tubes  as  ovaries;  the  uterus  filled  with  ova  and  larvae  (253.-262.  microm. 
in  length)  with  rounded  head  ends  and  long  pointed  tails. 

This  worm  is,  as  far  as  now  known,  confined  to  Western  Africa;  it 
has  been  known  in  America,  having  been  conveyed  in  negro  slaves  to  this 
country,  but  has  never  become  permanent  here.  The  adtilts  live  and 
wander  through  the  subcutaneous  tissues,  especially  about  the  face,  nose, 
and  eyes,  and  have  been  especially  found  in  the  subconjunctival  tissue. 
Crawling  in  the  skin,  the  worms  cause  considerable  itching  and  burning 
pain;  and  in  the  eyelids  and  conjunctivae  induce  more  or  less  troublesome 
inflammation  and  swelling.  The  adults  are  known  to  persist  for  months 
or  even  several  years  in  these  situations  in  the  host;  but,  as  a  rule,  there 
are  only  a  few  present  in  one  individual.  The  mode  of  escape  of  the  larvae 
from  the  host  and  their  subsequent  history  are  unknown.  The  treatment 
is  limited  to  the  removal  of  the  parasite  by  surgical  methods,  as  the  clipping 
of  an  opening  in  the  conjunctiva  and  withdrawal  of  the  worm  cautiously 
by  means  of  suitable  forceps. 


222  INFECTIOUS  DISEASES 

Family:  Trichotrachelid^; 

Genus:   Trichiuris. 
Trichiuris  trichiura  (Leuckart). 
(Ascaris  Iricliiura;  trichocephalus  trichiurus;  trichocephalus  hominis; 
Irichocephalus  dispar;  whip-worm.) 
Male:      35.-45.   mm.   long;   whitish;   anterior  three-fifths  slender  and   thread-like; 
posterior  two-fifths  thicker,  cylindrical,  terminally  rounded  and  curled;  anus  terminal; 
single  spicule  in  a  tubular  sheath  containing  small  spinules.     Female:   35.-50.  mm.  long; 
shape  as  in  male  for  front  and  body;  posterior  extremity  straight,  bluntly  pointed  termi- 
nally; vulva  at  beginning  of  thick  posterior  portion  of  body;  ova  brown,  oval,  thick- 
walled  with  a  colorless  shining  button-like  protuberance  at  each  pole   (50.-54.   microm. 
long;  23.  microm.  broad). 

This  parasite,  commonly  known  as  the  "whip-worm"  because  of  the 
shape  (the  anterior  filiform  end  suggesting  the  lash,  the  posterior  thicker 
part  the  handle  of  the  whip),  is  a  very  common  and  widely  distributed 
parasite  of  man,  finding  its  habitat  in  the  large  intestine,  where  the  worms 
are  found  adhering  to  the  wall  by  the  anterior  ends,  which  are  buried  a  short 
distance  ia  the  tissues  of  the  mucous  membrane.  It  is  one  of  the  most 
common  intestinal  parasites  in  this  country,  although  but  little  attention  is 
given  it  and  few  records  are  to  be  had.  The  ova  are 
discharged  with  the  fecal  matter  from  the  intestine,  and 
in  water  or  moist  earth  the  embryo  develops  within  the 
shell,  but  does  not  escape  to  free  larval 
life.  The  thick  shell  affords  consider- 
able protection  and  the  embryo  maj- 
Pic  ^2  —Trichi-     ^^^^  ^°'"  ^lonths  before  destruction,  thus         -~rr 

uris  trichiura,  nat-    incased.     Probably  vfith  water  or  food        pm   5, Ovum 

"B^fem^le  ^'  ^^^'^'     ^^^  developed  ova  are  introduced  into    of  trichiuris  trichi- 

the  intestine  of  the  next  host,  where  in 
about  a  month  or  less  the  fully  matured  adult  worms  will  be  fotmd.  The 
parasite  is  of  little  pathological  importance;  there  are  not  often  more  than 
a  dozen  present  in  one  host,  and  apparently  they  do  but  little  damage 
and  practically  never  give  rise  to  appreciable  symptoms  of  their  presence. 
Doubtless  some  little  irritation  and  a  very  slight  loss  of  blood  from  the 
lesions  occasioned  in  the  mucous  membrane  of  the  cecum  and  colon  may 
result,  but  these  are  not  of  sufficient  gravity  to  be  noted.  It  is  a  some- 
what diffictilt  worm  to  dislodge  with  the  ordinary  parasiticides,  probably 
yielding  more  readily  to  male  fern  than  to  other  drugs  of  this  class. 

Genus :   Trichinella. 
Trichinella  Spiralis  (Owen). 
{Trichina  spiralis.) 
Male:      Length,     1. 4-1. 5    mm.;    thickness    0.04    mm.;    cylindrical;    anterior    end 
tapering,  posterior  end  gradually  and  slightly  thickening  and  terminating  in  bifid  ex- 
tremity with  two  lateral  somewhat  conical  tail  appendages;  cloacal  aperture  between 
these,  which  form  a  sort  of  bursa;  back  of  cloacal  aperture  two  pairs  of  papillae.     Female: 
3.-4.  mm.  long;  anterior  end  as  in  male;  posterior  end  nearly  of  same  thickness  to  tail, 
which  is  rounded;  anus  terminal;  vulva  at  anterior  fifth  of  body;  viviparous.     Lan'ce: 
when  born,  90.-100.  microm.  in  length,  obtuse  anteriorly,  posteriorly  prolonged  to  a 
pointed  tail;  when  encysted  as  "muscle  trichinie"  the  larva;  measure  about  i.  mm.  long 
and  0.04  mm.  in  thickness,  tapering  anteriorly,  more  thick  and  obtuse  posteriorly,  with 
complete  organization  as  in  the  adult  and  showing  the  characters  of  the  different  sexes. 

This  important  parasite  in  its  adult,  sexual  stage  infests  for  a  brief 
period  the  intestinal  tract  of  man  and  a  number  of  animals  (mainly  mam- 
mals), gives  origin  to  a  large  ntmiber  of  larval  worms  after  which  the  adults 


TRICHINIASIS 


223 


die;  the  larvaa  make  their  waj^  into  the  muscles  of  the  same  host  and  pass 
an  indefinite  encysted  stage  in  this  situation  until  transferred  to  the  next 
host  by  the  ingestion  of  the  infested  flesh  by  the  latter.  The  species  was 
first  established  by  Owen  in  1835,  from  encysted  larvse  in  the  muscles  of 
htiman  anatomical  subjects;  in  1846  Leidy  announced  the  discovery  of  the 


Fig.  64. — Trichinella  spiralis:  a,  gravid  female  "intestinal  trichina  L  embryos;  G, 
vulva;  Oa,  ovary;  6,  adult  male  "intestinal  trichina";  T,  testicle^  c  joung  larva  i,  larva 
in  musculature;  e,  encapsulated  larva  in  muscle.     {Braiin,  after  Claus.) 


encysted  larvas  in  pork;  but  it  was  not  until  i860,  mainly  through  Zenker, 
that  the  full  relation  with  the  intestinal  form  and  the  development  of  the 
worm  were  understood. 

Besides  in  man  the  worm  is  commonly  found  in  the  hog  (domestic  and 
wild),  in  rats,  and  in  mice;  it  has  also  been  met  in  rabbits,  guinea-pigs,  cow, 


224 


INFECTIOUS  DISEASES 


sheep,  horse,  dog,  cat,  fox,  marten,  badger,  bear,  raccoon,  mole,  skunk,  hedge- 
hog, hippopotamus,  hamster,  and  in  birds  as  hen,  pigeon,  and  duck.  It  is 
most  common  in  man,  hog,  rat,  guinea-pig,  and  rabbit. 

Man  commonly  acquires  trichiniasis  by  eating  infected  ham  insuffi- 
ciently cooked.  The  capsules  are  digested  and  the  trichina?  set  free;  thej' 
pass  into  the  small  intestine  and  there  develop  into  the  sexually  matuer 
worms,  attaining  maturity  about  the  third  day ;  of  these  the  males  die  after 
fertilization,  while  the  females  adhere  to  the  mucous  membrane,  or  may  per- 
forate the  intestinal  wall  and  may  find  their  way  into  the  mesentery  and 
lymphatic  glands  of  the  mesentery.  Each  of  these  gives  birth  to  large 
numbers  of  larA'^as ;  the  young  brood  is  carried 
away  from  the  bowel  or  mesentery  in  the  lymph 
stream,  and  is  distributed  partly  through  the 
blood  and  lymph  streams  and  partly  by  active 
migration.  Before  birth  the  young  trichinas 
are  from  o.og  to  o.i  mm.  (0.0035  to  0.00393 
inch)  long,  growing  slightly  during  migration, 
say  from  0.12  to  0.16  mm.  (0.0047  to  0.0063 
inch).  Their  favorite  seat  of  lodgment  is  the 
striated  muscular  tissue,  within  the  striped 
muscular  fasciculus  itself,  or  between  the  mus- 
cular fasciculi  and  parallel  to  them.  In  nine 
or  ten  days  after  infection  the  first  brood 
reaches  its  destination,  to  be  followed  by 
others,  since  the  intestinal  trichinas  continue 
to  produce  young  throughout  a  life  of  seven 
weeks.  A  single  worm,  it  is  said,  may  bring 
forth  from  8,000  to  10,000. 

The  young  trichinje  begin  to  be  encysted  in 
the  muscle  about  the  second  or  tliird  week  after 
infection,  by  which  time  the  parasite  has  grown 
to  0.8  mm.  (0.0314  inch)  in  length.  Each  one  arranges  itself  in  a  spiral, 
of  which  the  outline  is  oval,  and  becomes  surrounded  bj'  a  capsule  of 
corresponding  shape,  the  worm  cyst  lying  with  the  long  axis  parallel  to 
the  direction  of  the  muscular  fibers.  The  cyst  is  transparent,  0.4  mm. 
(0.0157  inch)  long,  and  0.25  mm.  (0.0098  inch)  wide.  After  from  five  to 
eight  months  calcification  may  even  involve  the  inclosed  trichina  itself. 
On  the  other  hand,  the  capsule  may  undergo  fatty  degeneration  and  calci- 
fications, a  pathological  change  which  takes  place  at  times  early,  at  others 
only  after  the  lapse  of  years.  The  encapsulated  trichina  remains  living 
and,  capable  of  development  for  a  long  time — according  to  Damman, 
in  hogs  eleven  years,  while  in  man  they  have  remained  living  25,  27, 
30,  and  40  years  after  infection.  It  has  been  shown  by  Zenker  that  the 
encysting  is  not  a  necessary  condition  to  the  mature  development  of  young 
trichinae. 

Human  infection  having  been  conclusively  shown  to  be  due  to  the  eating 
of  raw  pork  infested  with  trichinae,  it  is  not  at  once  evident  how  swine  be- 
come infected.  It  is  well  known  that  the  rats  which  infest  slaughter  houses 
are  infected  in  large  nimibers,  but  it  is  plain  also  that  they  may  acquire 


Fig.  65. — Section  of  human 
muscle  containing  encysted  Iriclii- 
nclla  spiralis;  parasite  and  its  cyst 
cut  in  section,  and  but  a  part  of 
the  larval  worm  shown;  about 
upper  pole  a  local  fat  deposit. 


TRICIIINIASIS  225 

trichinae  by  eating  pork.  The  two  probably  contribute  mutually  to  the 
perpetuation  of  the  disease. 

As  to  the  distribution  of  the  trichiniasis :  most  epidemics  have  been 
in  Germany.  Even  in  America,  where  there  have  been  two  or  three 
epidemics,  it  has  been  in  German  immigrant  communities.  Apparently 
it  is  rather  the  imperfect  cooking  of  the  pork  which  is  responsible,  for  al- 
though a  larger  percentage  of  American  pork  appears  to  be  infected  than 
German,  yet,  as  already  stated,  the  disease  is  much  more  infrequent  in 
America  than  in  Germany.  It  is  to  be  remembered  that  while  thorough 
cooking  effectually  destroys  the  parasites,  the  requisite  heat  may  fail 
to  reach  the  interior  of  large  masses  of  meat  containing   viable  larvae. 

Symptoms. — The  immigration  of  numerous  active  parasites  in  mus- 
cular tissue  is  followed  by  intense  irritation,  manifested  at  first  by  fever 
and  muscular  pain.  The  latter  is  especially  severe  during  motion.  The 
acts  of  chewing,  swallowing,  and  breathing  are  particularly  difficult,  be- 
cause of  the  pain  excited  by  these  acts.  In  the  early  stage  of  the  disease 
diarrhea  is  quite  common,  so  that  certain  epidemics  have  been  mistaken 
for  typhoid  fever  and  as  often  also  for  rheumatism.  In  the  very  begin- 
ning of  the  immigration  into  the  muscles  edema  has  sometimes  been  ob- 
served. The  more  general  and  thorough  the  invasion,  the  more  intense 
the  symptoms.  Very  high  fever,  deliriima,  infiltration  of  the  limgs,  and 
fatty  degeneration  of  the  liver  have  been  observed.  Death  may  take 
place  either  from  exhaustion  as  the  result  of  extreme  irritation,  or  later 
in  the  disease  from  the  same  cause  preceded  by  anemia  and  gradual  loss  of 
strength.  Usually,  however,  improvement  sets  in  about  the  fotirth  or 
fifth  week,  though  convalescence  in  bad  cases  is  slow,  and  many  weeks 
elapse  before  recovery  is  complete. 

Diagnosis. — It  is  usually  the  unexpectedness  of  the  disease  which 
leads  to  delay  in  diagnosis.  The  resemblance  of  the  symptoms  to  those 
of  typhoid  fever  and  muscular  rheumatism  has  been  referred  to,  yet  in  the 
presence  of  a  possible  cause — as,  for  example,  a  German  picnic  or  other 
feasting  occasion  where  the  favorite  ham  or  sausage  has  formed  part  of  the 
feast — such  symptoms  should  immediately  excite  suspicion.  The  discovery 
by  Thomas  R.  Brown  in  1897^  that  eosinophilia  is  constantly  associated 
with  trichiniasis  is  important  and,  when  present,  is  confirmatory  of  the  ex- 
istence of  the  disease.  A  differential  blood  count  should  therefore  be  made 
in  suspected  cases.  When  doubt  exists,  the  harpoon,  designed  for  obtaining 
samples  of  muscles  for  examination,  should  be  unhesitatingly  used,  under 
ether  or  local  anesthesia,  and  the  part  removed  carefuUy  examined  under 
the  microscope.     Better  than  the  harpoon  is  a  scalpel 

Treatment. — Salting  of  the  pork,  while  causing  the  death  of  a  few 
of  the  encysted  larval  trichinae,  is  insufficient  to  destroy  any  large  pro- 
portion unless  prolonged  much  more  than  is  usually  practised;  smoking 
is  also  lethal  to  the  larvae,  but  insufficient  to  guarantee  the  death  of  all; 
cold  storage  is  of  little  or  no  value;  but  an  exposure  to  heat  of  70°  C.,as 
should  be  assured  in  thorough  cooking,  is  known  to  be  uniformly  fatal 
to  any  remaining  parasites  and  should  render  the  infested  flesh  innocuous. 
However,  it  must  be  remembered  that  heat  does  not  well  penetrate  to 

*  "Johns  Hopkins  Hospital  Bulletin,"  April,  1897, 


226  INFECTIOUS  DISEASES 

the  interior  of  large  masses  of  meat;  and  nothing  but  certainty  of  the 
thoroughness  of  cooking  can  be  reUed  upon;  and  imperfectly  cooked  pork 
is  more  apt  to  be  eaten  than  well  cooked  when  hams  are  boiled  entire. 
Here,  as  so  often  elsewhere,  an  "ounce  of  prevention  is  worth  a  pound 
of  cure."  Such  prevention  consists  in  thorough  ofiRcial  inspection  of 
all  pork  brought  to  market,  because  cooking  may  fail  of  its  purpose  for 
the  reasons  already  mentioned.  For  a  similar  reason  swine  should  be 
grain-fed,  rather  than  allowed  to  feed  on  offal.  It  is  doubtful  whether 
any  direct  measures  can  be  used  for  arresting  the  disease  after  the  muscles 
have  once  been  invaded.  It  is  a  simple  conflict  for  the  mastery  between 
the  strength  of  the  patient  and  the  life  of  the  trichinae.  In  the  majority 
of  cases  the  former  triumphs,  though  death  is  not  infrequent  from  the 
causes  named.  If  the  disease  is  recognized  early,  the  alimentary  caiial 
should  be  treated  with  vermicides  and  purgatives,  with  a  view  to  getting 
rid  of  all  the  sexually  mature  worms  which  may  happen  to  remain  there, 
since  it  will  be  remembered  that  successive  broods  develop  from  the  same 
mother-worm  while  in  the  intestinal  tract.  Glycerin,  given  in  a  table- 
spoonful  (30  c.c.)  dose  hourly,  is  said  to  destroy  the  trichinae.  Benzine, 
in  I  to  2-dram  (4  to  8  gm.)  doses  in  capsules,  and  picric  acid  in  dose  of 
from  5  to  8  grains  (o.  to  0.5  gm.),  are  also  recommended,  but  are  regarded 
as  less  reliable.  To  relieve  the  pains,  hypodermic  injections  of  morphin, 
1/4  grain  (0.0165  gm.),  or  warm  baths  may  be  used.  Restoratives  and 
stimulants  should  be  given  to  keep  up  strength. 

Family  Strongylid^; 
Genus:  Euslrongylus. 
Eustrongylus  gigas  (Rudolphi). 
{Ascai'is  canis  et  marlis;  a.  visceralis  et  renalis;  slrongyhis  gigas;  s.  renalis;  eiistr.  visceralis. 
Male:  red  in  color;  14. —  40.  cm.  in  length,  4.-6.  thick;  slightly  tapering  anteriorly; 
mouth  terminal,  with  a  hexagonal  orifice  surrounded  by  six  lips  bearing  papillae;  cuticle 
thin  and  transparent,  finely  striated  transversely;  about  150  papilte  along  the  longi- 
tudinal lines  laterally  (best  marked  near  middle  of  body  length);  caudal  extremity  with 
an  oval  plate-like  expansion  serving  as  a  bursa  (transverse  diameter  the  longer),  its 
margin  bearing  small  papillcc  and  slightly  indented  dorsally  and  ventrally;  single  sexual 
spicule.  Female:  general  appearance  and  head  end  as  in  male;  20.-100.  cm.  in  length 
and  5.-12.  mm.  thick;  caudal  extremity  obtuse,  straight,  with  anus  subterminal;  vulva 
50.-70.  mm.  posterier  to  mouth;  single  ovarian  and  uterine  tube  plicated  from  near 
anterior  end  along  the  intestine  nearly  to  anus,  then  returning  to  vulva  near  anterior 
end.  Ova  brown  ellipsoid,  with  thick  shell  marked  by  external  cribriform  depressions, 
64.-48.  microm.  long  and  40.-44.  microm.  broad. 

This  worm,  more  common  in  the  dog  (and  also  found  in  other  animals 
as  seal,  otter,  wolf,  horse,  cow,  marten,  and  skunk),  has  been  recorded 
a  number  of  times  as  a  parasite  of  man,  although  in  most  cases  with  some 
resen^ation  as  to  the  correctness  of  diagnosis.  It  is  the  largest  of  the 
nematodes  and  has  its  habitat  in  the  pelvis  of  the  kindey,  where  one  or 
several  of  the  parasites  may  exist.  It  has  been  known,  too,  to  be  free 
in  the  abdominal  cavity,  and  is  said  to  have  in  rare  instances  been  found 
in  the  liver  and  in  the  pleural  cavity  (in  lower  animals).  Little  is  known 
of  its  life-histor)'.  At  the  time  of  oviposition  the  interior  of  the  ova  is 
segmented.  Passed  with  the  urine  into  water  or  moist  earth  outside 
the  host,  a  larval  worm  develops  in  the  course  of  five  or  six  months  in 
winter  and  probably  much  more  rapidly  in  summer;  this  remains  for  a 
long   time  living  within  the  shell,  apparently  several  years.     If  removed 


STRONGYLUS 


227 


experimentally  from  the  ovum  it  soon  dies  in  pure  water,  but  may  be  kept 
.alive  for  a  longer  time  in  albuminous  fluids.  As  yet  no  successful  trans- 
ference of  the  larval  worm  has  been  accomplished  experimentally,  and  in 
consequence  it  is  thought  that  in  nature  it  passes  to  some  intermediate 
host,  possibly  some  fish. 

In  its  usual  habitat  the  worm  causes  considerable  dilatation  of  the 
renal  pelvis,  and  sometimes  the  whole  kidney  becomes  reduced  to  a  thin 
hydronephrotic  sac,  in  which  in  the  midst  of  a  red  and  bloody  urinous 
fluid  the  parasites  are  found.  In  man  the  worm  has  not  been  recognized 
antemortem,  having  only  accidentally  been  observed  in  autopsies;  and 


Euslrongylus  gigas:  female,  natural  size,  in  kidney  of  dog.     (Railliet.) 


this  is  also  usual  in  case  of  infestment  of  the  lower  animals.  However, 
in  the  dog  the  urine  often  becomes  notabty  bloody,  the  animal  sometimes 
whines  as  if  in  pain,  the  gait  becomes  tremulous,  the  bark  altered,  the 
animal  becoming  depressed  and  showing  nervous  s],Tnptoms  which  have 
been  confused  with  those  of  rabies.  The  diagnosis  in  man  must,  of  course, 
rest  upon  the  discovery  of  the  characteristic  ova  in  the  urine.  It  might  be 
located  in  one  or  the  other  kidney  by  catherization  of  the  lu-eters;  and  the 
only  treatment,  should  a  safe  conclusion  as  to  the  presence  of  the  worm  in 
one  or  other  renal  pelvis  be  arrived  at,  would  rest  with  the  enucleation  of 
the  worm  or  of  the  entire  kidney  by  surgical  procedure.  Thus  far  but  one 
kidney  has  been  found  infested  in  a  single  host,  although,  of  coxu-se,  care 
should  be  exercised  to  exclude  the  possibility  of  a  bilateral  infestment. 

Genus:  Uncinaria. 
Uncinaria  duodenalis  (Dubini). 
(Anchylostonia  duodenale;  strongylus   quadridentatus ;   dochmius   anchylostomum;   scleros- 
toma  duodenale;  strongylus  duodenalis;  dochmius  duodenalis;  European  or  old-world 
hook-worm.) 

Male:  whitish    or    blotched  with    brownish,  spots  when  intestine  contains  blood; 
8.- 10.  mm.  long;  cuticle  finely  striated  transversely;  tapering  to  a  blunt  point  ante- 


228 


INFECTIOUS  DISEASES 


riorly  and  with  head  curved  upon  dorsum  so  as  to  give  a  sHghtly  hooked  anterior  end;  on 
each  side  of  median  Hne  on  ventral  side  of  oral  border  two  hook-like  chitinous  teeth  and 
on  dorsal  border  on  each  side  of  median  line  one  less  curved  chitinous  tooth;  with  a. 
dorsal  conical  tooth  extending  along  back  of  oral  cavity  from  base  of  cavity;  in  oral 
cavity  about  esophageal  opening  a  delicate  armature  consisting  of  two  dorsal  and  two 
ventral  lancet-like  pieces;  posteriorly  the  body  ends  in  an  abruptly  pointed  tail  in  a 
copulatory  bursal  expansion  of  the  cuticle,  this  having  one  dorsal  and  two  lateral  lobes; 
in  folds  of  bursa  one  dorsal  subdivided  muscular  ray  each  division  ending  tridigitately, 
and  on  each  side  symmetrically  an  undivided  dorso-lateral,  a  divided  lateral,  undivided 
latero-ventral,  subdivided  ventral  and  undivided  small  subventral  muscular  rays;  cloa- 
ca! aperture  superterminal;  two  equal  spicules.  Female:  General  appearance  and  ante- 
riorly like  male;  12.-18.  mm.  long;  posteriorly  tapering  to  a  finely  pointed  tail;  anus 
subterminal;  vulva  about  posterior  third  of  body  length;  two  uterine  and  ovarian  tubes. 
Ova:  colorless,  elliptical  thin-shelled,  50.-60.  :  30.  microm. 

This  important  parasite  of  man  has  a  wide  distribution  in  tropical 
and  subtropical  countries,  but  probably  properly  belongs  to  such  localities 
in  the  older  hemisphere  as  southern  Europe  (especially  Italy,  Switzerland, 
and  Austria),  the  Mediterranean  borders  of  Africa,  southern  Asia,  and 
the  eastern  archipelago.  It  is  found  also  in  the  tropical  and  subtropical 
regions  of  America,  but  here  has  been  much  confused  with  the  American 


Fig.    67. — Ova  of  «nci- 
naria  duodenalis. 


Fig.  68. — Anterior 
end,  showing  mouth 
parts  of  imcinaria 
duodenalis  (dorsal 
view). 


Fig.  69. — Tail,  with  expanded  bursa, 
of  male  imcinaria  duodenalis. 


species  of  hook-worm  recently  recognized  as  a  separate  species.  As  im- 
ported cases,  perhaps  occasionally  giving  rise  to  small  endemic  foci,  it 
has  been  met  in  the  cooler  parts  of  the  United  States. 

Its  habitat  is  in  the  duodenum,  jejunum,  and  upper  part  of  the  ileum 
of  man,  where  it  is  found  in  ntmibers  varying  from  a  few  to  considerably 
more  than  a  thousand.  With  its  strong  armature  it  attaches  itself  to  the 
intestinal  mucous  membrane  producing  a  small  excavation,  and  thus 
fixed,  sucks  the  nutrient  juices,  lymph  and  blood,  from  the  mucosa.  Through 
the  agency  of  certain  glands  situated  in  the  anterior  end  the  worm  pro- 
duces a  substance  inhibiting  blood  coagulation;  and  thus  from  the  tiny 
lesions  produced  by  the  worm,  which  are  frequently  forsaken  for  fresh 
situations,  considerable  bloody  oozing  takes  place.  From  this  factor, 
as  well  probably  from  nutritive  faults  following  upon  the  intestinal  dis- 
turbances induced  and  perhaps  also  from  some  undiscovered  toxic  influences, 
there  restilts  a  loss  of  bodily  weight  and  strength  and  an  anemia  wliich 
in  its  severer  forms  ranks  among  the  pernicious  anemias.  Fatal  cases  are 
not  infrequent.  When  from  the  first  but  few  parasites  are  present  there 
may  be  practically  no  symptoms  appreciated  (unless  the  parasites  are  but 
a  complication  of  other  serious  disturbances  as  malaria,  the  anemic  results 


UNCINARIASIS  229 

of  which  they  are  likely  to  accentuate,  or  unless  the  host  be  quite  young 
or  a  weakling).  In  severer  grades  of  infestment,  discomfort  and  actual 
pain  in  the  abdomen,  nausea,  altered  appetite  (often  kakophagism),  and 
alternating  diarrhea  and  constipation  are  apt  to  be  noted.  In  course 
of  time  flesh  and  strength  are  lost,  the  patient  becomes  dull  and  slothful; 
the  young  do  not  develop  with  the  usual  vigor;  and  an  anemia  of  varying 
grade  comes  to  be  appreciated  (miner's  anemia,  tunnel  anemia,  etc.). 
This  latter  may  be  profound  in  loss  and  change  of  the  red  cells,  is  apt  to 
show  in  its  typical  appearance  some  increase  in  the  eosinophilic  leukocytes, 
and  a  comparatively  low  hemoglobin  proportion.  With  the  severer  anemia, 
and  probably  largely  secondary  to  this,  arise  wide-spread  degenerations, 
mainly  fatty  in  type,  involving  almost  any  of  the  body  structures,  but 
especially  noteworthy  in  the  important  parenchjmiatous  structures  as 
the  wall  of  the  heart,  the  liver,  and  kidneys.  These  in  turn  give  further 
manifestations  of  disease;  the  urine  becomes  albuminous,  the  circulation 
becomes  feeble,  and  a  cachectic  type  of  dropsy  is  apt  to  develop;  and 
eventually,  if  no  relief  be  afforded,  the  patient  may  die,  as  in  any  severe 
anemia,  from  exhaustion,  intercurrent  affection,  or,  perhaps,  accidental 
terminal  hemorrhage.  The  course  of  the  case  is  apt  to  be  a  prolonged 
one,  the  parasites  often  persisting  in  the  host  for  years. 

The  affection,  known  as  uncinariasis  or  anchylosiomiasis,  is  readily 
recognized  from  the  general  picture  and  the  discovery  of  the  ova  of  the 
worms  in  the  stool,  these  being  very  numerous  in  the  dejecta  from  subjects 
of  even  moderate  infestment.  They  are  readily  determined  by  means 
of  the  ordinary  laboratory  powers  of  the  microscope  in  thin  laj^ers  of  fecal 
matter,  diluted  if  needed  with  a  drop  of  water.       There  is  eosinophilia. 

Of  the  life-history  of  the  parasite  it  is  known  that  the  larvae  escape 
from  the  ova  within  from  24  to  48  hours  at  a  temperature  of  25°  C.  or 
thereabouts  in  the  fecal  matter,  in  moist  soil  or  in  dirty  water.  Hence, 
if  there  is  a  doubt  as  to  diagnosis  of  the  eggs  they  may  be  hatched  out 
and  the  characteristic  larva  sought  more  easily  after  centrifugation  (Dock 
and  Bass) .  The  incubation  goes  on  best  in  fair  access  to  air,  and  therefore 
the  most  favorable  situation  is  in  moist  sandy  soil.  When  first  emerged 
the  larva  measures  about  0.2  mm.  in  length,  is  obtuse  anteriorly,  and  poste- 
riorly tapers  to  a  finely  pointed  tail  and  shows  a  rhabditif  orm  type  of  esopha- 
gus. In  48-72  hours  a  moulting  occurs,  the  larva  having  grown  in  size,  but 
preserving  its  structural  features  unchanged;  a  second  moulting  follows 
about  the  fifth  day,  the  larva  remaining,  however,  in  the  old  cuticle  (so- 
called  "  encystment ")  and  assimiing  the  adult  type  of  esophagus.  In 
this  encysted  stage  it  is  still  motile  and  now  lives  well  in  water  or  moist 
soil  for  several  months,  eventually  dying  or  gaining  access  to  a  fresh  host. 
From  actual  personal  experience  and  from  experimentation  on  man  and 
dogs.  Loos  has  established  the  fact  that  at  this  stage  the  parasite  may 
pass  into  the  human  host  by  penetration  of  the  skin.  Should  the  moisture 
containing  these  larvae  come  in  contact  with  the  skin,  as  about  the  feet 
of  persons  walking  barefooted  on  the  wet  and  infested  sand,  or  wading 
in  infested  water,  the  larval  worms  attack  the  exposed  surface,  rapidly 
penetrating  the  skin  and  leaving  their  mantles  (old  cuticle)  behind.  In 
so  doing,  if  there  be  many  of  the  larvae  entering,  considerable  irritation 


230  INFECTIOUS  DISEASES 

and  consequent  mild  inflammation  may  be  induced.  It  is  supposed  that 
this  feature  is  the  origin  of  certain  inflammatory  skin  afi^ections  common 
in  tropical  regions  and  known  as  "ground  itch,"  "water  itch"  and  by  other 
local  terms;  probably  only  a  portion  of  cases  of  such  affections  depends 
upon  this  cause,  as  there  are  doubtless  many  other  possible  irritants  which 
may  act  in  a  similar  manner,  and,  moreover,  it  is  probable  that  much  of 
the  inflammatory  mischief  is  caused  and  prolonged  in  these  cases  by  bacteria 
of  one  or  other  sort  conveyed  by  the  larval  worms  to  the  subcutaneous 
tissues.  From  the  position  of  entrance  into  the  skin  the  lar\'ae  make  their 
way,  probably  largely  by  passive  convection  by  the  blood  and  lymph,  to 
the  lungs.  Here  they  penetrate  to  the  air-passages,  where  it  is  thought 
they  undergo  another  ecdysis,  or  moulting.  They  are  still  minute;  are 
supposed  to  be  carried  by  the  bronchial  mucus  upward  to  the  mouth  and 
then  to  be  swallowed,  thus  gaining  their  proper  habitat  and  growing  into 
adult  size  and  sexual  ability  in  the  upper  part  of  the  intestine. 

While  this  mode  of  infestment  may  be  regarded  as  established,  the 
older  belief  that  the  encysted  larvae  are  transmitted  to  the  host  by  direct 
ingestion  in  dirty  water  or  on  unclean  vegetables,  or  in  dirt  (in  kakophag- 
ism),  etc.,  cannot  be  as  yet  excluded,  and  must  be  kept  in  mind  in  con- 
siderations as  to  prophylaxis. 

Genus:  Necator. 

Necator  Americanus  (Stiles). 

(Uncinaria  americana;  anchylostoma  americanum.) 

Male:   differs   from   uncinaria  duodenalis  in  being  of  smaller  size  (6.-9.  mm.  long 

and  more  slender  than  u.  duodenalis),  in  the  smaller  size  and  more  conical  shape  of  the 

head,  in  having  no  hooklets  on  the  oral  rim,  but  instead  on  each  side  a  large  ventral  and 

smaller  dorsal  chitinous  lip  extending  from  the  rim  toward  the  median  line;  in  a  greater 

prominence  and  projection  into  the  oral  cavity  of  the  dorsal  conical  tooth;  in  the  smaller 

size  of  the  copulatory  bursa,  its  dorsal  lobe  being  subdivided  and  the  ventral  margin 

being  extended  so  as  to  form  an  indefinite  ventral  lobe  and  showing  the  dorsal  muscular 

ray  of  the  bursa  divided,  each  di\'ision  ending  in  a  bipartite  tip.     Female:  differs  from  u. 

duodenalis  in  being  shorter  and  more  slender  (8.-15.  mm.  long),  with  similar  difference 

of  the  anterior  end  as  above  outlined  for  male;  vulva  just  in  front  of  the  middle  of  body 

length  instead  of  at  posterior  third,  as  in  u.  duodenalis.     Ova  somewhat  larger  than  those 

of  u.  duodenalis  (68.-70.  :  38.-40.  microm.),  but  otherwise  similar. 

Necator  americanus,  originally  established  as  a  species  of  uncinaria  by 
Stiles,  but  subsequently  determined  as  generically  distinct  and  given  the 
name  now  used,  is  found  especially  in  tropical  and  subtropical  America,  and 
in  the  West  Indian  islands;  and  prior  to  1902,  when  the  species  was  estab- 
lished, was  probably  often  confused  with  uncinaria  duodenalis.  The  latter  is 
also  met  in  imported  instances  and  has  been  encountered  not  infrequently 
either  alone  or  in  association  with  the  American  form;  but  is  scarcelj-  to  be 
regarded  as  properly  an  American  parasite,  especially  since  it  is  almost  cer- 
tain that  many  of  the  records  of  its  occurrence  in  America  are  based  bj'  mis- 
take upon  necator  americanus.  The  two  worms  are  analogous  in  their 
influences  and  the  term  uncinariasis  is  usually  employed  to  indicate  the  state 
of  infestment  by  necator  americanus  or  uncinaria  duodenalis  more  or  less 
indifferently.  The  worm  in  question  is  very  common  on  our  own  Southern 
States,  where  it  is  apparently  responsible  for  a  group  of  anemic  conditions  in 
the  inefficient,  undernourished,  pallid,  and  complaining  classes  of  population 
known  by  various  contemptuous  terms  in  different  localities,  as  "poor 
white  trash,"  "crackers,"  "sand-lickers,"  "dirt-eaters,"  etc.     The  condi- 


UNCINARIASIS 


231 


tions  produced  by  the  American  hook-worm  are  comparable  to  those  caused 
by  the  old-world  form,  but  are  probably  less  intense  for  a  given  degree  of 
infection  in  the  individual  host.  The  affection  in  this  country  has  long 
been  popularly  known  as  dirt-eaters'  disease,  sand-lappers'  disease,  mountain 
anemia,  etc. 

Treatment  of  Uncinariasis. — For  the  expulsion  of  the  parasites,  thymol 
is  perhaps  the  most  efficient  remedy.  It  is  given  in  large  doses  of  the 
undissolved  drug  with  precautions  as  below  indicated,  reliance  being  had 
upon  its  slow  and  partial  solution  in  the  intestine  in  close  contact  with  the 
parasites,  thus  directly  influencing  the  latter,  but  not  being  sufficiently 
dissolved  to  afford  ease  of  serious  absorption  and  intoxication  of  the  host. 
The  patient  is  prepared  the  day  prior  to  the  administration  by  a  mild  cathar- 
sis and  by  taking  but  a  light  evening  meal  or  none.  The  following  morning 
thymol  is  given  in  capsule  or  cachet,  in  three  doses  an  hour  apart  of  0.6-2.  g. 
(9.-30.  grains)  each,  making  from  1.8  to  6.  grams  in  all.      During  the  period 


Fig.  70. — Ova  of    necator 
americaniis. 


Fig.     71. — Anterior  Fig.  72. — Tail,  with  expanded 

end,     showing     mouth  bursa,  of  male  necator  americaniis. 
parts,  of  necator  ameri- 
caniis (dorsal  view). 


in  which  the  drug  is  in  the  alimentary  canal  oils,  alcoholics,  and  other  sol- 
vents of  thymol  are  withheld  to  prevent  massive  solution  and  absorption  of 
the  substance.  Within  an  hour  after  the  last  dose,  if  free  purgation  has  not 
meanwhile  taken  place,  a  purgative  (an  ordinary  saline)  is  administered;  and 
the  stools  are  to  be  closely  examined  for  the  discharged  worms.  In  the 
course  of  a  week  or  ten  days,  if  examination  of  the  dejecta  continue  to  show 
the  presence  of  ova,  the  above  procedure  may  be  repeated.  Sometimes 
mental  wandering,  dizziness,  and  faintness  appear  as  toxic  symptoms  from 
absorption  of  thymol,  but  usually  rest  in  bed,  a  little  weak  coffee,  and  a 
small  amount  of  hot  bouillon  after  purgation  has  begun  allay  these  symptoms. 
Male  fern  is  strongly  recommended  by  a  number  of  European  writers  for 
the  old-world  hook-worm;  but  the  writer's  experience  with  the  American 
form  would  indicate  the  greater  efficiency  of  thymol.  Filmaron,  the  non- 
toxic active  principle  of  filix  mas,  has  been  recommended  by  Nagel. 

As  measures  of  prophylaxis  there  should  be  recommended  the  use  of  only 
boiled  or  well-filtered  water  for  drinking  purposes,  thorough  cleanliness  of 
all  vegetable  food  which  has  been  grown  in  suspicious  soils  and  which  is 
eaten  uncooked,  together  with  refraining  from  going  barefooted  and  wading 
in  dirty  water  or  mud  in  infested  districts.  The  drainage  of  soils  contam- 
inated by  the  dejecta  of  infected  persons,  together  with  its  exposure  to 


232 


INFECTIOUS  DISEASES 


Fig.  73. — Anterior  extremity  of  ascaris  lum- 
bricoidcs:  A,  seen  from  front;  B,  seen  from 
dorsal  surface.     {Railliel.) 


the  sun  by  plowing,  shotdd  also  be  considered ;  and  the  stools  of  infested 
persons  should  be  disinfected  before  disposal.  Persons  should  not  go  bare- 
foot in  infected  places. 

Family:  Ascarid^e; 
Genus:  Ascaris. 
I — Ascaris  lumbricoides  (Leuckart). 
(Max-worm;  common  round  worm  of  children.) 
Male:   whitish  to  reddish -yellow;   I5-— 17-  cm.  long,  3. — 3.5  mm.  thick;  elongate, 
fusiform;  cuticla  finely  ringed;  oral  orifice  terminal,  with  three  lips  (one  dorsal  and  the 

other    two   meeting    in   median   ventral 
A  line),   each   with  fine  denticulations   on 

margins;  at  base  of  superior  Up  two 
papUlae,  one  only  at  base  of  other  two 
lips;  posterior  end  terminating  conically, 
curved  ventrally,  with  two  slightly 
curved,  short,  equal  spicules  projecting 
from  subventral  cloaca;  70. — 75.  papillae 
on  ventral  face  of  posterior  end,  of  which 
seven  pairs  are  postanal.  Female:  20. — 
25.  cm.  long,  5. — 5.5  mm.  thick;  anterior 
end  and  general  appearance  as  in  male; 
posterior  end  tapering,  ending  in  conical, 
pointed,  straight  tail;  vulva  at  level  of 
first  third  of  body  length  (in  a  slightly 
depressed  annular  band) ;  anus  subterm- 
inal.  Ova  ellipsoidal,  50.-75.  microm. 
long  and  40. — 58.  microm.  broad;  thick-shelled;  stained  yellowish  from  fecal  matter 
when  found  in  dejecta,  but  colorless  in  uterus;  covered  with  a  mammilated  envelope. 

This  worm  has  a  world-wide  distribution,  its  habitat  being  in  the  small 
intestine  of  man.  It  is  more  common  in  the  young,  but  may  occur  in  per- 
sons of  any  age.  The  number  in  a  single  host  is  usually  small,  two  to  six 
or  eight,  but  in  rare  instances  there  have  been  reported  some  hundreds  from 
one  individual ;  and  Cruveilhier  found  in  the  small  intestine  of  a  young  idiot 
girl  great  masses  of  the  worms,  the  number  of  which  he  estimated  at  about 
one  thousand. 

The  presence  of  but  a  few  of  the  parasites  may  pass  unnoticed,  but  even 
where  the  parasites  are  but  few  there  may  result  in  children  severe  nervous 
disturbances,  either  reflex  from  intestinal  irritation  or  possibly  from  absorp- 
tion of  some  toxic  material  elaborated  by  the  worms  or  generated  in  the 
intestine  in  their  presence,  as  epileptiform  attacks,  cerebral  congestion  and 
headache,  vertigo,  chorea,  ocular  disturbances,  or  manifold  hysterical  mani- 
festations. Capricious  appetite,  nausea,  indefinite  abdominal  pains, 
symptoms  of  maldigestion,  restless  sleep  are  often  complained  of;  occasion- 
ally swelling  and  congestion  of  the  lachrymal  papillae,  undue  lachrymation, 
itching  about  the  eyes,  itching  and  swelling  of  the  fingers  are  encountered. 
The  worms  possess  active  motility  and  not  infrequently  wander  from  their 
proper  habitat,  either  up  or  down  the  canal  and  perhaps  into  some  of  the 
collateral  passages.  Thus,  the  wnriter  some  years  since  met  an  instance  in 
which  an  adult  ascaris  was  found  in  the  cavity  of  a  periappendiceal  abscess, 
the  worm  having  penetrated  the  appendix  and  escaped  tlirough  a  perforation 
in  its  distal  end  into  the  abscess  cavity,  having  probably  had  mcuh  to  do 
with  the  appendicitis  and  perforation  of  the  wall.  Not  infrequently  they 
wander  to  the  rectum  and  spontaneously  pass  from  the  anus.  They  have 
been  found  in  the  biliary  duct,  producing  obstructive  jaundice;  in  the  pan- 
creatic duct;  in  the  stomach,  whence  they  are  commonly  expelled  by  vomit- 
ing excited  hy  their  presence  and  movements.     A  specimen  was  formerly 


ASCARIS 


233 


in  the  collection  of  the  University  of  Pennsylvania,  in  which  the  worm,  hav- 
ing been  thus  carried  from  the  stomach  to  the  pharynx,  had  been  retracted 
into  the  larynx  in  the  deep  inspiration  following  the  retching,  obstructing 
the  lumen  and  causing  the  death  of  the  child. 
Bunches  of  these  worms  have  been  known  to 
cause  intestinal  obstruction,  and  occasionally  at 
such  positions  of  obstruction  perforation  of  the 
wall  has  taken  place  and  the  parasites  have  been 
found  in  the  abdominal  cavity. 

The  ordinary  life-history  is  about  as  follows : 
The  ovum,  after  discharge  in  the  fecal  matter, 
slowly  develops  in  water  or  moist  earth,  the  larval 
worm  being  retained  within  the  shell  and  pre- 
served for  months  from  destruction  by  the  re- 
sistant shell;  it  is  transferred  directly  to  the 
alimentary  canal  of  the  next  host  with  unclean 
water  or  food,  there  quickly  freed  from  its  wall 
by  the  action  of  the  digestive  juices,  and  develop- 
ing to  adult  stage  in  the  course  of  about  five 
weeks. 

The  recognition  of  the  presence  of  these  para- 
sites, while  perhaps  suggested  by  the  presence  of 
the  more  common  symptoms  above  indicated, 
is  only  established  by  the  discovery  in  the  stools 
of  the  host  of  the  ova  or  by  the  recognized 
passage  of  one  or  more  worms. 

Treatment. — The  remedy  which  has  been 
most  satisfactory  in  my  hands  is  santonin  in 
combination  with  calomel.  Powders  containing 
santonin  and  calomel,  of  each  i  or  2  grains 
(0.066  to  0.132  gm.),  may  be  prescribed  rubbed 
up  with  sugar  of  milk.  One  is  given  night  and 
morning  until  the  bowels  are  freely  moved.  The 
santonin  may  color  the  urine  and  produce  yellow 
vision,  or  xanthopsia,  but  I  have  never  seen 
harmfvd  results  in  a  large  experience,  though 
poisoning,  manifested  by  convulsion  is  said  to 
have  been  produced.  For  very  young  children 
the  dose  may  be  reduced  to  1/4  to  1/2  grain 
(0.0165  to  0.033  gui-)-  The  worm  tablets  ex- 
tensively advertised  usually  contain  santonin  as 
their  basis.  There  is  an  official  troche,  U.  S.  P., 
containing  1/2  grain  (0.033  gm-)  of  santonin. 
Santonica,  or  Levant  worm-seed,  whence  santonin 
is  derived,  is  no  longer  used.  What  is  known  as 
wormseed  oil,  the  oil  of  chenopodium,  another 

excellent  remedy  for  round  worm,  is  derived  from  the  chenopodium  anthel- 
minticum,  or  American  worm-seed.  The  dose  is  10  minims  (0.65  c.c.)  to  a 
child  of  five  years,  on  a  lump  of  sugar  or  in  emvdsion — before  breakfast, 


-Ascaris    lumbri- 


coides:  to  left,  male  in  lateral 
aspect;  to  right,  female,  ventral 
aspect,  natural  size.   {RaiUiei.) 


234 


INFECTIOUS  DISEASES 


dinner,  and  supper  for  two  days — followed  by  a  purge,  of  which  none  is 
more  suitable  for  children  than  calomel,  itself  a  vermicide. 


I        1 


\  \         (iiHiiiiq 


Fig.  75. — A,  Ovum  of  ascaris  lexana  drawn  from  specimen  in  uterus;  B,  ovum  of  ascaris 
liimbricoides  drawn  for  comparison  from  examples  taken  from  uterus  of  formaldehyd 
specimen. 


Fig.  76. — Lips  of  ascaris  lexana  (camera  lucida  drawing  from  compressed  specimen):  a, 
superior  lip;  6,  inferior  lips,  the  left  overl>'ing  the  right;  c,pulpa;  rf,  denticulate  anterior  margin 
of  superior  and  right  inferior  lips;  e,  keel  of  superior  lip  on  inner  surface;  /,  interlabium. 

The  prophylactic  measures  are  principally  the  careftil  filtration  or  boiling 
of  all  water  used  for  drinking  purposes,  and  thorough  cleanliness  of  all  un- 
cooked food. 


OXYURIS 


235 


Genus:  Oxyuris. 

Oxyuris  vermicularis  (Leuckart). 

(Ascaris  vermicularis;  fusaria  vermicularis;  pin- worm;  thread- worm ;  seat- worm.) 

Male:   whitish;    3.-5.    mm.    long,    0.3-0.4    mm.  thick;  cuticle  transversely  striated 

and  at  head  end  showing  a  vesicular  swelling  along  the  dorsal  and  ventral  median  lines; 

lateral  lines  distinct;  mouth  terminal,  with  three  retractile  lips;  esophagus  with  distinct 

bulb;  posterior  end  conical,  curved  ventrally,  with  si.\  pairs  of  papillce  and  slight  cuticu- 

lar  expansion  on  each  side;  one  spicule  hooked  at  free  end.     Female:  10.  mm.  long,  0.6 

mm.  thick;  anterior  end  and  general  appearance  as  in  male;  posterior  end  straight, 

extended  to  a  long  mucronate  tail;  anus  2.  mm.  in  front  of  tail;  vulva  at  anterior  third 

of  body   length.     Ova   oval,  flattened  on  one  side,  50.:  1 6.-20.  microm.;  thin-shelled; 

colorless  with  embryo  developed  at  oviposition. 

This  worm  is  an  extremely  common  parasite  of  man,  of  practically 
world-wide  occurrence,  having  its  proper  habitat  in  the  lower  end  of  the 
^  ileum  and  the  cectmi.      It  is  especially  frequent  in 

children,  but  is  also  found  in  individuals  of  any  age. 
The  worms  usually  are  in  large  numbers  in  the  indi- 
vidual host ;  and  are  possessed  of  considerable  activity, 
wandering  from  their  natural  habitat  so  that  occa- 
sionally they  are  found  in  the  upper  end  of  the  small 
intestine  and  have  been  knowTi  to  get  into  the 
stomach  and  be  vomited,  but  more  commonly  passing 
downward  to  the  rectum,  and  spontaneouslj'  crawling 
from  the  anus.  They  are  not  as  apt  to  be  found 
in  errant  positions  as  ascaris  lumbricoides,  but  in  this 
respect  much  that  has  been  said  of  the  latter  is  true 
also  of  the  present  type.  A  specimen  recently  brought 
into  the  pathological  laboratory  of  the  University  of 
Pennsylvania  shows  in  a  catarrhal  appendLx  large 
numbers  of  the  parasites.  It  was  long  thought  that 
the  entire  evolution  of  the  worm  from  the  ovtun  to 
adult  stage  takes  place  in  the  original  host,  and  Vix 
has  actually  seen  the  larval  worms  after  emergence 
from  the  egg  in  the  rectal  mucus;  but  that  this  takes 
place,  save  exceptionally,  is  no  longer  held.  It  is 
believed  that  the  ova  with  the  developed  embryos 
within  are  scattered  after  defecation  over  vegetables 
and  fruit,  being  strongly  resistant  for  some  time  at 
least  to  the  effects  of  drying;  or  they  may  become 
adherent  to  the  nails  and  fingers  of  the  host  when  the 
latter,  because  of  the  intolerable  itching  about  the 
anus,  scratches  himself.  It  is 
thought  possible,  too,  that  they 
may  be  transferred  from  the 
fecal  mass  to  food-stuffs  by  flies. 
Ingested  with  foods  they  are 
directly  swallowed.  Upon  the 
hands  of  one  host  they  may 
readily  be  transferred  to  the  hands  of  a  second  human  being  and  thus 
endanger  the  latter.  From  the  fingers  they  may  be  transferred  to  the 
mouth,  or  perhaps,  may  be  carried  into  the  ncse,  when  the  habit  of 
nosepicHng  exists;  and  in  the  nasal  mucus  the  larvae  may  emerge  from 


Fig.  79. — Oxyuris  ver- 
micularis: to  the  left,  fe- 
male; to  right,  male  (con- 
siderably enlarged).  A, 
anus;  0,  mouth;  »,  vulva. 
{Braun,  ajter  Claus.) 


Fig.    80. — Ovum    of 
oxyuris  vermicularis. 


236 


INF  EC  no  US  DISEA  SES 


1 .  Larval  strongyloides  inteslinalis . 

2.  Ovum  oljasciola  hepatica. 

3    Ovum  of  hymenolepis  nana. 

4.  Ovum  of  uncinaria  duodcnalis. 

5.  Ovum  of  necalor  americaims. 

6.  Ovum  of  taiiia  mediocandlata. 

7.  Ovum  of  IcEnia  solium. 

8.  Ovum  of  opislhorchis  sinensis. 


9.  Ovum  of  epislhorchis  fcliiieus. 

10.  Ovum  of  colylngniiimus  hclcrophyes. 

11.  Ovum  of  dipylidium  canitium. 

12.  Ovum  of  ascaris  lumhricoides. 

13.  Ovum  of  dicrocceliiim  laiiccatuin. 

14.  Ovum  of  dibotliriocephahis  lalus. 

15.  Ovum  of  tricliiuris  Irichiura. 

16.  Ovum  of  oxyuris  vermicularis. 


Fic.  81. — Parasitic  bodies,  ova  and  larva  met  in  human  feces;  color  approximate  only. 


ARACHNOIDS  237 

the  shell  and  later  be  swallowed.  It  is  not  likely  thay  they  are  trans- 
ferred by  water,  soon  dying  in  the  latter  fluid.  If  the  eggs  have  been 
swallowed,  the  larvae  probably  emerge  from  the  shells  in  the  stomach  and 
upper  intestine.  Here  they  undergo  several  moults  before  maturation, 
copulate,  and  the  females  become  gravid.  The  males  after  copulation 
apparently  soon  die  and  are  carried  ofE  in  the  intestinal  contents,  explaining 
the  comparative  rarity  of  the  latter  among  samples  obtained.  The  fe- 
males in  their  wanderings  lodge  for  the  most  part  about  the  ileo-cecal  region, 
where  most  of  the  ova  are  deposited;  but  are  apt  to  continue  moving  slowly 
along  the  gut  to  the  rectum,  continuing  to  deposit  their  eggs.  Their  dura- 
tion in  the  intestine  is  apparently  at  least  some  months;  and  the  common 
persistence  of  parasitism  in  spite  of  treatment  argues  for  the  ease  and  fre- 
quence of  self-infection  by  the  host. 

When  in  small  numbers  but  little  disturbance  is  ordinarily  occasioned, 
but  nervous  symptoms,  much  as  outlined  in  connection  with  ascaris  lumbri- 
coides,  may  be  induced.  The  greatest  common  inconvenience  is  occasioned 
by  their  movements  and  the  irritation  of  mucous  membrane  of  the  rec- 
tum, inducing  a  proctitis  and  troublesome  pruritus.  Sometimes,  especially 
at  night,  the  worms  spontaneously  escape  from  the  anus  and  may  be  found 
in  the  bedclothes;  or  they  have  been  known  to  crawl  into  the  genital  canal 
of  females,  where  they  may  set  up  a  vaginal  catarrh  and  by  the  itching  occa- 
sioned lead  children  to  take  up  the  habit  of  masturbation. 

Treatment. — Some  perseverance  is  commonly  necessary  to  get  rid  of  the 
thread-worm.  I  usually  prescribe  the  same  powder  of  santonin  and  calomel 
as  for  the  round  worm — i.  e.,  from  i  to  2  grains  (0.066  to  0.132  gm.)  of  each — • 
but  at  the  same  time  order  nightly  injections  into  the  rectum  of  vermicides, 
of  which  there  are  many— the  infusion  of  quassia,  of  aloes,  lime-water,  ^dnegar, 
corrosive  sublimate  (i  to  500°).  salt  and  water.  The  injection  should  be 
retained  for  some  time,  and  to  this  end  the  buttocks  should  be  raised,  or  the 
child  may  be  placed  on  its  hands  and  knees.  Only  as  much  should  be  intro- 
duced— from  2  to  4  ounces  (60  to  120  c.c.) — as  can  be  conveniently  retained. 
Too  large  a  quantity  is  promptly  rejected. 

Stools  from  infested  individuals  require  to  be  disinfected  before  dispo- 
sition; the  anal  region,  especially  in  children,  should  be  well  washed  after 
every  defecation;  and  under  no  circumstances  shoidd  the  infested  person  be 
permitted  to  scratch  about  the  anus  lest  the  ova  of  the  pin-worms  become 
adherent  to  the  nails,  and  through-  careless  and  uncleanly  habit  be  trans- 
ferred to  the  nose  or  mouth.  This  can  be  partially  prevented  by  clothing 
infested  children  in  stout  muslin  underdrawers,  thus  preventing  them  from 
putting  their  hands  to  the  anus.  Cleanliness  and  prevention  of  self-infest- 
ment,  if  persevered  in  will  eventually  be  followed  by  the  natural  death  and 
disappearance  of  the  parasites;  it  is  safe  to  say  in  all  cases  of  very  protracted 
presence  of  these  pin-worms  that  in  some  way  these  essentials  have  not  been 
fully  maintained. 

Ar-ARA  CHNOIDEA . 

Among  a  number  of  arachnoids  of  more  or  less  importance  as  parasites 
of  man,  either  transitorily  or  permanently,  the  following  species  may  be 
selected  for  brief  mention. 


238 


INF  EC  no  US  DISEA  SES 


Order:  Acarina  (Mites,  Ticks). 

I.  Sarcoptes  or  acarus  scabiei — the  itch  insect.  This  is  the  most  fre- 
quently met  of  the  arachnide  parasites.  Its  oval,  nearly  circular  little  body, 
provided  with  horns  and  bristles,  is  barely  visible  to  the  naked  eye  under 


Fig.  8o. — Acarus  scabiei  A:,  female,  dorsal  view;    B,  portion  of   human  cpiderm,  showing 
burrows  with  contained  ova  and  young  acarians.     {Gould,  ajlcr  Leuckart.) 

favorable  circumstances,  the  male  being  from  0.2  to  0.3  mm.  (0.0078  to 
0.00 II 8  inch)  by  0.145  to  0.19  mm.  (0.0057  to  0.0074  inch);  the  female,  from 
0.33  to  0.4s  mm.  (0.0129  to  0.0177  inch)  by  0.25  to  0.35  mm.  (0.0098  to 
0.0137  inch). 

The  female  lies  at  the  end  of  a  burrow  in  the  epidermis,  in  situations 
where  the  skin  is  most  delicate,  as  between  the  fingers, 
at  the  elbows,  and  under  the  knees,  in  the  groin,  and  on 
the  penis,  very  seldom  in  the  face,  but  in  anj'  delicate 
part.  In  this  burrow,  some  millimeters  to  a  centimeter 
long,  the  female  deposits  her  eggs.  The  male  is  seldom 
seen,  dying  after  copulation,  and  the  female  after  deposit- 
ing her  eggs.  The  eggs  hatch  in  from  four  to  eight  days, 
and  in  about  14  days  the  larvae  are  sufficiently  matured 
to  make  their  own  burrows.  The  disease  is  communi- 
cated by  personal  contact  or  by  clothing. 

Symptoms. — These  are  first  an  intense  itching  which 
incites  to  scratching,  which,  in  turn,  causes  excoriations, 
papules,  vesicles,  and  pustules. 

Diagnosis. — The  diagnostic  feature  is  the  shining 
little  vesicle  readily  recognized  by  a  moderate  magnifier 
in  the  webs  of  the  fingers,  though  it  is  often  obscured 
and  obliterated  by  the  eruption  and  marks  caused  by 
scratching. 

Treatment. — This  is  very  simple.     Sulphur  ointment 

is  a  prompt  specific.     The  body  should  be  first  bathed 

thoroughly   with   soft   soap,    and    then  as  thoroughly 

anointed  with  the  ointment,  which  should  be  allowed  to  remain  until  the 

next  day,  when  there  should  be  another  bath,  followed  by  another  vigorous 

application  of  the  ointment.     Three  or  four  days  of  this  treatment  should 


Fig.  81. — Demo- 
de X  folliculorum: 
from  dog,  enlarged. 
(Braun,  afler  Mig- 
uin.) 


PEDICULUS  CAPITIS  239 

stiffice.     An  ointment  of  naphthol,  one  dram  to  the  ounce  (4  gm.  to  30  gm.j 
is  recommended. 

2.  Demodex  Jolliculorum,  a  minute  parasite  from  0.3  to  0.4  mm.  (o.oiiS 
to  0.0157  inch)  long,  which  resides  in  the  sebaceous  follicles,  with  the  grease 
of  which  it  can  sometimes  be  squeezed  out.  It  is  oftenest  met  on  the  face 
and  nose.  It  is  said  to  be  present  in  about  50  per  cent,  of  persons,  but  this  is 
probably  exaggerated.  It  usually  gives  rise  to  no  symptoms,  but  is  said 
sometimes  to  be  the  cause  of  obstruction  of  the  follicles  and  produces  thus 
the  little  worm-like  accumulations  of  fat  which  may  be  squeezed  out  of  the 
follicles,  and  which  cause  inflammation  and  acne. 

Treatment. — Acne  is  well  treated  by  a  lotion  of  corrosive  sublimate,  2  to 
1000,  and  it  may  be  by  its  effect  on  the  demodex  that  it  is  usefrd. 

3.  Leptus  autuninalis,  or  harvest  bug,  is  a  minute  red  parasite,  from  0.3 
to  0.5  mm.  (0.0118  to  0.0196  inch)  long,  which  has  three  pairs  of  legs,  with 
rows  of  bristles  upon  its  back  and  belly.  It  prevails  in  summer  on  grasses 
and  plants,  attaches  itself  to  the  skin  of  man  and  animals  by  its  booklets, 
and  gives  rise  to  irritation. 

Treatment. — It  is  successfully  destroyed  by  sulphur  ointment  and 
corrosive  sublimate,  2  to  1000. 

Order:  Hemiptera. 
Family:  Pedicididw  (Lice). 

1.  The  pediculus  capitis,  or  head-louse.  The  male  is  from  i  to  1.5 
mm.  (0.0393  to  0.059  inch)  long,  the  female  from  1.8  to  2  mm.  (0.0708  to 
0.0757  inch)  long.  The  color  varies  somewhat  mth  the  races.  In  the 
white  it  is  gray  with  a  dark  border,  in  the  negro  and  Chinamen  darker. 
Its  eggs  are  0.6  mm.  (0.0236  inch)  long,  of  which  the  female  laj'S  about  50, 
which  mature  in  about  a  week,  and  in  18  days  are  ready  to  reproduce.  The 
eggs  are  attached  to  the  hairs,  and  are  easily  visible,  being  known  as  nits. 

The  head-louse  is  found  the  world  over,  upon  the  hairy  heads  of  men 
and  sometimes  in  other  parts  of  the  body  where  there  are  hairs.  Even  when 
they  are  quite  numerous  they  may  produce  no  symptoms.  Generally,  how- 
ever, they  cause  itching  and  scratching,  especially  when  the  louse  bores 
deep  into  the  skin  and  produces  pustular  dermatitis,  with  resulting  crusts 
and  scabs  in  which  the  hair  becomes  matted  and  tangled,  forming  the  plica 
polonica,  so  caUed  from  its  frequency  in  Poland. 

2.  The  pediculus  vestimenti,  or  body-louse,  is  considerably  larger,  being 
from  two  to  five  mm.  (0.1574  to  0.1968  inch)  long  and  whitish-gray  in 
color,  the  back  part  of  the  body  being  wider  than  the  thorax.  Its  eggs 
are  from  0.7  to  0.9  mm.  (0.0275  to  0.0354  inch)  long,  and  about  70  are 
laid  by  the  female.  It  lives  on  the  clothing,  in  which  it  deposits  its  eggs, 
about  the  neck,  back,  and  abdomen.  The  puncture  incident  to  sucking  is 
often  covered  by  a  hemorrhagic  point.  It,  too,  causes  itching  and  scratch- 
ing, with  irritation  and  inflammation  of  the  skin,  and  in  old  cases  a  rough- 
ness and  pigmentation  causing  dark  spots  and  a  condition  known  as  mor- 
bus errorum  or  vagabond's  disease,  which  has  been  mistaken  for  Addison's 
disease. 

3.  The  pediculus  pubis,  phthirius  inguinalis,  or  crab-louse,  is  smaller 


240 


INFECTIOUS  DISEASES 


than  the  head-louse,  grayish-yellow  or  grayish-white,  the  male  being  from 
0.8  to  I  mm.  (0.0314  to  0.0393  inch)  long,  the  female  1.12  mm.  (0.0441  inch) 
long.  The  eggs  are  pear-shaped,  from  0.8  to  0.9  mm.  (0.0314  to  0.0354 
inch)  long,  and  from  0.4  to  0.5  mm.  (0.0157  to  0.0196  inch)  wide.  They 
infest  the  parts  of  the  body  covered  by  shorter  hairs,  such  as  the  pubis. 


Fig.  82. — Ovum  of  head-louse  glued  to        Fig.  83. — Pediaitus  capitis:  XiS.     (Braun.) 
hair:  X70.     (Branti.) 

axilla,  and  eyebrows.  The  pediculus  pubis  does  not  wander  so  much  as  the 
pediculus  capitis  or  vestimenti,  but  adheres  more  closely  to  the  skin  and  there- 
fore removal  is  often  with  difficulty. 

These  lice  give  rise  to  annoying  itching  about  the  pubes. 

Treatment  of  Pediculosis. — For  the  head  lice:  The  hair  should  be  cut 


Fig.  84. — Pediculus  veslimenlorum:  Xio, 
circa.     {Braun.) 


Fig.  85.- 


-Phlhirius  inguinalis.     {Braun). 


short  and  burned,  the  head  thoroughly  washed  with  soap  and  water,  and 
then  anointed  with  mercurial  ointment  or  washed  with  tincture  of  coc- 
cvdus  indicus,  or  with  coal-oil  or  turpentine,  or  carbolic  acid,  i  to  50.  Coc- 
ciilus  indicus  is  to  be  preferred  because  of  its  freedom  from  odor.  The 
washing  should  be  repeated  for  several  days  in  succession. 


FLEAS  241 

The  treatment  for  the  crab-louse  is  the  same,  but,  as  mentioned,  it 
adheres  firmly  to  the  skin,  and  it  is  generally  necessary  to  pick  off  the  indi- 
vidual louse,  and  to  make  an  application  of  mercurial  ointment. 

To  get  rid  of  the  body-louse  the  clothing,  if  not  too  valuable,  should 
be  burned,  but  may  be  boiled,  or,  when  this  is  not  admissible,  treated  by 
superheated  steam. 

The  itching  promptly  disappears  with  its  cause,  but,  if  necessarj%  it  may 
be  allayed  by  a  warm  bath  to  which  4  or  5  ounces  (120  to  150  gm.)  of 
sodium  bicarbonate  are  added. 

Repeated  bathing  with  soft  soap  should  be  done  imtil  it  is  absolutely 
certain  that  the  parasite  and  its  ova  are  removed. 

Destruction  of  the  body  louse  is  now  doubly  important  because  of  its 
known  relation  to  typhus  fever. 

4.  The  cimex  lectulariiis,  or  common  bedbug.  This  familiar  insect  is 
reddish-brown,  oval  in  shape,  from  four  to  five  mm.  (0.0574  to  0.1967  inch) 
long,  and  three  mm.  (o.  1 1 8 1  inch)  wide.  The  female  lays  three  or  four  times 
.  a  year  about  50  eggs,  1.12  mm.  (0.0441  inch)  long,  which  require  about 
II  months  for  their  perfect  development  to  the  sexually  ripe  condition. 
They  live  in  the  crevices  of  beds,  floors,  and  rafters,  in  furniture,  behind 
wash-boards  and  wall-paper,  in  the  habitations  of  man.  During  the  day 
they  lie  concealed;  at  night  they  wander  in  search  of  the  blood  of  the 
human  being,  which  they  draw  by  means  of  a  long  proboscis.  The  peculiar 
odor  of  the  insect  is  due  to  a  secretion  of  a  special  organ  with,  which  the  bug 
is  provided. 

Human  beings  are  variously  susceptible  to  the  bite  of  the  bedbug,  some 
being  quite  indifferent  to  it,  others  being,  as  it  were,  special  favorites  of  the 
little  creattire. 

Treatment. — The  irritation  is  confined  to  the  moment  of  the  bite. 
The  aim  to  be  sought  is  the  extermination  of  the  insect.  This  is  often  diffi- 
cult when  a  thorough  lodgment  is  secured,  and  it  is  often  necessary  that  all 
wall-paper  shovild  be  removed  as  well  as  loose  woodwork.  Bedsteads 
should  be  thoroughly  scalded  and  then  treated  with  the  following:  Two 
tablespoonfuls  of  metallic  mercury  should  be  thoroughly  beaten  up  with  the 
white  of  one  egg  until  a  froth  is  attained.  Apply  freely  with  a  small  paint- 
brush, filling  in  carefully  all  cracks  and  crevices.  The  pest  is  less  apt  to 
invade  iron  bedsteads,  but  even  these  must  not  be  neglected,  for  they,  too, 
in  careless  hands,  may  become  infested.  Solution  of  corrosive  sublimate,  2 
to  1000,  may  also  be  applied  in  the  same  manner. 

Order:  Diptera. 

Suborder:  Aphaniptera  (Fleas). 

I.  The  pulex  irritans,  or  common  flea.  Of  these  little  creatures,  the 
male  is  from  2  to  2.5  mm.  (0.0787  to  0.0984  inch)  long,  the  female  as  much 
as  four  mm.  (0.1574  inch),  red  or  dark-brown  in  color.  It  is  also  highly 
capricious  in  its  tastes,  disturbing  some  persons  not  at  all,  others  seriously. 
It  is  not  a  parasite  of  man,  and  invades  him  usually  because  of  its  great 
abundance  in  certain  places  and  countries.  Though  of  world-wide  distri- 
bution, it  is  more  troublesome  in  hot  countries  where  cleanliness  of  house- 


242 


IXFECTIOUS  DISEA SES 


hold,  city,  and  person  is  a  matter  of  indifference.  The  eggs  are  not  laid 
on  human  beings,  but  in  the  cracks  of  boards,  sweepings,  and  wooden  spit- 
boxes. 

Treatment. — The  essential  oUs  applied  to  the  infested  parts  cause  the 
retreat  of  fleas  when  applied. 


\  ""  .--^''"''^■^■^J 

\d^.      I 

HRV^          m. 

jTx7'  '         ^jfe 

Vj^jpE^P^ 

wSfjx'vCf^ 

m 

fS 

:   n 

I 

Fig.  86. — Pidex  irriians:   X14.     (Braun.) 


Fig.  87. — Larva  of  pulcx  irriians. 
(Gould.) 


2.  The  pulex  penetrans,  or  sand-flea  or  jigger.  The  female  buries  her- 
self in  the  skin  of  human  beings  as  well  as  of  dogs,  swine,  and  other  mam- 
mals, producing  painful  irritation,  circumscribed  swelling,  and  even  suppura- 
tion. It  especiall}^  attacks  the  feet.  It  prevails  in  tropical  countries, 
especially   in   Central   and   South  America.     The  eggs   are  land-hatched. 


Fig.  88. — Sarcopsylla  {pulcx)  penetrans:  Fig.  89. — Sarcopsylla  (pulcx)  penetrans: 

gravid    female,   enlarged.      (Braun,  ajler       voung   female,   enlarged.        (Braun,    after 
Moniez.)  Moniez.) 

Treatment. — The  flea  may  be  picked  out  with  a  needle,  after  which  the 
essential  oils  are  rubbed  in  on  the  parts  to  keep  it  away. 

Suborder:  Brachycera  (Flies). 

Myiasis. — The  diptera  also  contribute  to  parasites  through  their  larva, 
which  are  deposited  sometimes  in  open  sores  which  have  been  neglected  and 


MYIASIS 


243 


sometimes  in  the  nasal  passages  and  cavities — the  ear,  pharynx,  vagma 
etc.     The  condition  is  called  myiosis,  from  the  Greek  /^"i",    a  fly. 

The  most  common  of  these  is  myiasis  vulnerum,  in  which  an  ulcer  be- 
comes filled  with  maggots,  which  are  the  larvje  of  the 
blue-bottle  or  common  flesh-fly,  sarcophaga  carnaria. 

Myiasis  narium,  aurium,  conjunctives,  vagina,  etc., 
are  due  to  the  lucilia  macellaria,  whose  larva  is  de- 
posited in  these  situations  usually  when  they  are 
diseased,  and  may  produce  serious  mischief,  perforat- 
ing mucous  membrane  and  even  cartilage.  The  larvae 
of  the  lucilia  nobilis  have  also  been  found  in  the  audi- 
tory passages,  producing  ringing  of  the  ears  as  a  symp- 
tom. The  larvae  of  sarcophaga  magnifica  had  been 
found  in  ulcers  and  other  situations,  throughout 
Europe,  and  especially  in  Russia. 

Cutaneous  myiasis  is  commonly  due  to  the  larva  of 
the  hypoderma  bovis  or  bot  fly,  the  female  of  which 
lays  her  eggs  on  the  skin  of  cattle  and  sheep,  in  which 
the  larva  bores  its  way  and  forms  the  gad  boil,  about 
as  large  as  a  pigeon's  egg.  Rarely  in  tropical  coun- 
tries this  happens  in  the  skin  of  man.  Cutaneous 
myiasis  is  sometimes  caused  by  the  larva  of  the  musca  voniitoria,  one  of  the 
domestic  flies.  More  frequently  it  causes  internal  myiasis,  having  been 
swallowed  and  again  discharged  by  vomiting. 


Fig.  go. — Larva  of 
lucilia  macellaria:  X4. 
{Braun,  after  Conel.) 


Fig.  91. — Larva  of  musca 
votnitoria  {calliphora  vomi- 
toria):  below,  of  natural 
size;  above,  enlarged. 
(Leuckart.) 


Fig.  92. — Larva  of  derma- 
tobia  cyaniventris  ("Macaque 
worm:  to  left,  natural  size; 
to  right,  enlarged.  (Braun, 
after  Blanchard.) 


Fig.  93.  — Larva  of 
anthomyia  canicidaris,  en- 
larged. Rarely  found  in 
the  stool.     {Gould.) 


In  the  tropics  the  macaque  or  moyaquil  worm,  the  larva  of  a  derma- 
tobia,  is  not  uncommon.  More  rarely  dipterous  larvae  are  found  in  the 
feces,  including  those  of  the  common  house-fly  and  the  trichomyza  fusca, 
which  has  also  been  vomited. 


244  INFECTIOUS  DISEASES 


GONOCOCCUS  INFECTION. 

Experience  shows  that  the  gonorrheal  infection  is  no  less  harmful  and 
\videspread  in  its  effects  than  syphilis.  These  effects  include  the  primary 
infection,  ophthalmia  and  gonorrheal  arthritis,  the  majority  of  inflam- 
matory pelvic  troubles  in  women  that  make  life  a  martyrdom  and  child- 
bearing  an  impossibility.  The  explanation  of  this  appears  to  lie  in  the 
fact  that  a  urethral  discharge  continues  to  be  infectious  long  after  it  has 
lost  its  purulent  character,  and  the  only  test  of  recovery  from  gonorrheal 
infection  is  a  bacteriological  one.  This  is  a  startling  statement,  but  should 
be  proclaimed  from  the  housetops  if  it  will  have  any  influence  in  prevent- 
ing infected  men  from  infecting  innocent  women  whom  they  have  married 
under  the  impression  that  they  are  free  from  disease. 

These  ills  which  have  been  referred  to  are  largely  surgical  and  do  not 
concern  us  as  physicians,  for  medical  treatment  is  generally  unavailing. 

GoNOcoccus  Septicemia. 

This  is  a  true  generalized  infection  with  the  gonococcus,  and  has  all  the 
characteristics  of  streptococcic  septicemia.  Thayer  and  Bloomer,  however, 
cultivated  the  gonococcus  from  the  blood  in  Osier's  wards,  and  the  cases 
have  been  thoroughly  studied  by  Cole  since  that  time.  The  mortality, 
however,  does  not  seem  to  be  so  high  as  the  mortality  from  streptococcic 
septicemia.  Sometimes  there  is  an  actual  endocarditis  complicating  the 
conditions,  and  aU  of  the  cases  are  not  fatal.  Sometimes  there  is  local  sup- 
puration with  the  features  of  pyemia;  sometimes  there  is  a  long-continued 
fever  without  any  local  manifestations.  At  other  times  there  is  a  purpural 
septicemia  due  to  gonococci.  Twelve  out  of  twenty-nine  cases,  reported  by 
Cole,  died.  It  would  thus  seem  as  before  stated,  that  the  mortality  is  not 
so  great  as  in  streptococemia. 

Gonococcus  Arthritis. 

Definition. — Gonorrheal  arthritis  is  a  septic  arthritis  due  to  the  gono- 
coccus. 

Morbid  Anatomy  and  Pathology. — The  exudation  into  the  joint  cavity  is 
rarely  purulent.  The  periarthritic  tissues,  including  the  sheaths  of  tendons, 
are  invaded  by  the  exudate,  and  pus  has  been  found  in  these  sheaths. 
There  may  be  not  only  change  in  the  shape,  but  impairment  also  in  the 
motilit}^  of  the  joints.     They  may  become  stiff  and  swollen. 

Usually  arthritis  appears  from  six  to  ten  days  after  the  discharge  is  seen. 
It  may  appear,  however,  much  later — as  much  as  four  or  five  months  or 
even  a  year  after  the  discharge  sets  in,  or  during  a  chronic  gleet.  A  latelj' 
married  woman  may  be  infected  by  a  husband  who  has  gleet,  indeed,  as 
has  been  mentioned,  after  aU  visible  objective  signs  of  gonorrhea  have  dis- 
appeared from  him,  though  a  bacterial  examination  may  discover  the 
gonococcus.  There  seems  to  be  no  relation  between  the  severity  of  the 
symptoms  and  that  of  the  original  disease.     The  discharge,  if  present,  gen- 


GONOCOCCUS  INFECTION  245 

erally  continues  \vith  the  onset  of  the  joint  symptoms,  although  it  often 
abates,  and  may  even  cease  altogether  for  a  time.  It  maj'-  even  recur  with 
the  disappearance  of  the  joint  symptoms. 

Gerhardt  found  that  out  of  928  cases  of  arthritis  7.43  per  cent,  were 
gonorrheal,  while  Gricolle  found  that  out  of  4423  cases  of  gonorrhea  16  per 
cent,  developed  arthritis. 

Symptoms.— A  study  of  these  admits  a  classification  as  made  by  R.  P. 
Howard,  of  Montreal,  into  seven  subdivisions: 

1.  The  purely  arthralgic  form,  i.  e.,  cases  characterized  by  pain,  but 
not  much  other  evidence  of  local  inflammation.  Fever  is  also  absent, 
although  the  condition  is  apt  to  be  polyarthritic,  wandering  from  joint  to 
joint.  t 

2.  Gohorrneal  Polyarthritis,  resembling  verj^  closely  acute  inflammaton.- 
rheumatism.  In  this  division  fever  is  added  to  the  local  symptoms  of 
rheumatism.  The  fever,  however,  is  less  severe  than  would  be  expected 
from  the  severity  of  other  symptoms.  The  maximum  temperature  may  be 
102°  F.  (39°  C),  more  frequently  it  is  less  than  this. 

3.  Acute  gonorrheal  nwnarthritis,  in  which  one  joint  only  is  involved, 
with  severe  pain  and  swelling  and  moderate  fever.  It  is  the  knee-joint 
that  is  most  commonly  attacked  ia  this  monarthritic  variety.  Next  in 
order  follow  the  ankle,  shoulder,  elbow,  and  wrist;  any  one  of  these  is  liable 
to  be  the  seat  of  the  trouble.     Suppuration  is  rare. 

4.  Chronic  gonorrheal  arthritis,  without  or  with  effusion  (chronic  hydro- 
arthrosis).  Suppuration,  though  rare,  does  take  place  and  pus  is  found  in 
the  joint  cavity.  In  these  cases,  too,  there  is  generally  slight  elevation  of 
temperature. 

5.  The  periarthritic  variety,  including  cases  in  which  the  periarthritic 
tissues  are  involved,  including  the  capsule,  ligaments,  tendons,  and  adjacent 
fibrous  structures.  The  periostetmi  is  included  among  these,  but  the  joint 
cavity  itself  is  not  affected. 

6.  A  variety  which  invades  fibrous  tissue  not  connected  mith  joints,  as 
the  plantar  fascia,  the  sclerotic  coat  of  the  eye  and  iris,  the  pericardium  and 
endocardium. 

7.  The  septicemic  form,  where,  in  addition  to  the  arthritis,  there  is 
general  sepsis  and  endocarditis.  In  this  event  there  are  the  usual  signs  of 
blood  invasion,  high  fever  with  or  without  chills,  and  sweats. 

Complications. — Isolated  and  even  miiltiple  cases  of  endocarditis 
associated  with  gonorrheal  arthritis  have  been  reported  by  German  and 
French  physicians  during  the  past.  The  studies  of  Gluzinski  (1888)  and 
R.  L.  MacDonnelH  (1891)  have  settled  the  question  in  favor  of  a  causal 
relation,  the  latter  having  foiind  endocarditis  present  in  four  out  of  27  cases 
of  gonorrheal  arthritis,  while  Gluzinski  collected  3 1  cases.  They  may  reason- 
ably be  attributed  to  the  action  of  the  microorganisms  on  the  valves. 
Malignant  endocarditis  may  be  thus  caused. 

Pericarditis  and  pleiuisy  similarly  caused  may  complicate  the  disease, 
as  may  also  iritis  and  sclerotitis. 

Diagnosis. — This  depends  chiefly  on  the  history  of  infection. 


"Gonorrheal  Rheumatism,"  "Am.  Jour,  of  the  Med.  Sci.,"  January,  l8 


24()  INFECTIOUS  DISEASES 

Prognosis. — The  disease  is  difficult  to  cure  at  times  and  prolonged 

treatment  is  necessary. 

Treatment. — This  is  not  always  satisfactor>^  The  primary  urethritis 
must  first  be  attended  to.  The  salicylates  frequently  relieve  the  pain 
but  have  no  effect  on  the  morbid  process.  lodid  of  potassium  is  perhaps 
the  drug  most  commonly  found  useful,  and  its  effect  is  increased  when 
combined  with  the  bichlorid  of  mercury.  It  must,  however,  be  associated 
with  rest  and  local  treatment.  Every  gonorrheal  joint  should  be  fixed  in 
a  comfortable  position  by  a  properly  applied'  splint.  Often  active  surgical 
interference  is  necessar\\  A  surgeon  should  be  consulted  in  regard  to  the 
special  form  of  local  treatment.  General  treatment  by  tonics  and  good 
food  may  also  be  necessary.  In  sheeted  cases  gonococcic  vaccine  or  serum 
may  be  tried,  though  its  use  has  not  been  followed  by  the  success  anticipated. 

RHEUMATIC  FEVER. 

Synonyms. — Acute    Rheumatism;    Acute    Articular    Rheumatism;    Inflam- 
matory Rheumatism. 

Definition. — An  acute  febrile,  infectious,  but  noncontagious  fever, 
characterized  by  arthritis,  usually  multiple. 

Etiology. — While  no  distinctive  bacterium  has  as  yet  been  isolated, 
Hermann  Sahli  found  in  inflamed  joints  in  which  there  was  no  suppuration 
a  bacterium  closely  resembling  the  staphylococcus  ciireus,  and  Leyden  a 
diplococcus  differing  from  that  of  pneumonia.  F.  J.  Poynton  and  F.  A. 
Paine  with  the  diplococcus  isolated  from  rheumatic  fever  have  obtained 
in  rabbits  results  which  go  to  show  that  the  organism  with  which  the_v 
experimented  is  able  to  produce  lesions  of  rheumatic  fever,  namely,  mitral 
valvulitis,  pericarditis,  and  polyarthritis.  The  diplococcus  experimented 
with  was  obtained  from  the  joints,  from  the  throat  in  a  case  of  rheumatic 
angina,  from  the  bladder,  and  after  death  from  the  morbid  product  of  rheu- 
matic pericarditis  and  endocarditis.  Again,  by  injecting  a  young  rabbit 
with  the  organisms  from  the  blood  and  cerebrospinal  fluid  of  the  infected 
rabbit  they  also  produced  polyarthritis  and  endocarditis  in  the  second 
animal.  Some  of  the  animals  recovered  and  others  perished.  In  addition 
to  the  symptoms  mentioned,  there  were  wasting  and  involuntary  clonic 
movements  like  those  of  chorea  and  the  animal  was  also  very  nervous.  With 
the  chorea  there  was  valvulitis.'  In  another  instance  the  micrococcus 
lanceolatus  was  found.  In  view  of  the  fact  that  several  organisms  have  been 
found  associated  with  rheumatic  polyarthritis  it  may  be  true,  as  Flexner 
and  Barker-  suggested,  that  acute  articular  rheumatism  has  no  etiological 
unity,  but  maj'  be  brought  about  by  the  entrance  into  the  blood  of  one  of 
several  different  pyogenic  organisms  under  circumstances  incompatible 
with  the  development  of  the  phenomena  of  a  general  septicemia,  but  which 
may  give  rise  to  an  inflammation  of  one  of  the  several  serous  membranes, 
including  the  synovial,  as  well  as  the  meninges,  pleura,  pericardium,  or 
endocardium. 

Among  sources  of  infection  always  to  be  thought  of  are  suppurative 

'  Communication  to  the  PatholOKical  Society  of  London,  Tuesday,  October  l6.  1900;  published  in  the 
"British  Med.  Jour.."  October  20.  1901. 
=  "Am.  Jour.  Med.  Sci.."  1894. 


RHEUMATIC  FEVER  247 

affections  of  the  mouth  cavity,  such  as  tonsillar  abscess,  follicular  tonsillitis, 
carious  teeth  and  the  stumps  of  roots  of  teeth.  The  studies  of  Goodale,' 
Geo.  B.  Wood,^  Gurcih,'''  Isac  Adler,^  among  others,  go  to  show  that  the 
tonsils  are  the  route  of  many  general  infections,  of  which  rheumatic  fever 
is  the  most  common.  In  all  cases  of  articular  rheimiatism  the  mouth 
should,  therefore,  be  examined,  and  if  lesions  of  the  tonsils  or  adjacent  parts 
are  found,  they  should  be  treated  and  cured. 

A  predisposing  cause  seems,  however,  to  be  necessary  in  the  majority 
of  cases,  and  exposure  to  cold  is  the  most  common,  although  epidemics  of 
acute  rheumatism  occur  quite  independently  of  such  exposure.  While  sud- 
den changes  in  temperature,  also,  often  afford  the  needed  conditions,  the 
continued  action  of  moderate  degrees  of  cold,  especially  when  accompanied 
by  moisture,  is  almost  as  frequently  responsible.  If  to  these  be  added  a 
lowered  vitality  due  to  insufficient  food,  fatigue,  overwork,  or  all  these  com- 
bined, we  include  the  majority  of  predisposing  causes.  The  winter  and 
spring,  being  the  seasons  in  which  the  conditions  of  temperature  and  mois- 
ture operate  most  strongly,  are  those  in  which  the  disease  is  most  prevalent. 
For  a  like  reason  it  is  more  common  in  the  temperate  zones,  the  extreme 
North  as  well  as  the  extreme  South  being  for  the  most  part  exempt.  It  is  a 
disease  especially  of  young  adults,  being  rare  before  fifteen  and  after  fifty; 
while  the  exposing  occupations,  including  those  of  driver,  servant,  and 
laborer,  favor  its  development. 

Morbid  Anatomy. — There  is  little  to  be  added  to  what  will  be  described 
in  treating  of  symptoms,  and  to  what  is  furnished  b}^  the  complications, 
whose  morbid  anatomy  will  also  be  considered  in  connection  with  the 
diseases  that  constitute  them.  The  synovial  membrane  is  hyperemic  and 
swollen,  and  in  some  cases  the  fluid  in  the  joints  is  increased,  is  turbid,  and 
contains  flakes  of  lymph,  rarely  pus.  The  fibrin  of  the  blood  is  usually 
increased. 

Symptoms. — While  rheumatic  fever  is  seldom  ushered  in  by  a  chill, 
there  is  more  frequently  a  short  prodrome  of  a  day  or  two,  during  which  the 
patient  feels  uncomfortable  or  has  an  unpleasant  aching  feeling  in  his  joints. 
More  often,  however,  the  painful  arthritis,  which  is  the  first  symptom  to 
attract  attention,  develops  rapidly,  coming  on  in  a  single  day  or  night,  or 
seemingly  in  a  much  shorter  time,  making  locomotion  at  once  difficult  or 
impossible. 

The  joint  affection  has  some  peculiarities.  In  the  first  place,  the 
involvement  is  almost  always  multiple,  and  generally  includes  the  larger 
joints,  such  as  the  knee,  ankle,  elbow,  wrist,  shoulder,  and  hip,  although 
none  are  exempt,  and  the  phalangeal  and  metacarpophalangeal  articula- 
tions also  suffer.  The  toe-joints  escape  most  frequently.  It  rarely  happens 
that  a  single  joint  is  involved,  but  its  occasional  occurrence  must  be  ad- 
mitted. More  rarely,  if  ever,  does  it  happen  that  all  are  affected,  although 
even  the  vertebrsl  articulations  are  sometimes  invaded.  The  inflammation 
is  further  characterized  by  a  tendency  to  involve  various  joints  in  succession. 

1  Goodale,  "  Archiv  for  Laryngologie,"  vii,  I. 

2  Wood,  The  functions  of  the   Tonsils,  "University  of  Pennsylvania  Medical  Bulletin,"  1904. 

3  Gurich,  "Der  Gelenkrheumatismus,  sein  tonsilarer  Ursprung  and  seine  tonsilare  Heilung,"  Breslau, 
igos,  aus  "  Verhandlungen  des  Congresses  fur  innere  Medicin,  190,";. 

*  Adler  remarks  on  some  General  Infections  through  the  Tonsil,  "  New  York  Medical  Journal."  March, 
I905. 


248  INFECTIOUS  DISEASES 

Now  it  will  be  the  elbow,  then  the  wrist ;  again,  the  knee,  and  then  the  ankle 
or  shovdder  or  hip,  either  on  the  same  side  or  the  other;  but  while  there  will 
be  a  reduction  in  the  degree  of  inflammation,  and  correspondingly  of  pain 
in  the  relieved  joints,  the  relief  will  not  be  total.  On  another  day,  again, 
the  pain  wtII  have  returned  to  the  joint  which  had  been  temporarily  relieved. 

While  the  joint-affection  always  includes  a  synovitis,  the  process  is  by 
no  means  confined  to  the  synovial  membrane.  The  whole  joint  is  red, 
swoUen  and  tender.  The  adjacent  tissues,  including  the  capsular  and 
lateral  ligaments,  and  the  tendons,  with  their  sheaths,  coursing  over  the 
joint,  and  even  muscles,  are  all  the  seat  of  involvement,  contributing  to 
the  swelling  and  to  the  pain  by  the  exudation  pervading  them.  Comparing 
two  hands,  one  of  which  is  involved  and  the  other  not,  the  normal  depres- 
sions between  the  metacarpal  bones  in  the  former  may  be  obliterated  by 
swelling,  while  they  remain  distinct  in  the  latter.  It  is  for  such  reasons 
that  we  prefer  the  name  acute  rheumatism  to  that  of  acute  articular  rheu- 
matism, which  would  limit  the  process  to  the  joints.  Rheumatic  fever  is 
probably  the  best  term. 

Finally,  mention  should  not  be  omitted  of  the  nonarticular  rheumatic 
fever  to  which  Kohler'  has  called  attention,  in  which  there  are  no  joint- 
symptoms. 

The  pain  is  almost  always  extremely  severe,  making  all  motion  an 
agony,  while  jarring  of  the  bed,  or  even  the  weight  of  bed  clothing,  may 
cause  the  patient  to  cry  out.  To  diminish  the  tension,  which  aggravates 
the  pain,  the  patient  is  disposed  to  lie  with  aU  the  limbs  semiflexed. 

From  the  beginning  there  is  fever,  but  being  seldom  high  at  this  stage, 
it  is  not  commonl}^  the  first  symptom  to  attract  attention.  Later,  it  usually 
increases  proportionately  to  the  extent  of  joint  involvement,  but  only  in  the 
meningeal  forms  is  it  extremely  high.  Nor  does  it  pursue  a  course  at  all 
distinctive.  In  one  case,  for  example,  the  temperature  remained  at  102°  F. 
(38.8°  C.)  and  a  fraction,  night  and  morning  and  throughout  the  day  for  a 
number  of  days.  More  rarely  it  rises  to  104°  F.  (39.9°  C).  Occasionally, 
however,  there  is  intense  hyperpyrexia,  when  the  temperatxire  rises  rapidly 
from  104°  to  110°  F.  (39.9°  C.  to  44.3°  C),  and  even  higher.  With  this 
are  associated  cerebral  symptoms  of  an  alarming  and  dangerous  kind,  intense 
headache,  and  delirium — symptoms  otherwise  rather  unusual  in  acute 
rheumatism.  To  these  are  often  added  unconsciousness,  pulselessness,  and 
cyanosis,  rapidly  followed  b}'  death,  unless  the  temperature  is  promptly  re- 
duced. The  sudden  onset  of  these  symptoms  adds  to  their  alarming  char- 
acter. This  combination  of  severe  symptoms  is  known  as  the  meningeal 
form  of  rheumatism. 

The  pulse  in  rheumatic  fever  is  rapid,  often  disproportionately  so  to  the 
fever,  probably  because  of  the  nervous  demoralization  caused  by  the  acute 
suffering. 

Nex<  to  the  fever  and  joint-inflammation,  the  most  distinctive  symp- 
tom of  acute  rheumatism  is  the  sweating,  which  is  copious  and  usually  acid 
in^reaction,  sometimes  even  to  such  an  extent  as  to  impart  an  acid  odor  to 
the  air  of  the  room.  Sudamina  are  a  frequent  consequence  of  such  profuse 
sweating. 

>  "Zeitschrift  f.  klin.  Med.,"  Bd.  xix,  1891.' 


RHEUMATIC  FEVER  249 

Discolorations  of  the  skin,  varying  in  intensity  and  character,  make  their 
appearance  in  certain  cases.  There  may  be  a  simple  diffuse  ery them'' ,  or  it 
may  be  papular  or  tuberculated  or  marginate.  There  may  be  true  urticaria, 
or  there  may  be  extravasations  of  blood,  purpuric  patches  of  such  extent 
and  depth  as  to  result  in  sloughing  of  the  tissues,  hemorrhages  from  the 
mucous  membranes,  and  hematima.  In  one  case  under  our  observation 
there  ensued  permanent  blindness  from  extravasation  into  the  retina. 
These  cases  of  peliosis  rheumatica  are  not  acknowledged  bj^  all  to  be  truly 
rheumatic,  the  joint-affection  being  declared  to  be  of  a  different  nature, 
analogous  to  that  of  scorbutus  and  hemophilia. 

The  urine  is  scanty,  of  high  specific  gravity',  verj-  acid  in  reaction,  and 
deposits  a  copious  sediment  of  pink-hued  mixed  urates. 

Subcutaneous  nodules,  attached  to  tendons  and  fascia,  which  have  long 
been  observed  as  occasional  events  in  connection  with  acute  rheumatism, 
and  have  been  especially  studied  by  Barlow  and  Warner.  They  var\'  in 
size  from  a  shot  to  that  of  a  pea,  and  may  be  numerous  or  but  few.  They 
occur  on  the  fingers,  hands  and  wrists,  elbows,  knees,  scapulae  spines  of 
the  vertebrae,  and  more  particular^  after  the  acuteness  has  passed  away. 
They  may  last  a  few  days  or  for  months,  and  are  more  common  in  children 
than  in  adults. 

Disposition  to  recurrence  must  be  mentioned  as  a  characteristic  feature 
of  acute  rheumatism.  Quite  rarely  does  a  person  who  has  had  one  attack 
escape  another,  and  it  is  these  successive  attacks  which,  augmenting  pre- 
vious cardiac  lesions,  finally  cripple  the  heart  until  its  work  is  greatl}'  ham- 
pered. The  intervals  between  successive  attacks  are  various — from  a  year 
to  four  or  five  j^ears — and  they  are  the  more  frequent  and  more  liable  to 
occur  the  younger  the  subject. 

Complications.  Pulmonary  Affections. — Both  pneumonia  and  pleurisy 
may  occur,  usually  as  the  result  of  an  extension  of  the  pericarditis,  or  from 
the  more  severe  cardiac  involvement — carditis. 

Cardiac  disease,  including  endocarditis  and  pericarditis,  carditis  and 
myorcarditis,  the  former  being  by  far  the  most  frequent,  and  confined 
almost  exclusively  to  the  left  leart.  Again,  the  mitral  leaflets  are  much 
more  frequently  attacked  than  the  aortic.  While  the  cardiac  involve- 
ment bears  some  relation  to  the  severity  of  the  disease,  the  mildest  cases 
may  become  complicated  as  well  as  the  severest.  Hence,  during  an  attack 
of  rheumatism  of  whatever  severity,  the  heart  should  be  daily  examined, 
a  further  reason  is  that  the  approach  of  the  cardiac  complication  is  often 
exceedingly  insidious.  Cardiac  oppression  and  palpitation  may  occur, 
however,  without  actual  structural  change,  and  even  a  fimctional  murmur 
may  be  present  in  acute  rheumatism,  and  this,  too,  not  only  at  the  base, 
but  also  at  the  apex  of  the  heart,  an  unusual  site  for  such  a  murmur. 

The  proportion  of  cases  in  which  cardiac  complications  occur,  though 
difficult  to  estimate,  is  not  less  than  25  to  33  per  cent,  for  endocarditis,  with 
10  per  cent,  more  for  pericarditis,  making  in  all  35  to  43  per  cent.,  while 
some  estimate  even  a  larger  proportion. ^  Young  subjects  are  more  vulner- 
able than  adults,  and  Fagge  mentions  an  interesting  difference  in  the  sexes 


^  De  Lancey  Rochester  in  a  paper  published  in  the  "Jour,  of  the  Am.  Med.  Assn.,"  December  15, 
X900.  says  60  per  cent,  for  endocarditis  and  10  per  cent,  for  pericarditis. 


250  INFECTIOUS  DISEASES 

after  adtilt  life,  which  is,  that  pericarditis  is  more  frequent  in  men  above 
25  than  in  women  of  the  same  age,  probably  because  at  this  age  men  work 
much  harder  than  women. 

The  variety  of  endocarditis  is  usually  the  verrucose,  or  warty — ulcera- 
tion, laceration  or  perforation  of  the  valve  flaps  being  very  rare.  The 
inalignant  form  of  endocarditis  does,  however,  occur.  WhUe  the  endo- 
cardial murmurs  in  the  endocarditis  of  acute  rheumatism  are  commonly 
soft,  the  pericardial  murmurs  are  often  loud,  rough,  and  rasping,  and  the 
vibration  resulting  from  the  friction  may  even  be  communicated  to  the  hand 
laid  upon  the  precordiim:!.  Both  conditions  may  result  in  complete  recover^', 
but  the  former  more  commonly  is  the  beginning  of  a  chronic  valvular  defect 
and  the  latter  may  result  in  adhesive  pericarditis. 

Carditis  may  occur  where  all  the  structures  of  the  heart  are  involved. 

Myocarditis  is  not  imcommon.  In  the  grave  cases  of  carditis  it  is  one  of 
the  must  serious  features. 

The  seqtielcB  directly  traceable  to  acute  rheumatism  are  also  few.  Chorea, 
acute  nephritis,  are  among  those  so  regarded.  The  nephritis  is,  perhaps, 
better  considered  a  complication  resulting  from  the  same  cause,  just  as  is  the 
endocarditis. 

Diagnosis. — The  diagnosis  of  acute  rheumatism  is  seldom  difficult,  the 
multiple  painful  involvement  of  the  joints,  the  fever,  and  sweating  seldom 
mean  anything  else;  but  pyemia  and  scarlatinal  and  gonorrheal  arthritis 
must  be  remembered  as  possible  events.  It  is  the  monarticular  variety 
which  demands  most  discrimination  in  its  determination.  Traumatic 
synovitis,  tuberculosis,  gonorrheal  infection,  and  the  so-called  nervous 
arthropathies  are  to  be  eliminated. 

It  is  not  always  easy  at  first  visit  to  distinguish  gout  from  acute  rheuma- 
tism, but  the  most  serious  possible  error  in  diagnosis  is  to  mistake  a  pyemic 
arthritis  for  a  rheumatic  arthritis.  This  is  not  an  uncommon  mistake  where 
there  is  no  evident  surgical  lesion  to  suggest  it.  Osteomyelitis  is  said  to  be 
the  most  common  cause  of  such  pyemias;  but  other  bone  diseases,  puerperal 
sepsis,  and  gonorrhea  are  also  causes. 

Acute  arthritis  deformans  frequently  begins  exactly  as  an  acute  rheumatic 
fever.  The  longer  course,  its  failure  to  react  to  salicylates  and  the  finalh' 
deformed  joints  make  the  diagnosis. 

Prognosis. — The  course  of  acute  rheumatism  is  characterized  by  many 
fluctuations  independent  of  treatment,  and  its  duration  is  various.  Sooner 
or  later  recovery  generally  takes  place,  although  it  may  be  with  a  crippled 
heart  and  a- susceptibility  to  return.  More  rarely  the  attack  passes  over 
into  a  subacute  condition  which  makes  the  patient  a  sufferer  for  a  long 
time. 

Subacute  Rheumatism. — This  term  is  applied  to  forms  in  which  aU  the 
symptoms  are  less  marked  and  more  prolonged.  The  fever  is  not  so  high, 
ranging  from  99°  to  101°  F.  (37.2°  to  38.3°  C).  The  inflammation  of  joints 
is  not  so  intense  and  the  joints  involved  are  less  numerous.  It  exhibits  the 
same  "flying"  tendency.  It  may  also  be  associated  with  cardiac  compli- 
cations, especially  in  children. 

Treatment. — Absolute  rest  in  bed.  and  fixation  of  the  aft'ected  joints 
are  of  prime  importance.     INIany  cases  are  prolonged  and  many  complica- 


RHEUMATIC  FEVER  251 

tions  occur  from  neglect  of  those  important  measures.  The  drug  which  is 
most  useful  is  salicylic  acid  or  one  of  its  preparations. 

Salicylic  acid  and  salicylate  of  sodium  are  equally  efRcient,  but  the 
former  has  been  largely  superseded  by  the  latter,  because  less  irritating 
and  easier  of  administration.  Still  better  borne  is  strontium  salicylate. 
Whichever  is  used,  there  is  one  necessary  condition  of  its  efficiency,  and 
that  is  its  constitutional  impression.  The  aim  in  the  administration  is,  of 
course,  to  relieve  the  patient,  but  this  effect  is  seldom  obtained  or,  if  obtained, 
is  of  fleeting  character,  until  the  peculiar  ringing  in  the  ears  is  secured.  To 
do  this  in  the  adult  1 1/2  to  2  drams  (5.8  to  7.7  gm.)  of  salicylic  acid  and  from 
2  to  3  drams  (7.7  to  11.6  gm.)  of  the  sodium  salicylate  in  the  first  24  hours 
are  required.  If  the  salicylic  acid  is  given,  it  should  be  in  capsules  or 
compressed  pills  containing  7  1/2  to  10  grains  (0.49  to  0.65  gm.)  every  two 
hours,  followed  by  a  little  water  or  milk.     This  drug  is  now  rarely  used. 

The  salicylate  of  sodium  may  be  given  in  doses  of  10  to  15  grains  (0.65 
to  I  gm.)  well  diluted  every  three  hours  or  oftener,  if  the  pain  be  severe, 
until  relief  comes,  after  which  it  should  be  kept  up  until  the  toxic  effect 
is  produced,  when  the  dose  should  be  diminished,  but  the  drug  continued; 
or  the  interval  may  also  be  prolonged.  The  doses  laid  down  may  be  pushed 
more  rapidly  if  the  suffering  is  extreme,  but  it  is  seldom  necessary-.  Under 
this  treatment  the  pain  fades  away,  the  swelling  diminishes,  and  the  anxious 
expression  of  the  patient  is  changed  to  one  of  comfort  in  from  24  to  48 
hours.  Those  who  object  to  the  salicylate  treatment  do  so  on  the  ground 
that  the  relief  is  not  permanent,  and  it  must  be  admitted  that  relapses  do 
occur;  however,  this  is  often  because  the  remedy  is  discontinued  too  soon. 
As  stated,  the  drug,  while  it  should  be  cut  down  wdth  the  appearance  of 
relief  and  toxic  effect,  must  be  continued  for  some  time  after  relief  is  obtained. 

We  shoidd  not,  however,  rely  wholly  upon  the  treatment  by  salicylates. 
Warmth  is  commonly  a  useful  adjuvant,  and  to  this  end  the  joints  and 
limbs  should  be  kept  surrounded  by  warm  flannels  or  carded  wool  or  cotton. 
The  patient  should,  further,  sleep  between  blankets  and  in  a  flannel  gown  so 
made  that  it  may  be  easily  removed,  with  split  sleeves  and  split  skirt, 
because  of  the  extreme  sensitiveness  of  the  sufferer.  The  bed,  if  possible, 
should  be  narrow  because  of  greater  convenience  in  handling.  The  joints 
should  be  surrounded  by  cotton  or  flannel  soaked  in  a  saturated  solution 
of  magnesium  sulphate  or  lead  water  and  laudanum,  both  these  applica- 
tions frequently  giving  much  comfort  to  the  patient. 

Sometimes  the  salicylates  are  not  tolerated  by  the  stomach,  even  in  the 
smallest  doses  likely  to  be  useful.  They  may  then  be  given  by  injection  as 
follows :  The  rectum  is  washed  out  with  warm  water,  and  after  a  short  rest, 
20  to  40  grains  (1.3  to  2.6  gm.)  or  more  of  sodium  salicylate  in  solution  are 
injected  well  up  into  the  bowel.  This  may  be  done  once  in  six  hours  with 
the  happiest  result,  as  I  can  attest  from  personal  experience.  If  larger  doses 
are  thus  given,  90  to  120  grains  (6  to  8  gm.)  being  recommended  by  some,  it 
is  well  to  guard  them  with  a  little  tincture  of  opium. 

But  the  salicylate  treatment  is  not  always  successful,  even  when  the  drug 
is  well  borne.  Then  the  oil  of  wintergreen,  which  contains  90  per  cent, 
of  salicylate  of  methyl,  may  be  tried,  in  doses  of  10  to  15  minims  (0.6  to  i  c.c.) 
every  two  hours,  in  capsules  or  in  emulsion.     Or  it  may  be  alternated  with 


252  INFECTIOUS  DISEASES 

the  salicylate,  if  it  be  a  question  of  tolerance  of  the  latter,  the  gaultheria  being 
usually  better  borne  for  a  time  by  the  stomach. 

Oil  of  gaultheria  is  also  used  locally,  at  times  with  excellent  results. 
It  may  be  used  as  an  embrocation  in  the  proportion  of  one  part  of  oil  of  gaul- 
theria to  two  parts  of  olive  oil.  More  usually  it  is  applied  to  the  affected  joint 
on  lint,  which  is  thoroughly  moistened  vnth.  the  oil,  wrapped  about  the  joint, 
and  surrounded  by  gutta-percha,  oiled  silk,  or  other  impermeable  covering 
to  prevent  evaporation.  This  is  further  prevented  by  bandaging  the  whole 
limb.  That  the  salicylate  of  methyl  is  thus  absorbed  is  seen  from  the  fact 
that  salicyluric  acid  appears  in  the  urine  a  few  days  later,  while  the  usual 
evidence  of  the  physiological  action  of  salicylates — viz.,  headache  or  fullness 
of  the  head  with  ringing  in  the  ears — takes  place.  In  view  of  the  gastric 
disturbances  which  the  salicylates  cause  in  some  persons,  this  mode  of  ad- 
ministration should  not  be  overlooked.  Salophen,  acetyl  salicylic  acid 
(aspirin)  and  phenol  salicylis  (salol),  may  be  substituted  for  the  salicylates 
when  the  latter  are  not  well  borne. 

The  alkaline  treatment  of  acute  rheumatism,  most  relied  upon  before  the 
salicylic  treatment  came  into  vogue,  is  a  treatment  which  is  by  no  means 
worthless.  This,  originally  instituted  by  Sir  A.  Garrod,  received  an 
additional  impulse  from  H.  W.  Fuller,  who  insisted  upon  the  administration 
of  such  doses  as  secured  and  maintained  an  alkaline  reaction  of  the  urine. 
This  is  accomplished  by  sufficient  doses  of  almost  any  of  the  alkaline  salts, 
as  potassium  citrate,  potassium  acetate,  sodium  carbonate,  or  liquor  potasses. 
Twenty  grains  (1.33  gm.)  every  two  hours  of  the  first  three  are  generally 
sufficient,  or  20  minims  (1.3  c.c.)  of  the  last.  The  dose  may  then  be  reduced, 
but  enough  should  be  given  to  maintain  the  allvalinity  of  the  urine. 

Failing  for  any  cause  in  the  treatment  •with  salicylic  acid,  the  alkaline 
treatment,  or  what  is  called  the  "mixed"  treatment,  may  be  employed.  By 
this  is  meant  the  combined  alternate  use  of  the  salicylates  and  alkaHes. 
This  may  be  tried,  for  example,  where  sufficient  doses  of  the  salicylates  are 
not  weU  borne  by  the  stomach,  when  they  may  be  supplemented  by  alkalies. 

For  relief  of  pain,  opium  or  its  derivatives  is  sometimes  necessarj^  but 
less  frequently  than  formerly.  Here,  again,  the  hypodermic  injection  of 
morphin,  1/4  grain  (0.016  gm.)  is  most  comforting,  but  sometimes  Dover's 
powder  in  10  grain  (0.6  gm.)  doses  acts  most  kindly.  Phenacetin,  acet- 
phenadin,  aspirin,  acidum,  acetj^  salicylates,  or  acetanilid,  may  be  used  for 
milder  degrees. 

The  treatment  of  the  hyperpyrexia  of  acute  rheumatism  must  be  prompt 
and  energetic,  as  the  danger  to  life  is  imminent,  the  extraordinarily  high 
temperatures  thus  encountered  being  ine\dtably  fatal  in  a  few  hours.  There 
is  but  one  treatment.  It  is  the  application  of  cold.  The  bath  is  to  be  pre- 
ferred, although  in  its  absence  affusions  of  ice-cold  water  and  rubbing  the 
head  and  body  with  ice  may  be  substituted.  As  soon  as  the  temperature 
begins  to  mount  rapidly  above  105°  F.  (40.3°  C.)  it  should  be  used,  and  if 
delirium  or  unconsciousness  is  associated  with  such  temperature,  its  need  is 
even  more  imperative.  When  time  permits,  the  application  of  cold  may  be 
more  gradual.  Thus  the  patient  may  be  put  in  the  bath  at  70°  F.  (21°  C.) 
and  the  temperature  further  reduced,  if  necessary,  by  the  addition  of  ice  or 
colder  water.     As  stated,  there  seems  now  to  be  no  doubt  about  the  necessity 


PNEUMONIA  253 

of  this  treatment.  Numerous  cases  of  recovery  have  been  reported,  some 
even  where  the  temperature  had  reached  107°,  108°,  and  even  109°  F.  (41.6°, 
42.2°,  42.7°  C).  With  the  reduction  of  temperature,  the  cerebral  symptoms 
gradually  disappear. 

As  the  disease  becomes  more  subacute  or  chronic,  the  necessity  for  more 
active  local  and  tonic  treatment  becomes  urgent.  It  would  seem  that  at 
such  a  stage  the  pathogenic  cause  has  exhausted  itself,  and  the  disease  has 
become  more  a  local  one,  maintained  by  the  dyscrasic  state  of  the  blood,  it- 
self brought  about  by  the  prolonged  suffering.  Hence  treatment  with  iron, 
arsenic,  and  nourishing  food  becomes  necessary.  Indeed,  the  patient  with 
acute  rheumatism  should  be  well  fed  throughout.  JMassage  is  especially 
valuable,  and  often  surprisingly  soothing  viltimately,  even  although  at 
first  somewhat  painful,  while  by  it  the  mobility  of  the  joints  may  be  gradu- 
ally restored.  There  results  sometimes  in  the  muscles  in  the  neighborhood 
of  the  joint,  and  especially  in  the  case  of  the  shoulder,  a  paretic  state, 
which  is  also  benefited  by  massage,  especially  when  associated  with 
electricity. 

When  a  case  runs  over  weeks,  the  focus  of  infection,  ear,  sinus,  tonsil, 
or  suppiu"ating  area  should  be  carefully  sought  for.  Excision  of  the  tonsils 
has  been  followed  by  the  cture  of  subacute  and  chronic  cases,  confirming 
the  fact  that  these  organs  may  be  a  route  of  infection. 

Diet  in  Rheimiatic  Fever. — The  diet  of  the  patient  wdth  rheumatic  fever 
should  be  simple  and  easily  assimilable,  but  nourishing.  While  there  is 
fever  the  food  should  be  liquid,  but  the  rule  of  conduct  should  be :  feed  well — 
do  not  starve. 

PNEUMONIA. 

CROUPOUS  PNEUMONIA. 

Synonyms. — Pneumonitis;   Lobar  Pneumonia;   Fibrinous  Pneumonia; 
Genuine  Pneumonia. 

Definition. — An  acute  infectious  disease  characterized  by  inflammation 
of  the  Itmgs  and  high  fever,  usually  terminating  by  crisis  in  from  five  to 
nine  days.  A  bacterium  especially  prone  to  occtir  in  pairs  or  chains, 
known  as  the  pnemnococcus,  diplococcus  pneumonicB  and  microccus  lanceolatus, 
is  found  in  75  per  cent,  of  all  cases  of  lobar  pneumonia  and  is  commonly 
regarded  as  its  cause. 

Varieties. — The  term  lobar  pneumonia  is  used  for  this  form  because  it 
generally  involves  at  least  a  single  lobe  or  the  greater  portion  of  one.  The 
term  pneumonia  of  the  apex  is  used  where  one  or  both  apices  of  the  lung  are 
involved.  A  rare  form  of  croupous  pneumonia  is  double  pneumonia  in  which 
both  lungs  are  involved,  though  not  necessarily  the  whole  of  each  lung.  A 
massive  pneumonia  is  an  inflammation  not  only  of  the  air-vesicles,  but  of 
the  bronchi  and  interstitial  tissue  of  a  lobe  or  even  of  the  whole  lung.  A 
creeping  or  migratory  pneumonia  afl:ects  successively  different  lobes  of  the 
lung.  Epidemic  pneumonia  invades  large  numbers  or  communities.  The 
term  larval  pneumonia  is  applied  to  a  form  of  the  disease  in  which  but  a 
partial  development  of  symptoms  occurs,  such  as  a  moderate  chill,  slight 


254  INF  EC  TIO  US  DISK.  1 SES 

fever,  and  imperfect  local  signs.  It  is  found  more  particularly  in  connec- 
tion with  epidemics  or  with  pneumonias  in  crowded  places,  as  ships,  camps, 
and  garrisons. 

Etiology. — The  diplococcus  of  Frankel,  to  which  the  name  Weichselbaum 
has  also  been  added,  is  the  true  pneumococcus.  It  occurs  in  pairs,  sometimes 
in  rows  or  beads.  It  is  also  pointed  at  one  end.  When  stained  by  the 
carbol  fuchsin  solution  the  occus  is  intensely  red,  while  the  capsule  assumes 
a  light  reddish  tint.  It  can  also  be  stained  by  Gram's  method.  It  thrives 
on  agar  and  in  bouillon,  but  not  on  gelatin.  It  is  probably  the  same  organ- 
ism as  that  found  by  Sternberg  in  rabbits  inoculated  with  his  own  saliva  in 
1880,  but  not  announced  until  April,  1881.  Pasteur  had  also  recognized  the 
same  organism  in  the  saliva  and  published  several  notes  on  the  same  subject, 
January  to  March,  1881.  The  coccus  occurs,  according  to  Netter,  in  20  per 
cent,  of  all  persons.  Frankel,  Talamon,  and  especially  Weichselbaum 
showed  the  relations  of  this  organism  to  pneumonia.  The  latter  found  it  in 
92  per  cent,  of  cases  of  croupous  pneumonia.  William  H.  Welch  found  it  in 
every  one  of  ten  cases  of  croupous  pneumonia  studied  at  the  Johns  Hopkins 
Hospital  at  Baltimore.  It  has  been  found  in  the  blood,  in  the  spleen  and 
kidney,  in  endocardial  vegetations,  in  the  spinal  fluid  as  well  as  in  the 
saliva  of  healthy  persons  and  in  the  dust  on  the  floors  of  houses.  Its  route 
of  entrance  is  probably  the  respiratory  passages,  since  it  has  been  found  in 
the  nose,  larynx  and  Eustachian  tube,  and  is  said  to  persist  for  months  and 
even  years  in  the  saliva  of  healthy  persons  who  have  had  pneumonia.  On 
the  other  hand,  it  is  a  very  perishable  organism,  maintaining  its  virulence 
outside  of  the  body  for  four  or  five  days  only. 

That  the  pneumococcus  of  Frankel  is  not  the  only  organism  capable  of 
producing  pneumonia  is,  however,  evident  from  the  experiments  of  Frankel 
himself,  of  Weichselbaiun,  and  of  Pansini  and  Neumann.  It  may  be  accom- 
panied by  pus  organisms  and  others  which  may  be  responsible  for  com- 
plications and  modifications  of  the  ordinary  pneumonic  process.  Strepto- 
coccus-pneumonia has  come  to  be  recognized  as  a  variety  of  pneumonia 
having  a  more  or  less  distinct  clinical  picture  that  will  be  again  referred  to. 

Pneumococci  have  been  found  in  cultures  from  the  blood  by  many 
observers,  but  by  no  means  uniformly  in  pneumonia.  The  presence  of 
pneumococci  in  the  blood  is  said  to  emphasize  gravity  of  prognosis,  con- 
stituting a  pneumococcic  septicemia. 

Nature  of  Pneumonia. — Thus  caused,  pneumonia  may  be  regarded 
as  a  general  disease  with  a  local  expression  in  the  lungs,  analogous  to  the 
inflammation  of  Peyer's  patches  in  typhoid  fever.  As  in  the  case  of  typhoid 
fever,  there  were  facts  which  pointed  to  the  infectious  nature  of  pneumonia 
long  before  the  discovery  of  any  organism  that  could  be  regarded  as  its 
specific  cause.  The  occurrence  of  pneumonia  in  epidemic  form  was  recog- 
nized by  Laennec  and  Grisolle,  and  since  their  day  innumerable  epidemics 
have  been  described — house  epidemics  including  those  in  which  a  number 
of  individuals,  from  three  to  ten  or  more,  have  been  attacked  under  the  same 
roof,  and  general  epidemics,  invading  institutions,  ships,  and  garrisons, 
in  which  large  numbers  of  persons  are  congregated.  Out  of  a  ship's  crew 
of  815,  410  were  attacked  in  rapid  succession,  and  out  of  720  attacked, 
298  perished. 


PNEUMONIA  255 

The  lowered  vitality  consequent  on  exposure  must  be  regarded  as  a 
predisposing  cause,  preparing  the  system  for  the  operation  of  the  ever- 
present  organism  as  the  exciting  cause.  Pneumonia  is  much  commoner 
in  the  winter  months.  Other  predisposing  causes  are:  a  previous  attack, 
fatigue  of  mind  or  body,  and  debilitating  conditions  of  all  kinds,  such  as 
previous  or  present  illness,  especially  a  chronic  complaint,  such  as  Bright' s 
disease.  Traumatism  is  certainly  a  cause.  Pneumonia  may  follow  a 
traumatism  without  actual  injury  to  the  lung  having  been  done. 

Morbid  Anatomy. — The  lung  in  croupous  pneumonia  exhibits  three 
distinct  stages: 

I.  Congestion  or  engorgement. 

3.  Red  hepatization. 

3.  Gray  hepatization. 

Pneumonia  seeks,  by  preference,  the  lower  lobes  of  the  lungs,  and  the 
right  lung  more  than  the  left.  Pneumonia  of  the  apex,  however,  not  infre- 
quently occurs,  more  often  in  children  than  in  adults. 

The  Stage  of  Congestion. — In  this  stage  the  lung  is  engorged  with  blood, 
yet  permeable  to  air.  The  capillaries  surrounding  the  air-vesicles  are 
turgid  and  intrude  upon  the  lumina  of  the  air-vesicles.  There  is  a  small 
amount  of  transudate,  in  which  may  be  found  a  few  exfoliated  alveolar  cells 
and  red  blood-disks.  The  part  of  the  lung  invaded  is  redder  than  normal 
and  heavier,  but  not  nearly  so  heavy  as  in  the  next  stage.  On  section,  blood 
transudes  from  the  cut  vessels  and  bathes  the  surface. 

The  Stage  of  Red  Hepatization. — In  this  the  lung  is  dark  red  in  color, 
hard,  and  very  much  heavier  than  in  health — as  much  as  three  and  four 
times  the  normal  weight.  A  piece  dropped  in  water  rapidlj^  falls  to  the 
bottom.  The  lung  pits  on  pressure,  and  in  consequence  the  marks  of  the 
ribs  are  often  seen  on  it  after  removal.  On  section  the  aptness  of  the  name 
red  hepatization  is  at  once  apparent.  The  surface  is  darker  in  color  than  in 
the  first  stage,  and  it  has  the  appearance  of  a  section  of  liver.  On  passing 
the  finger  over  it,  innumerable  little  hard  spots  like  grains  of  sand  are  felt. 
These  are  air-vesicles  filled  with  the  croupous  exudate.  Corresponding  to 
this,  a  granular  appearance  is  recognized  by  the  eye,  the  distended  air- 
vesicles  appearing  as  glistening  points.  By  scraping,  little  plugs  of  fibrin 
and  cellular  detritus  mixed  with  serum  can  be  removed.  The  lung,  though 
thus  hard,  is  nevertheless  friable,  and  may  be  broken  up  by  the  fingers. 

Histologically,  the  air-vesicles  are  found  to  contain  a  delicate  reticu- 
lum, the  meshes  of  which  are  filled  with  red  blood-disks,  and  with  alveolar 
cells  in  different  stages  of  degeneration,  including  numerous  granular  fatty 
cells  or  compound  granular  cells.  The  vesicular  walls  are  found  infiltrated 
with  lymphoid  cells,  which  extend  even  into  the  interlobtilar  tissue  beyond 
them.  Plugs  of  fibrin  may  sometimes  be  traced  into  the  smaller  bronchi 
from  the  air-vesicles. 

The  pneumococcus  may  be  demonstrated  in  cover-glass  preparations 
made  from  the  exudate.  It  may  be  associated  with  the  streptococcus  and 
staphylococcus' 

The  Stage  of  Gray  Hepatization. — This  is  also  well  named,  the  cut  lung 
exhibiting  a  grayish-white  coloration.  It  is  still  dense  and  heavy,  but  much 
moister  and  softer,  and  more  friable.     The  granulations  are  less  distinct. 


256  INFECTIOUS  DISEASES 

and  on  microscopic  examination  the  alveoli  are  found  filled  with  white  blood- 
corpuscles,  while  the  red  corpuscles  and  fibrin  filaments  have  disappeared. 
Sometimes  aU  three  stages  are  seen  alongside  of  one  another. 

A  stage  beyond  gray  hepatization  is  sometimes  spoken  of  as  a  stage  of 
purulent  infiltration.  In  this  stage  the  lung  has  assumed  a  more  j'ellowish 
appearance,  it  is  much  softer,  almost  liquid  in  consistence,  and  more  like  pus. 
On  minute  examination  the  air-vesicles  are  filled  with  pus-cells,  the  points  of 
greatest  softness  constituting  small  abscesses  as  large  as  a  pin's  head  and 
larger.  The  stage  of  gray  hepatization  is  the  stage  of  beginning  resolution, 
while  that  of  j^eUow  hepatization  represents  the  same  stage  in  which  the  pro- 
portion of  leukocytes  undergoing  fatty  degeneration  is  larger. 

If  recovery  takes  place  the  contents  of  the  air-vesicles  liquefy,  the 
product  being  mostly  absorbed. 

The  pleura  adjacent  to  the  inflamed  lung  is  almost  always  inflamed,  the 
most  distinctive  sign  of  this  being  a  plastic  deposit.  There  may  also  be 
.thickening  and  some  serous  effusion. 

After  death  from  pneumonia,  the  heart  is  found  in  a  pathological  con- 
dition typical  of  the  disease.  The  left  cavities  are  generally  found  empty 
or  nearly  so,  while  the  right  are  distended  with  firm  coagula,  which  often 
extend  into  the  branches  of  the  ptdmonary  artery.  The  spleen  is  often 
enlarged.  The  cells  lining  the  renal  tubes  are  often  found  in  a  state  of 
cloudy  swelling;  rarely  there  is  nephritis. 

Symptoms. — Perhaps  no  other  disease  except  malarial  fever  is  so  invari- 
ably ushered  in  by  a  chill  as  is  croupous  pneumonia,  and  often  a  chill  of  great 
severity.  It  may  come  on  at  night,  waking  the  patient  out  of  a  deep  sleep. 
It  may  or  may  not  be  preceded  by  a  day  or  two  of  prodromal  discomfort, 
with  headache,  which  may  be  very  severe.  Almost  immediately  there 
succeeds  a  high  fever,  in  which  the  temperatiore  rises  rapidly  to  from  103° 
to  105°  F.  (39.4°  to  40.5°  C).  A  significant ^M5/j  on  each  cheek  is  character- 
istic, occasionally  more  marked  on  the  affected  side.  The  pulse  is  full  and 
strong,  resisting  pressiu-e,  rate  100  to  120.  There  is  thirst,  and  the  urine  is 
scanty  and  high  colored,  sometimes  albuminous.  Equally  promptly  ensues 
a  pain  in  the  side,  which  may  be  dull,  but  is  often  also  sharp  and  severe, 
caused  in  the  latter  instance  by  involvement  of  the  pleura.  The  respirations 
rise  rapidly  in  frequency,  and  there  is  cough,  at  first  dry  and  hard.  It  is 
often  restrained  on  account  of  the  pain  it  occasions.  Soon  there  is  a  small 
amount  of  mucous  expectoration  from  the  coincident  bronchitis,  but  usually 
in  24  to  48  hours  after  the  chill  the  sputum  exhibits  distinctive  charac- 
teristics. It  is  tenacious,  light  red  in  hue — "rusty" — and  is  ejected 
from  the  mouth  with  difficulty.  At  other  times  it  is  much  thinner  and 
darker,  and  has  received  the  name  "prune-juice"  expectoration.  The 
amount  of  blood  and  the  degree  of  coloration  vary  greatly.  The  respirations 
are  exceedingly  rapid — 30,  40,  50.  60,  and  even  more  in  the  minute.  The 
appearance  of  a  patient  at  this  stage  is  verj^  striking.  The  face  is  flushed, 
the  eye  is  brilliant,  the  breathing  is  rapid,  the  alae  nasi  move  with  each 
breath,  while  a  frequent  short  cough,  held  back  until  irresistible,  increases 
at  times  the  already  anxious  expression  of  the  patient.  There  is  practically 
always  a  leukocytosis  the  white  cells  averaging  from  16,000  to  25,000  per 
millimeter. 


PNEUMONIA  257 

This  state  of  affairs  continues  unchanged  for  from  five  to  nine  days, 
when,  if  recovery  takes  place,  a  sudden  drop  in  the  temperature  occurs, 
accompanied  often  by  free  perspiration,  while  a  state  of  comparative  com- 
fort succeds  to  one  of  great  distress,  to  be  further  followed  oftentimes  by  a 
long  and  refreshing  sleep.  This  is  known  as  the  crisis.  It  may  be  preceded 
by  a  fall  of  temperature  a  day  or  two  earlier,  which  is  again  followed  by  a 
rise,  whence  such  fall  is  called  the  pseudo-crisis.  The  accompanying 
temperature  chart  (Fig.  94)  illustrates  the  actual  crisis.  The  fall  during 
crisis  is  sometimes  as  much  as  7°  F.  (12.6°  C.)  in  24  hours,  and  the  minimimi 
is  quite  often  slightly  subnormal,  whence  it  rises  rapidly  to  the  normal. 
Sometimes  the  fall  takes  from  two  to  four  daj's  when  the  case  ends 
by  lysis. 

From  this  point  onward  convalescence  is  rapid,  and  in  four  or  five  days 
more  the  patient  is  seemingly  well,  the  temperatiu-e  and  pulse-rate  normal, 
the  breathing  natural.  A  muscular  weakness  and  vulnerability,  however, 
reihain,  which  demand  care  for  a  long  time. 

Physical  Signs. — The  phj^sical  signs  of  a  tj'pical  pneumonia  are  very 
distinctive. 

The  first,  or  stage  of  congestion,  in  which  the  air-vesicles  are  stiU  open, 
is  of  short  duration,  terminating  within  the  first  24  hours,  and  may  there- 
fore be  overlooked.  Inspection  shows  the  face  flushed,  increased  fre- 
quency of  respiration,  with  restricted  movement  upon  the  affected  side  and 
increased  excursion  of  motion  on  the  sound  side.  The  patient  lies  b}' 
preference  on  the  affected  side  because  of  the  greater  comfort  it  gives  him. 
This  posture  not  onlj^  diminishes  the  pain  by  hindering  the  motion  of  the 
affected  side,  but  also  lessens  the  dyspnea  by  permitting  unrestrained  ex- 
pansion of  the  side  that  is  doing  the  work. 

Palpation  at  first  may  even  find  vocal  fremitus  diminished  on  account 
of  the  relaxation  of  the  air-vesicles,  but  it  becomes  decidedly  increased  as 
the  latter  fill  up.  The  skin  is  hot  and  the  pulse  is  frequent,  full  and  strong, 
as  a  rule.  Percussion  obtains  but  sHght,  if  any,  impairment  of  resonance. 
In  fact,  tympany,  or  the  vesiculo-tympany  of  Flint — Skoda's  resonance — 
may  be  present  in  this  stage  as  a  result  of  the  relaxation  of  the  partially 
filled  air-vesicles,  giving  resonance  by  immediate  relaxation.  In  the  latter 
part  of  the  first  stage  there  is,  however,  impairment  of  resonance. 

Auscultation  in  the  very  earliest  stage  may  find  the  vesicular  murmur 
feeble  and  less  well  heard  over  the  affected  arc  a,  but  very  soon  is  heard  the 
distinctive  physical  sign  of  the  first  stage  of  pneumonia,  the  crepitant  rale 
at  the  end  of  inspiration.  If  there  be  coincident  pleurisy — the  closely 
simulating  friction  sound  may  be  added.  Under  such  circimistances  it 
may  be  difficult  to  distinguish  between  these  two  physical  signs.  Over 
the  normal  part  of  the  lung  there  is  exaggerated  vesicular  breathing. 

But  all  these  physical  signs,  even  if  carefully  sought  for,  may  be  want- 
ing if  the  pneumonia  be  central  and  deep-seated,  as  is  not  infrequently  the 
case.  They  appear  as  the  surface  is  approached,  or  they  may  not  be  recog- 
nized at  all  if  the  disease  remains  central. 

The  second  stage,  or  stage  of  red  hepatization  or  solidification,  lasting 
four  or  five  days,  fximishes  unmistakable  signs.  All  the  signs  revealed  to 
inspection  in  the  first  stage  are  intensified  in  the  second,  and  the  breathing 
17 


258 


INFECTIOUS  DISEASES 


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PNEUMONIA  259 

is  niarkedly  abdominal.  To  palpation,  vocal  fremitus  is  now  increased. 
Occasionally  the  fremitus  is  decreased  on  account  of  a  layer  of  liquid  or  a 
plugged  bronchus.  The  skin  is  hot  and  dry,  and  the  pulse  continues 
frequent.  Mensuration  almost  always  and  even  inspection  may  recognize 
an  enlargement  of  the  involved  side,  the  former  to  the  extent  of  0.5  to 
2.5  cm. 

Percussion  gives  dullness  over  the  solidified  area,  with  high  pitch  and 
short  duration,  except  in  those  very  rare  instances  where  the  extreme  con- 
solidation throws  the  column  of  air  in  the  trachea  and  bronci  into  vibration, 
producing  tympany.  Over  the  adjacent  normal  areas,  also,  resonance  is 
exaggerated,  not  so  much,  perhaps,  in  consequence  of  supplemental  fimction 
as  from  relaxation  of  the  adjacent  air-vesicles — Skoda's  resonance  by 
mediate  relaxation.  Even  cracked-pot  sound  may  be  produced  by  percus- 
sion over  the  solidified  lung  as  a  result  of  the  sudden  expulsion  of  air  from  a 
large  bronchus  leading  to  the  solidified  area. 

Auscultation  discerns  high-pitched  bronchial  breathing  over  the  solidi- 
fied lung.  Indeed,  these  are  the  circumstances  that  give  the  typical  bron- 
chial or  tubal  breathing.  The  air-vesicles  are  obliterated,  and  the  resulting 
excellent  conducting  medium  brings  the  tracheo-bronchial  blowing  to  the 
ear.  In  very  rare  instances,  when  the  larger  bronchi  are  filled  with  exudate, 
there  may  be  no  bronchial  breathing.  The  ausculted  voice  gives  us  typical 
bronchophony  and  occasionally  even  pectoriloquy,  as  well  as  whispering 
bronchophony  and  pectoriloquy.  The  heart-sounds  are  also  heard  with 
great  distinctness  over  the  consolidated  lung,  owing  to  the  improved  conduc- 
tion, while  the  sounds  of  a  concurrent  bronchitis  are  similarly  intensified. 
A  lingering  crepitant  rale  may  also  be  heard. 

The  third  stage,  or  stage  of  gray  hepatization  or  resolution,  occupies 
six  to  ten  days.  It  repeats  largely,  to  inspection,  palpation,  and  ausculta- 
tion, the  phenomena  of  the  first.  Resonance  continues  impaired  for  a 
variable  time,  the  lung  sometimes  clearing  up  in  a  couple  of  days,  at  others 
in  a  longer  time.  The  normal  manner  of  breathing  gradually  returns,  the 
temperatvue  of  the  skin  is  notably  less,  the  crepitant  rale  returns,  technically 
known  as  the  "crepitans  redux,"  and  is  finally  replaced  by  the  normal 
vesicular  breathing  sound,  by  which  time  the  dullness  has  disappeared. 

Croupous  pneumonia  may  rarely  terminate  in  abscess  or  gangrene;  in 
either  event  the  signs  of  the  second  stage  continue  and  the  temperature  does 
not  fall — in  a  word,  the  crisis  does  not  occvur.  No  changes  in  the  physical 
signs  take  place  as  a  rule,  and  it  is  rather  by  the  general  symptoms,  viz., 
the  failure  to  recover,  the  continued  high  temperature,  the  expectoration 
of  pus,  and,  in  the  case  of  gangrene,  the  intensely  disagreeable  odor,  that 
we  are  informed  of  the  issue.  The  termination  in  abscess  probably  repre- 
sents on  a  large  scale  what  takes  place  in  every  instance  in  minute  areas 
in  the  third  stage  of  all  pneumonias  which  terminate  favorably.  The  oc- 
casional termination  in  tubercular  phthisis  exhibits  a  similar  arrest  of  the 
resolving  process  in  the  second  stage,  and  the  phenomena  of  catarrhal  or 
fibroid  phthisis  supervene. 

The  obscuring  effect  of  a  thickened  pleura  upon  all  these  signs  is  to  be 
remembered,  and  too  much  stress  cannot  be  laid  upon  the  fact  that  we  may 
have  a  central  deep-seated  pneumonia  that  may  give  no  physicial  signs;  also 


260  INFECTIOUS  DISEASES 

that  in  old  persons  the  physical  signs  of  a  pneumonia  are  very  apt  to  be 
delayed  from  one  to  three  days. 

Carefiil  differential  percussion  and  palpation  may  recognize  a  moderate 
enlargement  of  the  spleen. 

The  heart  should  be  careftdly  watched  in  pneumonia.  The  sounds,  at 
first  loud  and  clear,  becomes  less  so  as  the  disease  progresses  and  the  lungs 
become  engorged.  The  ptdmonic  second  sound  is  particularly  sharp  as 
long  as  the  heart  is  strong,  and  its  failure  is  an  unfavorable  sign,  as  it 
means  that  the  right  ventricle  is  failing  in  power  and  may  be  yielding  to 
distention. 

Modifications  in  Symptoms  and  Special  Symptoms. — The  foregoing 
is  the  course  of  a  typical  case  of  pneumonia,  perhaps  of  three-fourths  of  all 
cases,  and  the  symptoms  mentioned  suffice  for  a  diagnosis.  All  of  them  are, 
however,  subject  to  modifications. 

Thus,  the  chill  may  be  absent  or  imperfectly  developed,  in  which  case 
all  the  symptoms  arise  more  gradually.  The  temperature ,  especially  in  old 
persons  and  drunkards,  may  not  be  nearly  so  high;  in  children  it  maj'  be 
higher.  The  same  is  true  of  the  respirations,  which  may  be  increased  to 
ICO  to  the  minute  in  children.  Pain  is  especially  absent  in  old  persons, 
cough  and  expectoration  also,  so  that  a  careful  physical  examination  of  the 
lungs  shotdd  be  made  in  all  ailments  in  the  old  and  in  drunkards  also,  as  it 
not  infrequently  happens  that  pneumonia  is  overlooked  in  them.  The  pulse 
is  often  feeble  and  rapid  instead  of  full  and  strong.  Nay,  more,  even  the 
physical  signs  may  be  absent  in  the  old,  and  they  are  especially  apt  to  be 
delayed  in  their  development.  It  is  unsafe  to  say  of  an  old  person  at  the 
first  visit,  after  a  negative  physical  examination,  that  he  has  not  pneumonia, 
for  the  physical  signs  may  not  make  their  appearance  until  the  second  or 
third  day  and  even  later.  It  would  seem,  too,  that  central  pneumonia  is 
more  common  in  the  old  than  in  the  j^oung,  while  even  an  afebrile  pneu- 
monia is  a  possibility  in  the  old.  Even  in  younger  persons  the  appearance 
of  physical  signs  is  sometimes  delayed  three  or  four  days. 

The  expectoration  varies  a  good  deal  when  present,  especially  as  to  the 
quantity  of  blood.  Sometimes  it  is  bright  red  and  quite  liquid,  almost  like 
a  hemorrhage.  More  frequently  it  is  viscid  and  glutinous,  simply  stained 
with  blood.  The  term  "prune-juice  expectoration"  has  long  been  associ- 
ated with  pneumonia,  and  sometimes,  when  it  is  thin  and  dark-hued,  the 
comparison  is  an  apt  one.  Under  the  microscope  the  sputum  is  found  to 
contain  blood-discs,  leukocytes,  and  alveolar  epithelium  in  various  stages 
of  degeneration,  including  numerous  compound  granule-cells,  also  ciliated 
epithelium.  Fibrinous  bronchial  coagula,  sometimes  large  enough  to  be 
seen  by  the  naked  eye,  are  also  met  with  in  the  expectoration,  and,  after 
suitable  staining,  diplococci.  Should  gangrene  supervene,  the  expectoration 
becomes  very  fetid. 

The  urine  is  especially  characterized  by  a  reduced  amount  of  chlorids, 
which  are  often  absent  until  the  crisis  is  passed,  when  they  reappear.  It 
is  supposed  that  diu-ing  this  period  they  are  transferred  to  the  exudate  in 
the  lungs.  A  trace  of  albumin  is  often  present  and  it  presents  the  other 
featiu^es  of  febrile  urine. 

There  is  sometimes  marked  jaundice.     It  may  even  be  the  first  sym.ptom. 


PNEUMONIA  261 

The  cases  attended  by  it  are  rather  more  serious.  Sometimes  the  jaundice 
is  of  catarrhal  type.  Frequently  it  is  due  to  a  hemolytic  action  of  the 
toxin  liberated. 

The  blood  exhibits  usually  a  leukocytosis,  the  number  of  corpuscles  being 
increased  from  6000  per  cubic  millimeter  to  ig,ooo,  or  more.  As  many  as 
68,000  have  been  found.  A  moderate  leukocytosis  is  regarded  as  a  favor- 
able symptom.  The  increase  is  almost  always  in  the  polymorphonuclear 
cells.  The  proportion  of  fibrin  is  also  increased  from  foxir  to  ten  parts  in 
1000.  This  increase  of  fibrin  shows  itself  also  on  the  microscopic  slide  in 
the  shape  of  filaments  of  fibrin.  According  to  Hayem,  the  blood-plaques 
are  increased. 

Herpes  is  very  common  on  the  lip — present,  it  is  said,  in  from  12  to  40 
per  cent,  of  all  cases.     It  may  occur  elsewhere,  as  on  the  nose  and  genitals. 

Phlegmasia  alba  dolens,  or  milk-leg,  is  a  rare  sequel.  J.  M.  DaCosta' 
collected  nine  cases,  of  which  three  were  his  own.  The  complication  occurs 
late  and  has  been  more  frequent  in  the  left  leg,  and  in  women.  W.  H. 
Welch,  W.  R.  Steiner,  Sears  and  Larrabee  and  D.  J.  Milton  Miller  have 
increased  the  cases  reported  to  48  up  to  1903.^  They  are  due  to  bacteria 
or  their  toxins  not  always  from  the  concurrent  pneumonia,  but  from  strep- 
tococcus and  other  cocci. 

When  typhoid  fever  coexists  with  croupous  pneumonia  the  tongue  is 
coated,  and  becomes  dry  and  leathery.  Constipation  is  usual,  but  occasion- 
ally there  is  diarrhea,  especially  in  epidemics.  Except  in  typhoid  cases 
delirium  is  not  common,  but  may  be  very  active  in  the  young.  In  old  per- 
sons it  may  be  low  and  muttering.  In  drunkards,  in  whom  the  disease  is 
common  and  very  grave,  especially  after  a  debauch,  the  delirium  may  be 
taken  for  mania  a  potu,  or  the  two  may  coexist.  Such  a  patient  may  rise 
from  his  bed  and  wander  out  into  the  city  or  to  another  hospital  that  he 
prefers,  having  just  intelligence  and  strength  enough  to  accomplish  this 
purpose  and  will  die  after  its  attainment. 

Streptococcus-pneumonia  has  been  mentioned,  with  the  statement  that 
it  presents  some  clinical  features  different  from  those  of  the  ordinary 
croupous  pneumonia,  at  least  at  times  recognizable.  We  must  say,  how- 
ever, that  we  have  never  been  able  to  recognize  such  pneumonia  by  these 
symptoms,  since  many  of  them  are  the  same  as  those  heretofore  regarded 
as  peculiar  to  bronchopneumonia  as  ordinarily  caused.  In  the  first  place, 
it  is  held  that  the  serious  form  of  pneumonia,  which  often  complicates 
influenza,  is  thought  to  be  a  streptococcus  pneumonia.  Such  pneumonias, 
like  bronchopneumonia,  commonly  begin  obsciurely,  are  atypical,  while 
the  local  signs  are  slow  to  develop.  The  rusty  expectoration  is  delayed; 
in  like  manner  the  crisis  which  may  be  substituted  by  lysis;  or  death  super- 
venes instead  of  crisis.  The  physical  signs  also  rather  resemble  those jof 
bronchopneumonia,  while  it  is  said'  that  the  disease  is  more  frequently 
found  in  the  upper  lobe,  not  at  its  apex,  but  in  its  lower  part  between  the 
inferior  angle  of  the  scaptda  and  the  axilla.  It  may  also  be  irregularly 
migratory.     The  sputum  may  be  mucopiirulent  at  the  outset,  and  is  always 

1  "Philadelphia  Med.  Jour.,"  vol.  ii.,  1898,  p.  sro. 

2  See  Miller's  paper  in  "  Philadelphia  Medical  Journal,"  May  16,  1903,  where  references  to  other  authors 
will  be  found.  ' 

3  G.  Baumgarten,  "Variations  in  the  Clinical  Course  of  Croupous  Pneumonia,"  "International  Clinics," 
vol.  ii.     Sixth  Series,  1896. 


262  INFECTIOUS  DISEASES 

less  conspicuously  red  or  rusty.  Like  bronchopneumonia,  it  is  also  insidious 
in  its  onset,  the  fever  is  irregular,  and  there  is  often  chilliness  or  actual 
rigor  with  sweats;  in  a  word,  septic  symptoms  are  prominent. 

Termination. — i.  When  the  pneimionia  terminates  favorably,  promptly 
after  the  crisis  is  passed,  it  is  said  to  terminate  by  resolution,  bj'  which  is 
meant  that  the  inflammatory  product  liquefies,  is  absorbed  or  expectorated, 
and  the  lung  resumes  its  natural  state  and  normal  physical  features.  The 
time  at  which  these  events  are  thoroughly  established  varies  greatly,  and 
if  there  happen  to  have  been  associated  plevuisy,  with  resulting  thickened 
membrane,  impairment  of  resonance  may  last  a  long  while.  On  the  other 
hand,  it  may  terminate  spontaneously  even  earlier  than  the  periods  named 
for  the  crisis.  In  such  event  the  pneumonia  is  said  to  abort.  This  promptly 
favorable  termination  does  not  always  take  place.  Resolution  may  be 
unduly  delayed  and  yet  ultimately  take  place.  Such  cases  natiirally  occa- 
sion anxiety,  for  resolution  may  not  take  place  at  all. 

2.  When  the  disease  terminates  unfavorably,  it  is  usually  by  one  of  five 
causes,  viz. : 

(a)  Death  from  cardiac  failure. 

(b)  Abscess. 

(c)  Gangrene  of  the  lung. 

(d)  Interstitial  or  fibroid  pneumonia. 

(e)  Tubercular  phthisis. 
(/)  Some  complication. 

(o)  Cardiac  failtu-e  may  be  due  to  overdistention  of  the  right  heart  or 
to  toxic  influence  on  the  cardiac  muscle. 

(b)  Abscess  of  the  lung  is  a  termination  of  pneumonia  in  about  four  per 
cent,  of  fatal  cases.  Flint,  Sr.,  found  it  in  four  out  of  133  cases  recorded. 
When  this  occurs,  the  interstitial  tissue  of  the  lungs  becomes  infiltrated  with 
pus  cells,  small  foci  of  leukocytes  aggregate  to  form  larger,  until  a  large 
abscess  results,  which  may  occupy  a  whole  lobe  or  even  a  whole  lung.  In 
such  cases  the  fever  continues  high,  there  is  expectoration  of  pus  containing 
elastic  tissue  of  the  lung,  and  the  physical  signs  of  a  cavity  may  rarely  be 
present.  It  is  not  impossible,  however,  for  such  a  process  to  be  arrested  by 
a  reactive  inflammation,  by  which  a  tough  protective  laj'^er  of  embr>'onic 
tissue  is  formed  about  the  abscess. 

(c)  Gangrene  of  the  lung  occurs  in  about  three  per  cent,  of  fatal  cases. 
It  is  especially  prone  to  occur  where  the  pulmonary  vessels  become  so  en- 
gorged that  the  circulation  is  arrested,  and  where,  as  a  consequence,  the 
hemorrhagic  element  is  conspicuous.  Bronchiectatic  ca\'ities  in  an  inflamed 
lobe  that  are  swarming  with  putrefactive  bacteria  are  an  important  predis- 
posing cause.  It  is  recognized  by  the  sickening  fetor,  which  per^^ades  a 
whole  ward,  and  which,  once  met,  is  never  forgotten.  The  expectoration 
is  thin  and  similarly  fetid,  and  contains  large  quantities  of  elastic  tissue  from 
the  Itmg.  The  lung  is  converted  into  a  gray-green,  fetid  pulp,  in  which 
cavities  mth  ragged  walls  arise,  from  disintegration  and  expectoration  of 
lung  tissue.  Gangrenous  portions  may  be  surrounded  by  a  zone  of  true 
inflammation,  contrasting  by  its  red  color  with  the  gray  of  the  gangrene. 
Such  sloughs  have  been  successfully  excavated  by  surgical  treatment. 

(d)  In  fibroid  induration  or  cirrhosis,  which  is  occasionally  met  with, 


PNEUMONIA  263 

there  is  also  invasion  of  interstitial  lung  tissue,  but  instead  of  being  infil- 
trated by  such  an  excess  of  leukocytes  as  to  produce  pus,  only  as  many 
wander  out  as  can  undergo  organization  and  conversion  into  permanent 
tissue.  Sometimes  this  results  from  the  lung  failing  to  expand  after  reso- 
lution and  absorption  of  the  exudate,  the  walls  of  the  unexpanded  alveoli 
collapsing  and  uniting.  In  other  cases  there  is  partial  absorption  of  the 
exudate,  repeated  infiltration  takes  place  into  the  alveolar  septa,  and  or- 
ganization takes  place  in  both.  The  fibrinous  plugs  may  also  be  trans- 
formed into  connective  tissue.  Three  successive  stages  may  be  present. 
In  the  first  the  cirrhotic  patches  are  gray,  grayish-red,  or  grayish-yellow, 
and  a  small  amount  of  turbid  exudate  can  be  here  and  there  squeezed  out  of 
them.  In  the  second  stage,  where  the  formation  of  the  fibrous  tissue  in  the 
alveoli  or  their  walls  has  set  in,  the  lung  is  dense,  firm,  airless,  and  fleshy, 
whence  the  term  carnification.  In  the  third  stage  the  fibroid  transformation 
is  complete;  the  tissue  is  tough  and  slate-gray  in  color.  Such  induration  is 
generally  in  bands  and  patches  that  merge  gradually  into  the  normal  ves- 
icular structure. 

(e)  Tuberculosis  of  the  lungs  is  another  termination  of  pneumonia.  It 
results  from  infection  by  the  tubercle  bacillus.  Pneumonia  of  the  apex 
terminates  thus  most  frequently. 

Complications. — The  most  frequent  complication  is  pleurisy.  It  is 
probably  always  present  to  a  certain  extent,  except  in  the  central  forms.  It 
manifests  itself  in  the  first  stage  more  by  the  characteristic  severe  cutting 
pain  than  by  physical  signs,  as  the  friction  sound  characteristic  of  that  stage 
is  commonly  obscured  by  the  physical  signs  of  the  pneumonia.  Should  the 
stage  of  effusion  be  reached,  the  physical  signs  of  the  pneumonia  are  ob- 
scured. Such  a  pleurisy  is  especially  apt  to  be  followed  by  an  empyema 
with  its  septic  fever.  This  empyema  is  very  frequently  interlobar  and 
confusing  in  its  physical  signs,  and  in  its  symptoms. 

Diagnosis  of  Empyema. — When  a  frank  case  of  pneumonia  has  a  crisis 
there  maj'  continue  for  two  or  three  days  very  slight  rises  of  temperature 
which  may  be  disregarded.  But  when  the  temperature  rises  decidedly, 
when  it  becomes  intermittent  in  character,  especially  with  an  increasing 
leukocytosis,  in  all  probability  there  is  a  focus  of  pus  somewhere  in  the  chest 
cavity.  This  must  be  carefully  searched  for  by  dail}'  physical  examination, 
by  the  use  of  the  :j;-ray  and  by  the  insertion  of  a  good  sized  exploring  needle. 
These  signs  may  be  due  to  tuberculosis  but  are  much  more  frequently  due 
to  an  interlobar  empyema.  If  the  pus  is  free  in  the  pleural  ca-\aty  the  con- 
dition can  be  easily  recognized  by  the  ordinary  signs  of  pleural  effusion. 
No  case  should  escape  constant  examination.  In  severe  cases  a  pleurisy 
may  surround  the  entire  lung  and  bind  it  to  the  chest-wall.  A  pneu- 
monia on  one  side  and  a  pleurisy  on  the  other  is  a  possibility.  That 
very  interesting  pathological  state  knoMm  as  pleurogenic  pneumonia  is 
sometimes  seen  in  the  human  being  as  a  form  of  tubercular  pleuris3^  In  it 
the  lung  becomes  partitioned  off  by  an  interstitial  framework  starting  from 
the  pleura.  It  has  its  typical  anatomical  product  in  the  pleuropneumonia 
of  cattle-     The  extension  takes  place  chiefly  by  way  of  the  lymphatics. 

Endocarditis  is  a  comparatively  frequent  complication.  William  Osier 
especially  called  attention  to  this  fact  in  his  Gulstonian  lectures  for  1885. 


264  INFECTIOUS  DISEASES 

He  ascertained  that  of  209  cases  of  malignant  endocarditis  54,  or  over  25 
per  cent.,  occurred  as  complications  of  pneumonia.  It  is  more  prone  to 
attack  persons  with  old  valvular  disease,  and  to  involve  the  left  heart. 
There  is  good  reason  to  believe  that  the  specific  lancet-shaped  bacillus  is 
responsible  for  this  form  of  valvulitis  as  a  complication  of  pneumonia.  The 
endocarditis  constantly  escapes  detection,  since  physical  signs  are  sometimes 
absent,  at  others  deceptive,  but  it  may  be  suspected: 

1.  When  the  fever  is  protracted  and  irregular. 

2.  When  signs  of  a  septic  condition  arise,  such  as  irregtdar  temperature 
with  chills  and  sweats. 

3.  When  embolic  pneumonia  develops. 

4.  When  a  loud,  rough  murmur,  especially  a  diastolic  aortic  murmur, 
develops  in  the  course  of  the  disease. 

Pericarditis  may  also  be  a  complication,  to  be  diagnosed  first  by  pericar- 
dial friction  sounds,  soon  to  be  replaced  by  signs  of  pericardial  effusion. 
The  exudate  may  be  purulent  or  serous. 

Meningitis  is  another  complication  to  which  Osier  has  called  especial 
attention,  finding  it  in  eight  per  cent,  of  fatal  cases.  It  usually  comes  on  at 
the  height  of  the  fever,  and  may  be  confounded  with  delirium.  Meningitis 
can  frequently  be  diagnosticated  by  spinal  puncture  the  pneumococcus  being 
found  in  the  spinal  fluid.  It  is  often  associated  with  endocarditis,  and  it 
may  be  accompanied  by  cerebral  embolism,  producing  hemiplegia.  Neuritis  is 
a  possible  complication. 

Parotitis  occasionally  occurs,  commonly  in  association  ■nath  endocarditis. 
In  children  middle-ear  disease  is  not  an  infrequent  complication. 

Any  of  the  above  cases  may  produce  a  postcritical  fever. 

Acute  dilatation  of  the  stomach  is  a  more  frequent  complication  than  has 
been  supposed.  1  It  is  usually  mistaken  for  obstruction  of  the  bowel.  It  is 
characterized  by  pain,  constipation,  abdominal  distention,  vomiting  of  large 
quantities  of  ill  smelling  material  and  collapse. 

Diagnosis. — The  diagnosis  of  a  case  of  typical  pneumonia  is  easy.  The 
chill,  the  rapidly  developed  fever,  the  physical  signs  and  early  leukocytosis 
are,  as  a  nde,  easily  recognized.  It  is  to  be  remembered,  however,  that  the 
physical  signs  may  be  delayed  or  not  appear  at  all  in  the  central  varieties. 

Pleurisy  is  the  disease  from  which  pneumonia  has  most  frequently  to  be 
distinguished.  The  resemblance  between  the  friction  sound  and  the  crep- 
itant rale  in  the  first  stage  is  often  very  close,  while  there  is  impaired  reso- 
nance to  percussion  in  both.  Most  valuable  in  diagnosis  is  vocal  tactile 
fremitus,  which  is  invariably  increased  in  pneumonia  and  as  invariably 
diminished  in  pleurisy  of  any  variety.  In  the  not  very  rare  instances  of 
pleurisy  with  effusion,  second  stage  of  pleurisy,  attended  by  bronchial  breath- 
ing and  bronchophony,  Bacclli's  sign,  tactile  fremitus  being  diminished, 
whereas  it  is  increased  in  pneumonia.  Commonly,  too,  in  this  stage  of 
pleurisy  \\4th  effusion  we  have  a  change  in  the  line  of  dullness  as  the  patient 
changes  position,  though  this  is  not  invariable.  Dislocation  of  the  heart 
and  other  organs  is  the  rule  in  pleural  effusion.  The  exploring  needle,  if 
needed,  may  also  help  settle  the  question. 

Frequent  examination  of  the  lungs  should  be  made  in  alcoholism,   in 

'  "Trans.  Assoc.  Amer.  Phys."  191 1, 


PNEUMONIA  265 

chronic  valvular  disease  of  the  heart,  in  diabetes,  and  in  Bright's  disease, 
since  all  these  affections  are  prone  to  become  complicated  with  insidious  forms 
of  pneumonia. 

Typhoid  fever  and  pneumonia  are  sometimes  confounded.  The  former 
is  apt  to  become  associated  with  hypostatic  congestion  of  the  lungs,  and 
pneumonia  with  a  typhoid  state.  The  hypostasis,  however,  occurs  late  in 
typhoid  fever;  the  dullness  in  pneumonia  sets  in  early.  In  typhoid  fever 
there  is  the  Widal  reaction,  and  usually  a  leukopenia,  in  pneumonia  there  is 
a  polymorphonuclear  leukocytosis.  Acute  tuberculosis  or  an  acute  ex- 
acerbation of  tuberculosis  may  begin  with  a  chill,  while  the  resemblance  to 
ordinary  pneumonia  is  otherwise  very  close,  especially  in  physical  signs. 
Microscopic  examination  of  the  sputum  should  recognize  the  bacilli  of  tuber- 
culosis. An  examination  of  the  sputum  should  be  frequently  repeated  when 
a  pneumonia  is  prolonged  beyond  two  weeks  without  a  crisis.  In  pneumonic 
phthisis  the  appearance  of  bacilli  is  generally  late.  It  must  be  remembered 
that  pneumonia  is  not  uncommon  in  tuberculosis. 

Appendicitis  and  lobar'  pneumonia  have  been  sometimes  confounded 
owing  to  the  production  of  certain  reflex  symptoms  including  pain  and 
rigidity  in  the  appendicial  region  reflected  through  the  lower  intercostal 
nerves.  Careful  examination  should  therefore  be  made  for  the  presence  of 
right  lobar  pneumonia  in  such  cases. 

Prognosis. — Pneumonia  is  a  treacherous  and  uncertain  disease  at  any 
age.  Young,  robust  men  of  25,  taken  mildly  ill  with  every  reasonable  ex- 
pectation of  recovery,  sometimes  die  suddenly  and  unexpectedly.  On  the 
other  hand,  while  in  the  old  and  intemperate  the  disease  is  especially  danger- 
ous, old  men  and  women  over  70  often  recover  completely.  The  intem- 
perate are  less  fortunate,  yet  even  among  them  some  surprising  recoveries 
are  observed.  The  mortality  ranges  from  20  to  40  per  cent.,  or  about  one  in 
four  or  five  die.  It  is  the  most  fatal  of  the  acute  infections  of  adults  in 
temperate  climates.  Children  recover  often,  even  when  desperately  ill. 
The  disease  seems  to  be  more  fatal  in  cities  than  in  the  country,  and  is 
certainly  so  during  epidemics,  or  in  ships  or  other  crowded  places. 

Terminations  in  the  cases  of  croupous  pneumonia  treated  at  the 
Pennsylvania  Hospital  in  five  years  prior  to  1907 : 

1902  254  cases  53  deaths  20.8%  mortality 

1903  328  cases  46  deaths  14-0%  mortality 

1904  249  cases  48  deaths  19-2%  mortality 

1905  282  cases  64  deaths  22.6%  mortality 

1906  238  cases  25  deaths  10.5%  mortality 

The  seriousness  of  an  attack  varies  more  or  less  with  the  extent  of  lung 
involved,  pneumonia  of  a  whole  lung  being  more  dangerous  than  that  of  a 
part,  double  pneumonia  more  than  that  affecting  one  lung,  while  massive 
pneimionias  are  always  fatal.  Meningitis  is  frequently  fatal,  but  its  presence 
must  not  be  inferred  from  every  violent  delirium.  Endocarditis  is  almost 
as  fatal.  Death  is  usually  by  heart  failure,  the  right  ventricle  becoming 
stretched  by  the  accumulated  blood,  and  the  valves  and  columnas  carneae 
embarrassed  by  fibrinous  coagula,  which  may  extend  from  auricle  to  ven- 


266  INFECTIOUS  DISEASES 

tricle  and  even  into  the  branches  of  the  pulmonary  artery.  Heart  failure 
may  be  caused  by  toxins  inherent  to  the  disease. 

A  high  leukocytosis  indicating  a  corresponding  phagocytic  power 
is  regarded  as  favorable  to"  recovery.  At  any  rate  in  cases  which  have 
taken  a  favorable  turn  a  leukocytosis  takes  place,  while  in  fatal  infections 
leukocytosis  and  presumably  phagocytosis  is  absent. 

Some  aid  to  prognosis  is  derived  from  a  study  of  the  blood  pressure. 
When  the  arterial  pressure  estimated  in  millimeters  of  mercury  does  not 
fall  below  the  pulse  rate  expressed  in  beats  per  minute  the  indications  are 
favorable;  while  if  the  blood  pressure  falls  below  the  pulse  rate,  it  is  unfavor- 
able (G.  A.  Gibson) .     The  same  general  truth  is  applicable  to  all  acute  fevers. 

Treatment. — The  tripod  upon  which  the  treatment  of  all  cases  of  pneu- 
monia must  be  based,  are  rest,  fresh  air  and  proper  food.  Beyond  these 
three  essentials  the  treatment  is  always  symptomatic.  Some  cases  need  no 
drugs,  others  need  drugs  and  other  measures  promptly  and  properly  applied. 

Rest  must  be  absolute  even  in  the  mildest  cases.  The  patient  must  use 
a  bed  pan  rising  neither  to  urinate  nor  to  defecate.  Food  must  be  taken 
with  the  patient  in  the  reclining  position.  This  absolute  rest  must  con- 
tinue several  days  after  convalescence  is  established. 

Fresh  air  means  all  the  words  implies ;  the  patient  is  best  on  a  protected 
porch  with  the  front  entirely  open.  If  this  cannot  be  obtained  then  all  the 
windows  in  the  room  must  be  raised  to  their  fullest  extent.  If  the  weather 
is  cold  the  patient  must  be  protected  by  abundant  warm  clothing,  a  cap  and 
woolen  socks  if  necessary,  and  hot  water  bottles  also. 

Food  may  be  of  any  character  that  can  be  taken  and  digested  by  the 
patient.  Milk  reenforced  by  cream  and  sugar  as  directed  for  typhoid  fever 
must  be  the  basis.  Care  of  the  mouth  is  important.  The  bowels  should  be 
moved  daily. 

These  essentials  must  be  carried  out  by  a  capable  trained  nurse.  If  this 
is  impracticable  the  patient  should  be  in  the  wards  of  a  good  hospital. 

Bleeding  from  an  arm  vein  in  the  beginning  of  certain  cases,  with  high 
blood  pressure,  a  full  bounding  pulse,  high  temperature  and  a  flushed  face 
sometimes  does  good.  The  same  results  may  be  accomplished  by  wet  cups, 
provided  a  sufficient  amount  of  blood  be  taken,  and  cupping  has  the  appear- 
ance of  being  less  formidable,  although  it  is  actually  more  painful  and  dis- 
turbing to  the  patient.  After  the  removal  of  the  cups  a  poultice  or  warm 
cotton  jacket  is  comforting.  If  doubt  is  entertained  as  to  the  propriety 
of  either  of  these  two  methods  of  bleeding,  the  affected  lung  may  be 
covered  with  dry-cups,  and  after  the  removal  of  these  the  hot  poidtice  or 
hot  jacket  applied.  Even  by  this  method  the  relief  to  the  pain  and  dyspnea 
is  often  very  great,  but  is  it  more  likely  to  be  temporary.  Dr\'-cupping 
may,  however,  be  repeated  daily,  if  it  affords  relief.  While  there  are  cases 
in  which  the  adynamia  is  so  great  as  to  make  blood-letting  in  any  form  of 
doubtful  propriety,  there  can  be  no  possible  objection  to  the  dry-cups. 

Bleeding  may  be  cautiously  done  in  the  second  period,  when  the  right 
heart  is  over-distended,  as  indicated  by  rapid  breathing  with  cyanosis  and 
laboring  pulse.  At  this  stage  the  removal  of  lo  to  i6  ounces  of  blood  is 
often  of  signal  ser\'ice. 

These  measures  may  also  relieve  the  cough,  but  usually  something  addi- 


PNEUMONIA  267 

tional  is  required.  Until  expectoration  sets  in,  opium  is  pre-eminently  the 
remedy,  and  no  preparation  is  so  good  as  morphin  in  doses  of  from  1/16  to 
1/12  grain  (0.004  to  0.005  g"^-)  for  adults  every  two  to  four  hours  in  1/2 
ounce  (15  CO.)  of  the  solution  of  citrate  of  potassium  flavored  with  lemon 
or  other  syrup.  Dover's  powder  sometimes  acts  admirably.  It  is  best 
given  in  pill  form  Commonly  in  2  1/2  or  5  grain  doses  (0.16  to  0.32  gm.). 
Hypodermics  of  morphin  are  essential  in  the  delirium  and  restlessness  which 
so  frequently  accompany  the  disease.  The  patient  should  not  be  strapped 
to  restrain  him,  he  should  be  given  rational  doses  of  morphin;  one-fourth  of 
a  grain  to  one-sixth  usually  being  sufficient.  Expectorants  are  rarely  needed 
at  the  outset,  but  ammonium  chlorid  in  doses  of  5  to  10  grains  (0.32  to  0.65 
gm.)  in  brown  mixture,  also  combined  with  morphin  if  necessary,  may  meet 
the  indications.  If  a  still  more  stimulating  expectorant  is  required,  the 
carbonate  of  ammonium  may  be  used  in  doses  of  5  to  10  grains  (0.32  to  0.65 
gm.)  frequently  repeated.  It  is  an  important  fact,  often  overlooked  in 
prescribing  diffusible  stimulants,  that  to  get  a  desired  effect  they  should 
be  frequently  repeated,  and  it  is  better  to  give  small  doses  often  than  large 
doses  at  longer  intervals. 

Alcohol  is  not  always  required.  The  indications  for  its  use  are  a  former 
alcoholic  habit  when  it  seems  absolutely  necessary,  and  a  running  feeble 
pulse,  but  here  it  must  be  given  as  directed  in  tj^phoid  fever  not  'in  large 
amounts,  but  sufficient  for  food,  not  more  than  a  tablespoonful  every  two 
hours.  The  index  of  sufficiency  or  the  reverse  is  the  state  of  the  pulse  and 
heart.  Whisky  or  brandy,  as  selected,  should  be  given  in  milk,  which  is 
the  most  suitable  nourishment.  From  4  to  8  ounces  (120  to  140  c.c.)  of 
milk  every  two  or  three  hours,  containing  the  proper  dose  of  alcohol  may 
be  given. 

Strychnin  is  an  invaluable  heart  tonic  in  pneumonia,  and  may  be  given 
in  doses  of  1/30  grain  (0.002  gm.)  or  more,  every  four  to  six  hours. 

Digitalis  is  a  remedy  much  used  in  pneumonia,  and  it  is  a  useful  drug, 
but  it  is  not  always  judiciously  used.  It  is  best  given  and  indicated  when 
the  heart  dilates  as  shown  by  falling  blood  pressure,  cyanosis,  rapid  heart. 
It  should  then  be  given  in  full  doses,  preferably  hypodermically  in  the  form 
of  a  fat  free  tincture  in  doses  of  1 5  to  30  minims  every  3  hovu"S.  Occasionally 
in  sudden  adynamia  very  large  doses,  say  i  dram  (3.7  c.c),  hypodermically, 
may  turn  the  tide  toward  recovery.  Aromatic  spirit  of  ammonia  is  an  im- 
portant adjuvant  in  straits  like  these,  and  may  be  substituted  with  advan- 
tage for  the  carbonate.     Camphor  in  the  form  of  camphorated  oil  is  useful. 

Inhalation  of  oxygen  is  of  undoubted  advantage  in  relieving  the  dyspnea 
and  thus  comforting  the  patient.     It  is  not  curative. 

High  temperature  may  be  reduced  by  sponging,  though  the  temperature 
itself  in  pneumonia  cannot  be  regarded  as  dangerous  per  se.  It  is  better 
accomplished  by  the  local  application  of  ice  to  be  presently  described. 

The  use  of  veratrum  viride  is  warmly  recommended  by  some  instead 
of  bleeding  in  the  earliest  stages  of  the  disease.  It  diminishes  the  force  of 
the  heart,  furnishes  a  diverticulum  for  the  excess  of  blood,  and,  as  our  col- 
league, Horatio  C.  Wood,  says,  "The  patient  is  bled  into  his  own  circu- 
lation."    We  have  never  felt  comfortable  in  relying  upon  it. 

The  treatment  of  pneumonia  by  ice-cold  applications  is  in  vogue.     It 


268  INFECTIOUS  DISEASES 

is  of  some  value  in  relieving  the  local  pain,  and  perhaps  helps  to  lower  the 
temperature. 

Hypodermoclysis  of  normal  hot  saline  solution  was  used  in  desperate 
cases  of  pneumonia  in  the  Philadelphia  Hospital  by  Frederick  P.  Henry 
as  early  as  the  spring  of  1889.  The  injection  is  made  in  the  usual  way, 
under  the  skin,  at  any  stage  in  bad  cases  of  pneumonia — from  1/2  pint 
to  a  pint  (236  to  473  c.c.)  of  a  .6  of  one  per  cent,  solution  being  injected 
daily  or  oftener — about  50  grams  to  the  pint  (3.3  gms.  to  the  liter).  If 
there  is  distention  of  the  right  heart  as  evidenced  by  cyanosis,  flagging  pulse, 
and  sharp  accentuation  of  the  second  pulmonic  sound,  the  injection  of  a 
large  quantity  of  salt  solution  will  be  disastrous — causing  more  dilatation 
with  all  its  symptoms.  However,  if  the  dilatation  be  relieved  by  bleeding 
the  hypodermoclysis  or,  what  is  better,  intravenous  injection  of  a  pint  of 
warm  salt  solution  is  of  value. 

The  eliminative  treatment  has  of  late  assumed  importance  because  of 
the  r61e  assigned  to  the  toxins  in  causing  certain  serious  symptoms.  Hence 
the  free  ingestion  of  liquids  and  measures  to  promote  perspiration  and 
purgation  are  advised. 

Serum  Treatment. — Pneumonia  was  one  of  the  first  diseases  the  treat- 
ment of  which  by  serum  engaged  attention.  Unfortunately  up  to  the 
present  the  antipneumococcic  serum  seems  to  be  of  as  little  value  as  most 
other  internal  remedies. 

BRONCHOPNEUMONIA. 

Synonyms. — Catarrhal  Pneumonia;  Capillary  Bronchitis;  Suffocative  Catarrh; 
Lobular  Pneumonia;  Aspiration  Pneumonia;  Deglutition  Pneumonia. 

Definition. — Bronchopneumonia  is  an  inflammation  of  lobules  or 
patchy  areas  of  lung  tissue  caused  by  microbic  or  other  irritants  that  find 
their  way  to  it  through  a  bronchus. 

Etiology. — The  effects  of  recent  studies  go  to  show  that  the  broncho- 
pneumonias of  children  are  the  result  of  the  same  causes  as  the  lobar  pneu- 
monias of  adults,  producing  however  in  the  latter  lobar  consolidation  and  in 
the  former  lobular  or  patchy  consolidation.'  Usually  bronchopneiunonia 
succeeds  a  bronchitis  of  the  terminal  bronchus  leading  to  the  part.  Some 
would  consider  bronchopnetmionia  and  capillary  bronchitis  one  and  the 
same  thing.  Parts  of  a  lobule,  a  whole  lobule,  or  scattered  groups  of  lobules 
are  thus  affected,  and  may  unite  to  form  larger  areas.  Thus,  while  a 
bronchopneumonia  is  primarily  lobular,  we  may  have  even  a  lobar  broncho- 
pneumonia if  all  the  lobules  of  a  lobe  are  simultaneously  affected.  Aspira- 
tion pneumonia  is  a  bronchopneumonia  caused  by  the  irritation  of  inhaled 
or  indrawn  particles,  including  bacteria,  among  which  must  be  included 
also  streptococci  and  staphylococci,  as  well  as  pneumococci  and  tubercle 
bacilli.  Tubercular  bronchopneumonia  is  one  variety  of  this.  Syphilitic 
bronchopneumonia  is  a  rare,  but  possible,  affection. 

The  recognition  of  bronchopneumonia  as  a  separate  disease  is  usually 
credited  to  Barthez  and  Rilliet. 

'  See  Samuel  West.  "Clinical  Lecture  on  Bronchopneumonia."  to  show  that  pneumococoal  pneu- 
monia in  a  child  takes  the  lobular  and  not  the  lobar  form.  Reprinted  {or  the  author  from  the  "British 
Med.  Jour..  May  28.  1898. 


BRONCHOPNEUMONIA  269 

Simple  bronchopneumonia  is  pre-eminently  a  disease  of  the  very  young 
and  the  old.  In  the  young  it  occurs  as  an  idiopathic  affection,  though  it  is 
also  a  frequent  complication  of  the  infectious  fevers,  measles,  whooping- 
cough,  scarlet  fever,  diphtheria,  and  small-pox.  In  adults,  especially  the 
old,  it  occurs  during  influenza,  erysipelas,  typhoid  fever,  and  all  debilitating 
affections,  including  Bright's  disease  and  organic  disease  of  the  heart.  The 
inhalation  variety  especially  occurs  in  comatose  states,  however  induced. 
William  Pepper  laid  especial  stress  on  vesicular  emphysema  as  a  predispos- 
ing cause.  In  both  young  and  old  it  may  succeed  a  simple  bronchitis 
from  cold,  but  it  is  as  a  complication  of  the  infectious  diseases  named 
that  it  becomes  during  the  first  five  years  of  life  a  very  common,  serious, 
and  fatal  disease,  causing,  it  is  said,  more  deaths  among  children  than 
any  other  disease  except  infantile  diarrhea.  Diarrhea  itself  and  rickets  are 
also  to  be  included  as  predisposing  causes.  All  influences  depressing  to 
life,  such  as  overwork,  fatigue,  the  air  of  badly  ventilated  and  crowded 
houses,  insufficient  food,  and  defects  of  hygiene,  act  similarly.  Collapse  of 
the  lung  is  at  once  a  cause  and  a  consequence  of  bronchopneumonia. 

Another  cause  of  bronchopneumonia  more  common  in  adults  and  the 
aged  is  the  inhalation  of  fine  irritant  particles  or  the  aspiration  of  particles 
of  food.  In  comatose  states  from  any  cause  the  sensibility  of  the  larynx  is 
benumbed,  and  minute  particles  of  food  are  permitted  to  pass  beyond  the 
rima  glottidis  to  enter  the  larynx,  and  thence  the  smaller  bronchial  tubes, 
where  they  excite  inflammation.  Hence  the  term  aspiration  or  deglutition 
pneumonia  above  mentioned.  Glossopharyngeal  palsy  is  often  associated 
with  deglutition  pneumonia  which  may  follow  tracheotomy  and  cancer  of 
the  larynx  and  esophagus.  The  inflammation  thus  excited  is  sometimes 
so  intense  as  to  cause  suppuration  and  even  gangrene.  Stone-cutting, 
steel-grinding,  and  coal-mining  become  causes  by  the  irritating  particles 
inhaled  in  these  occupations. 

Morbid  Anatomy. — The  morbid  anatomy  of  simple  bronchopneumonia 
is  quite  definite,  yet  somewhat  complex  and  difficult  of  description.  The 
lungs  may  be  superficially  unaltered  or  they  may  be  large  and  heavy. 
The  exterior,  especially  at  the  base,  may  be  mottled  because  of  an  alter- 
nation of  dark-blue  or  bluish-black  depressed  areas  with  projecting  portions 
more  natiu-al  in  hue.  The  depressed  areas  represent  collapsed  lung,  and 
can,  for  the  most  part,  be  reinfiated.  In  places  they  are  continuous,  forming 
large  patches.  Where  there  is  much  of  this  diffuse  pneumonia  correspond- 
ing patches  of  fibrin  may  be  seen  on  the  pulmonary  pleura. 

On  section  the  surface  of  the  lung  is  dark  red  in  color  and  from  it  pro- 
ject reddish-gray  spots  representing  areas  of  bronchopneumonia.  These 
may  be  separated  by  tracts  of  uninflamed  and  collapsed  tissue,  or  may  unite 
to  form  more  extensive  inflamed  areas.  A  section  made  transverse  to  the 
lobule  will  be  found  penetrated  by  a  central  bronchiole  filled  with  muco-pus, 
while  if  the  section  is  parallel  with  the  length  of  the  bronchiole,  the  central 
alveolar  passage  with  its  alveoli  may  be  readily  recognized,  being  rendered 
distinct  by  the  same  muco-purulent  contents.  Around  the  bronchus, 
from  i/8  to  1/5  inch  (3  to  5  mm.)  or  more,  is  an  area  of  grayish-red  con- 
solidation elevated  above  the  surface,  usually  slightly  granular  to  the 
touch,  but  still  lacking  the_hard,  shot-like  feel  of  croupous  pneumonia. 


270  INFECTIOUS  DISEASES 

On  pressure,  a  mixture  of  pus  and  desquamated  cells  may  be  squeezed  out, 
which,  at  a  later  stage,  becomes  almost  pure  pus,  appearing  as  white  points 
in  the  nondepressed  tissue.  Surrounding  the  imperfectly  hepatized  areas 
and  at  a  lower  level  is  a  smooth,  dark,  airless  tissue,  representing  collapsed 
lung,  which  may  be  the  seat  of  beginning  inflammation.  At  a  later  stage, 
if  the  patient  survive,  especially  in  adults,  the  inflammatory  areas  may 
assume  a  darker  hue,  even  that  of  gray  hepatization.  vStill  later,  in  the  per- 
sistent forms,  the  areas  may  contain  the  white  foci  above  described  resem- 
bling miliary  tubercles,  from  which  they  may  be  always  distinguished  by  the 
fact  that  the  white  droplets  can  be  squeezed  out,  whUe  the  tubercle  remains 
firm.  These  areas  may  be  converted  into  cirrhotic  patches.  During  the 
progress  of  a  bronchopneumonia  the  air-cells  in  the  adjacent  lobules  are 
found  dilated,  and  the  edges  of  the  lung  and  upper  portions  have  also  become 
emphysematous.  The  bronchioles  themselves  are  also  dilated  in  places. 
The  uninflamed  areas  are  generally  congested. 

The  contents  of  the  bronchioles  and  air-vesicles  are  pus-cells  and  swollen 
exfoliated  epithelium.  The  walls  of  the  bronchiole  and  of  the  air-vesicles 
are  thickened  and  infiltrated  with  leukocytes.  Rarely  do  they  contain 
blood  or  the  fibrin-network  characteristic  of  lobar  pneumonia.  Occasion- 
ally, minute  extravasations  of  blood  may  be  found. 

The  phenomena  in  the  aspiration  form  of  bronchopneumonia  are  more 
intense  in  every  respect  than  in  the  other  forms,  the  infiltration  of  the  air- 
vesicles  with  leukocytes  leading  sometimes  to  suppuration  or  even  to 
gangrene. 

Symptoms. — The  initial  symptoms  vary  with  the  precursory  disease. 
In  a  child — and  here  the  disease  has  its  greatest  practical  interest — there 
may  have  been  measles,  whooping-cough  or  diphtheria,  in  which  con- 
valescence may  or  may  not  have  set  in.  To  incipient  or  aggravated  cough 
decided /CTer  is  added,  a  temperature  of  102°  F.  (38.9°  C.)  and  higher  being 
attained;  the  cough  becomes  more  severe  and  painful,  the  breathing  becomes 
rapid,  and  an  easily  visible,  distressing  dyspnea  super\'enes.  The  embar- 
rassed breathing  grows  worse,  the  fever  is  higher,  the  lips  and  face  become 
cyanosed,  the  short,  incessant  cough  is  ineffectual  in  the  raising  of  expecto- 
ration, and  the  little  sufferer  is  a  picture  of  pitiable  distress.  For  such  a 
state  of  affairs  the  term  suffocative  catarrh  given  by  the  older  authorities  is 
well  chosen.  Happily,  as  the  disease  advances  and  the  blood  becomes 
charged  with  carbon  dioxid,  sensibility  wanes,  the  suffering  abates,  and  the 
cough  grows  less;  but  the  frequent  breathing,  often  60  to  80,  the  lividity  of 
the  face,  and  the  frequent  pulse  show  that  the  fury  of  the  disease  is  not  spent, 
but  wtII  probably  terminate  only  in  death,  which  is  directly  due  to  exhaustion 
of  the  muscle  of  the  right  ventricle.  At  times,  however,  and  even  when 
least  expected,  a  favorable  turn  takes  place  and  a  surprisingly  rapid  con- 
valescence sets  in. 

In  adults,  as  in  children,  the  symptoms  vary  with  the  mode  of  origin. 
In  the  idiopathic  form,  which  is  recurrent  in  some  old  persons,  there  are 
fever,  a  burning  spot  in  the  cheek,  and  shortness  of  breath,  but  a  cough  less 
troublesome  than  would  be  expected.  The  physical  signs  rather  than  the 
symptoms  determine  the  diagnosis.  There  are  fine  moist  rales,  with  harsh 
breathing  rather  than  bronchial  breathing,  and  relatively  clear  percussion. 


BRONCHOPNEUMONIA  271 

The  symptoms  in  a  case  of  deglutition  pneumonia  are  very  similar. 
In  the  inhalation  pneumonia  of  miners,  stone-cutters,  and  steel-grinders 
the  symptoms  are  slower  in  their  development  and  resemble  more  those  of 
tubercular  phthisis. 

Physical  Signs. — These  are  by  no  means  as  distinctive  as  those  of 
croupous  pneumonia.  The  association  of  capillary  bronchitis  and  broncho- 
pneumonia is  so  close  that,  given  the  fine  subcrepitant  rales  of  the  former, 
unaccompanied  by  impairment  of  resonance,  we  may  infer  that  broncho- 
pneumonia is  at  hand.  Further  signs,  however,  of  actual  involvement 
of  the  lung-substance  are  moderate  impairment  of  resonance  and  harsh 
breathing,  rather  than  true  bronchial  breathing,  though  more  rarely  the 
latter  may  be  present,  especially  when  the  bases  of  the  lungs  are  involved. 
Inspection  may  recognize  retraction  of  the  cartilages  and  lower  sternum 
during  inspiration,  indicating  defective  expansion  of  the  lung. 

Diagnosis. — The  diagnosis  of  bronchopneumonia  is  usually  easy. 
High  fever,  cough,  mucous  expectoration,  fine  rales,  and  slight  impairment 
of  resonance,  following  one  of  the  infectious  diseases  in  a  child  under  five 
years,  and  developing  gradually,  admit  of  but  one  interpretation.  When 
a  member  of  small  foci  unite  to  form  a  large  area  corresponding  to  the  whole 
or  a  portion  of  a  lobe,  the  physical  signs  are  more  like  those  of  a  lobar 
pneumonia,  and  the  absence  of  expectoration  in  children  increases  the  diffi- 
culty of  diagnosis.  Lobar  pneumonia  develops  more  suddenly  and  resolves 
more  rapidly. 

The  similarity  in  the  morbid  anatomy  of  persistent  bronchopneumonia 
and  tuberculosis  has  been  referred  to,  and  the  clinical  resemblance  is  even 
greater,  so  that  it  may  be  impossible  to  s&y  in  a  child,  whether  it  is  broncho- 
pneumonia or  tuberculosis.  Signs  at  the  apices  are  to  be  sought  for,  and, 
if  found,  tuberculosis  may  be  suspected;  but  the  correct  diagnosis  is  some- 
times made  only  on  the  autopsy  table. 

Prognosis. — The  prognosis  varies  with  the  etiology,  but  broncho- 
pneumonia is  always  a  serious  disease.  From  30  to  50  per  cent,  of  all 
children  perish  from  it. 

In  fatal  cases  in  children  death  may  occur  in  24  hoiirs.  When  recovery 
takes  place,  the  disease  lasts  from  five  to  ten  days,  and  as  many  more  are 
required  for  complete  restoration  to  health. 

Yet,  as  mentioned  tmder  symptomatology,  some  remarkable  recoveries 
take  place.  In  adults  it  is  about  as  serious  as  croupous  pneumonia.  The 
deglutition  variety  is  almost  always  fatal,  and  is  the  usual  cause  of  death  in 
glossopharyngeal  palsy. 

Treatment. — The  indifference  of  parents  and  the  carelessness  of  nurses 
are  responsible  for  many  cases  of  bronchopneiunonia  occurring  during 
convalescence  from  measles,  diphtheria,  and  whooping-cough  which,  with 
proper  care,  might  have  been  averted.  Among  the  causes  thus  respon- 
sible are  exposure  of  children  with  uncovered  heads  at  open  doors  and 
windows,  insufficient  clothing  during  sleep,  overheated  rooms,  and  drafty 
corridors.     Fresh  air,  rest  and  food  are  as  important  as  in  the  lobar  type. 

Restorative  measures  are  indicated  in  this  disease  from  the  outset. 
Nauseating  expectorants  are  rarely  demanded  and  often  do  harm  by  lower- 
ing the  vitality  of  the  young  patient.     Blood-letting,  useful  in  some  cases 


272  INFECTIOUS  DISEASES 

of  croupous  pneumonia,  is  not  called  for  in  catarrhal.  Opiates  to  quiet 
the  cough  and  relieve  the  pain  are  strongly  indicated  in  the  earlier  stages 
of  the  disease  and  sometimes  throughout  it.  They  should  be  associated 
with  diaphoretics  and  febrifuges,  among  which  the  solution  of  acetate 
of  ammonium,  the  solution  of  citrate  of  potash,  and  sweet  spirit  of  niter 
are  the  best.  The  tincture  of  aconite  in  small,  but  often  repeated,  doses 
is  extremely  valuable  if  the  temperature  is  high  and  the  pulse  full  and 
rapid. 

When  secretions  become  free  and  a  stimulating  expectorant  is  required, 
there  is  none  better  than  the  aromatic  spirit  of  ammonium,  which  fulfills 
every  indication  and  spares  the  stomach  more  than  the  chlorid  or  carbonate 
of  ammonoium.  At  this  stage,  alcohol,  in  the  shape  of  whisky  or  brandy, 
becomes  an  important  adjuvant.  It  should  be  added  to  the  nourishment, 
of  which  the  best  form  is  milk,  although  nourishing  broths  are  also  indicated. 
As  digestion  is  likely  to  be  feeble,  the  milk  is  better  peptonized.  Quinin, 
and  especially  strychnin  as  a  respiratory  stiinulant,  are  useful  tonics. 

In  the  way  of  local  treatment  counterirritation  by  mustard  and  tur- 
pentine is  especially  useful.  The  former  should  be  used  in  the  shape  of  a 
weak  plaster,  one  part  of  mustard  to  five  or  six  parts  of  flour  or  flaxseed  meal. 
If  white  of  egg  and  glycerin  be  used  to  mix  it  instead  of  water,  the  plaster 
is  less  painful  and  may  be  kept  on  continuously.  One  of  the  best  modes  of 
applying  turpentine  is  by  the  St  John  Long  liniment,  which  may  be  made 
by  mixing  thoroughly  a  teacupful  of  vinegar,  a  wineglass  of  turpentine, 
and  one  egg.  This  may  either  be  rubbed  thoroughly  on  the  chest  or  it  may 
be  applied  on  flannel.  It  may  be  that  the  turpentine  is  absorbed  and  acts 
as  an  expectorant.     Blisters  are  not  recommended. 

The  poultice  is  a  measure  of  treatment  for  catarrhal  pneumonia  which  is 
variously  valued.  It  is  undoubtedly  useful  in  children  if  properlj^  employed, 
but  great  care  chould  be  taken  that'  it  does  not  become  cold.  It  should 
be  lightly  made  and  changed  often;  and  when  changed,  it  should  be  done 
rapidly,  a  fresh  hot  poultice  being  at  hand  to  replace  the  one  removed. 
When  poultices  are  not  used,  the  cotton  jacket  should  be  substituted,  as 
it  insures  a  uniform  temperature  of  the  body.  This  is  valuable  in  cold 
weather  in  order  to  protect  the  child  and  allow  of  the  freest  possible  cir- 
culation of  air  in  the  room. 

If  the  temperature  be  very  high,  it  may  be  reduced  by  sponging  or, 
better,  by  the  wet-pack  at  a  temperature  of  75°  F.  (25°  C).  The  child 
does  not,  however,  die  of  the  effects  of  high  temperature,  but  rather,  finally, 
of  a  failing  right  heart.  The  bath  is,  nevertheless,  very  calming  to  the 
nervous  system,  and  should  be  used  for  this  reason. 

The  same  measure  may  be  used  with  appropriate  modifications  in  the 
catarrhal  pneumonia  of  adults,  and  also  in  the  variety  known  as  deglutition 
pneumonia.  As  this  last  form  is,  however,  generally  the  beginning  of  the 
end  in  some  other  serious  condition,  treatment  avails  little. 

TUBERCULOSIS. 
I.  General  Etiology  and  Invasion.     Morbid  Anatomy. 
Tuberculosis  is  an  infectious  and  contagious  disease  due  to  implantation 
of  the  tubercle  bacillus  of  Koch.     It  may  affect  any  organ  or  tissue  in  the 


TUBERCULOSIS  273 

body.  Anatomically  it  gives  rise  to  nodules  which  may  soften,  become 
fibrous  or  calcify.  It  is  noled  clinically  by  the  symptoms  characteristic 
of  the  organ  affected,  though  irregular  fever  and  emaciation  are  symptoms 
common  to  all  forms.  It  may  be  acute  or  chronic  depending  upon  the 
virulence  of  the  infection  and  the  resistance  of  the  body. 

Etiology. — The  tubercle  bacillus  is  a  short  rod-bacterium  three  to  four 
microns  in  length,  equal  to  about  1/3  the  diameter  of  a  red  blood-disk,  and 
1/6  to  i/s  as  broad.  When  successfully  stained  and  viewed  with  high 
power  it  presents  at  times  a  beaded  appearance.  The  organism  is  spread 
widely  throughout  the  animal  kingdom.  Four  well-known  varieties  exist, 
the  htunan,  the  bovine,  the  avian,  and  the  piscium;  two  rarer  forms  have 
been  discovered,  one  in  the  turtle  and  one  in  the  blind  worm.  Of  these, 
the  human  and  the  bovine  varieties  concern  us  mostly.  The  badllus 
does  not  proliferate  outside  the  animal  body.  It  is  very  resistant  to  ordi- 
nary methods  of  destruction.  Direct  sunlight,  however,  will  kill  it  in  a 
few  hours,  diffuse  sunlight  will  kUl  it  in  a  few  days;  corrosive  sublimate 
will  not  destroy  it  well  in  sputum,  while  5  per  cent,  carbolic  acid  in  equal 
quantity  will  kill  it  in  24  hours.  It  resists  the  action  of  the  gastric  juice, 
hence  the  possible  infection  of  the  intestinal  tract.  It  contains  various 
toxic  substances,  among  them  the  so-called  tuberculin  and  a  fever-produc- 
ing substance. 

Tuberculin  Reaction. — When  tuberculin  is  injected  under  the  skin  of  a 
healthy  individual,  very  little,  if  any,  result  occurs;  if  on  the  other  hand 
the  individual  be  the  subject  of  tuberculosis,  malaise,  fever,  rapid  pulse, 
and  general  symptoms  of  intoxication;  this,  if  the  dose  be  small,  .5  to  i.o 
mg.  the  reaction  wiU  be  short  lived.  This  reaction  will  be  spoken  of  under 
diagnosis. 

Immunity. — Certain  animals  have  been  immunized  to  tuberculosis, 
and  this  immunization  is  the  object  of  tuberculin  treatment  to  be  made 
in  man,  later  to  be  described. 

Bovine  Tuberculosis. — Smith,  Ravenel,  Park  and  others,  have  demon- 
strated beyond  question  both  that  cattle  may  be  infected  by  human  tubercle 
bacilli  and  that  certain  cases  of  tuberculosis  in  man  are  due  to  bovine  type 
of  bacUli.  Park  and  EIrumwiede  found  11.9  per  cent,  of  436  c?ses  due  to 
this  type. 

Healed  or  Healing  Tubercular  Lesions. — These  have  been  found  in 
human  autopsies  from  70  to  90  per  cent,  of  all  cases.  About  one-seventh 
of  all  deaths  are  due  to  tuberculosis. 

Methods  of  Entrance  into  the  Body. — According  to  Adami,  the  lungs 
are  perhaps  most  frequently  infected,  through  the  lymph  and  blood  stream, 
from  the  mouth,  nose  and  upper  respiratory  passages,  and  many  authors 
stUl  believe  that  the  lungs  are  infected  through  inhalation  of  the  bacilli. 
Ravenel  has  proven  that  tubercle  bacilli  may  enter  the  body  through  the 
intestinal  tract,  lodge  in  the  peri-bronchial  glands  and  leave  no  lesion  in  the 
mucous  membrane  of  the  intestine. 

It  is  now  a  well-recognized  fact,  proven  beyond  a  contravention  that 
tuberculosis  is  very  frequently  conveyed  by  one  person  directly  to  another, 
and  also  that  it  may  be  contracted  by  healthy  individuals  living  in  homes 
which  have  been  inhabited  by  tuberculous  individuals.     Thus,   Comet 


274  INFECTIOUS  DISEASES 

studied  the  records  of  certain  institutions  whose  immates  are  devoted  to 
nursing  of  tuberculous  cases,  and  discovered  the  fact  that  a  large  proportion 
of  these  (62.8  per  cent,  in  25  years)  died  of  phthisis;  also  that  of  100  nurses 
63  died  of  this  disease.  On  the  other  hand,  the  statistics  of  the  Brompton 
Hospital  for  Consumptives  in  London  is  decidedly  against  any  conclusion 
that  contact  with  patients  peculiarly  endangers  the  lives  of  doctors,  nurses, 
or  attendants.  This,  too,  though  they  cover  a  period  when  no  precautions 
were  taken  to  destroy  the  bacillus. 

Flick's  studies  point  to  a  greater  activity  of  the  contagium  than  was 
formerly  admitted.  He  examined  all  of  the  houses  in  a  ward  in  Philadel- 
phia where  there  had  been  deaths  from  consimiption,  and  found  that  33 
per  cent,  of  such  houses  had  more  than  one  case,  that  25  per  cent,  of  these 
houses  had  been  infected  prior  to  1888,  and  that  more  than  33  per  cent,  of 
the  deaths  which  occurred  since  1888  took  place  in  them.  These  observa- 
tions accord  with  the  results  of  Comet's  experiments,  which  demonstrated 
that  the  scraping  from  the  walls  of  phthisical  wards  inoculated  into  the  lower 
animals  produced  tuberculosis. 

The  conditions  which  favor  the  growth  and  multiplication  of  bacilli  in 
the  body  have  been  carefully  studied,  but  have  been  only  partially  deter- 
mined. 

Heredity. — Adami  says  tuberculosis  is  practially  never  inherited.  How 
much  influence  heredity  actually  plays  in  the  development  of  tuberculosis  is 
difficult  to  determine.  Even  though  there  be  such  an  influence  exerted, 
certain  cases  of  congenital  human  tuberculosis  are  rare.  It  must  be  re- 
membered that  children  bom  of  tuberculous  parents  and  living  with  them 
are  constantly  exposed  to  the  risks  of  contagion.  They  may  be  infected  in 
very  early  life  and  not  develop  the  disease  until  much  later  consequenth" 
such  cases  are  contagious  in  origin.  It  cannot  be  denied,  however,  that 
children  of  tuberculous  parents  may  be  feeble,  lack  resistance  and  hence  fall 
easy  prey  to  tubercvdosis  or  any  other  infection  late  in  life. 

Defective  and  insufficient  food,  especially  when  associated  with  imperfect 
ventilation  and  dark  living  rooms,  privation,  grief,  and  overwork,  are  also 
conditions  which  favor  the  growth  of  the  bacillus. 

Frequently  recurring  bronchial  catarrh  by  lowering  the  vitality  of  the 
mucous  membrane  engenders  a  soil  favorable  to  the  growth  and  multipli- 
cation of  the  tubercle  bacillus.  Anj^  of  the  causes  that  produce  such 
catarrh  may  be  included  among  predisposing  factors.  Measles,  whooping- 
cough,  and  typhoid  fever  with  bronchial  complications  are  sometimes 
followed  by  it.  Occupations  favor  it.  Particles  of  dust  inhaled  in  the 
pursuit  of  various  trades  and  avocations,  as  in  coal-mining,  stone-cutting 
and  steel-grinding,  are  well  known  to  have  this  effect.  It  is  said  (U.  S. 
Census  Report,  1890)  that  288  potters  die  of  consumption  to  100  farmers 
from  the  same  cause. 

No  race  is  exempt,  but  the  colored  race  is  especially  predisposed,  as  is  also 
the  American  Indian  when  brought  under  the  influence  of  civilization. 
Tuberculosis  appears  to  be  spreading  among  the  Indians,  even  in  districts 
in  the  Rocky  Mountains  where  the  disease  is  rare  among  the  whites.  The 
Irish  race  in  this  country  is  also  susceptible  and  many  die  of  it.  On  the 
other  hand,  the  Russian-Polish  Jews  arc  remarkably  exempt,  and  next  to 


TUBERCULOSIS  275 

them  are  the  native  American  whites.  Phipps  institute  in  Philadelphia  for 
1905  shows  16  per  cent,  of  their  patients  were  Jews.  W.  A.  King,  Chief 
Statistician  of  the  United  States  Census  Bureau,  furnishes  the  following 
figures  as  to  the  nationality  and  race  of  victims  of  this  disease : 


Six  years 

Calendar 

1 884-1 891 

year  1900 

White  persons  having  mothers  born  in: 

United  States, 

205.1 

151-8 

Ireland, 

645 -7 

526 . 1 

Germany, 

328.8 

214.2 

Russia  and  Poland, 

98.2 

88.5 

Our  Health  Commissioner  Dr.  vSamuel  Dixon  reports  to  us  that  during 
1912,  9,855  persons  died  of  tuberculosis  in  Pennsylvania.  Of  these  8,455 
died  of  tuberculosis  of  the  lungs  while  in  the  United  Kingdom  of  Great 
Britian  and  Ireland  60,000  are  said  to  die  annually;  and  it  is  probable  that 
at  least  three  times  this  number  are  suffering  from  one  form  or  another 
of  the  disease.  In  Philadelphia  in  1908  there  were  3,518  deaths  from  tuber- 
culosis of  which  2,065  were  from  pulmonary  tuberculosis. 

Climates  have  little  effect  upon  the  development  of  tuberculosis,  except 
in  that  inclement  weather  often  forces  individuals  to  live  indoors,  in  rooms 
that  are  usually  ill  ventilated  and  dark.  In  the  dark  rooms  tubercle  bacilli 
long  retain  their  virulence. 

Age  is  doubtless  a  predisposing  cause,  the  susceptible  period  for  pul- 
monary tuberculosis  being  between  20  and  35;  for  meningeal  tuberculosis, 
between  two  and  seven;  while  the  lymphatic  glands  including  the  mesenteric 
and  bronchial,  are  prone  to  involvement  in  the  first  ten  years  of  life.  The 
mesenteric  glands  are  more  commonly  infected  during  the  first  five  years  of 
life,  including  the  nursing  period  and  that  during  which  the  child  is  nourished 
on  milk. 

The  shape  of  the  chest  has  long  been  regarded  as  influencing  the  develop- 
ment of  tuberculosis,  but  except  where  the  chest  is  so  deformed  that  proper 
expansion  cannot  be  attained  it  is  doubtful  if  this  has  any  influence.  The 
"phthisical"  chest  is  flat.  At  the  present  day  two  varieties  of  chests  are 
described  as  phthisical,  the  alar  and  ih.eflat.  The  former  is  narrow,  shallow, 
and  long,  the  angles  of  the  scapulae  projecting  like  wongs  behind,  the  proper 
ratio  between  the  antero-posterior  and  transverse  diameters  being,  however, 
preserved.  Theribsdroopor  are  unduly  oblique.  The  throat  is  prominent, 
the  neck  long,  and  the  head  bent  forward.  In  the  flat  chest  the  antero- 
posterior diameter  is  disproportionately  short,  owing  to  the  absence  of 
convexity  in  the  cartilages,  which  are  sometimes  even  depressed,  carrying 
with  them  the  sternum  and  producing  a  form  of  chest  which,  on  section,  is 
kidney-shaped.  In  this  form  there  is  not  the  increased  obliquity  of  the  ribs 
characteristic  of  the  alar  chest. 

Traumatism  may  have  the  effect  of  causing  a  latent  tuberculosis  to  be- 
come active.  Undoubted  cases  are  cited  by  Weber.  Patients  may  die  of 
this  tuberculosis  thus  made  active.  On  the  other  hand  a  traiimatism  sus- 
tained at  the  hands  of  a  public  corporation  is  constantly  distorted  by  un- 
scrupulous lawyers  to  be  the  cause  in  cases  of  death  or  illness  from  tuberculosis 
after  the  accident,  when  no  such  relation  exists. 

Mode  of  Invasion  and  Spread. — The  bacillus  of   tuberculosis  derived 


276  INFECTIOUS  DISEASES 

from  ihe  drying  and  pulverization  of  expectorated  sputum  can  doubtless 
be  inhaled  and  thus  become  infective  either  by  being  absorbed  by  the  blood 
stream  or  by  local  action  in  the  bronchioles.  This  neglected  sputum  prob- 
ably has  little  affect  when  it  is  exposed  to  fresh  air  and  sunslight,  for  these 
factors  soon  kill  the  baciUus.  but  when  the  sputum  is  deposited  in  damp  and 
dark  places  such  as  living  rooms  frequently  are,  the  protected  germ  lives  much 
longer  and  can  easily  become  infective.  It  has  been  proven,  however,  that 
the  sputum,  when  it  is  first  expelled,  even  in  the  form  of  fine  spray  from 
the  mouth,  is  highly  infective.  The  entrance  into  the  body  in  the  vast 
majority  of  instances  is  by  the  respiratory  tract.  Hence  the  great  fre- 
quency of  tuberoilosis  in  the  lungs  and  bronchial  glands,  which  are  the 
first  tissues  open  to  its  approach.  The  comparative  studies  of  George  B. 
Wood^  go  to  show  that  the  tonsillar  tissue  of  the  throat  because  of  its  ana- 
tomic construction  and  topographic  relations  is  more  liable  to  become  infected 
by  tuberculosis  than  any  other  part  of  the  upper  respiratory  tract.  It  is 
possible  for  the  bacillus  to  enter  by  the  skin,  causing  lupus  or  skin  tubercu- 
losis. It  enters  more  readUy  by  open  wounds  such  as  those  caused  by  cir- 
cumcision. Through  the  alimentary  canal  we  have  an  undoubted  route  of 
infection.  The  work  of  Ravenel  proves  that  tubercle  bacilli  may  enter 
through  the  intestinal  tract  and  leave  the  mucous  membrane  of  the  intes- 
tine intact.  This  may  happen  in  children  using  the  milk  of  tuberciilous 
cows.  It  is  not  necessary  that  the  cow  should  have  tuberculosis  of  the 
udder  to  render  her  milk  tuberculous.  This  has  been  conclusively  shown  by 
Bollinger  and  confirmed  by  Hirschberger  and  Harold  Ernst.  The  boiling 
of  milk  destroys  its  infective  qualities.  Tuberculous  meat  is  less  fre- 
quently the  cause  of  tuberculosis. 

The  tubercle  bacillus  having  once  invaded  an  organ  produces  localized 
tuberculosis,  which  may  or  may  not  become  generalized  in  a  manner  to  be 
presently  described.  More  rarelv,  tuberculosis  may  become  general  from 
the  onset  without  any  local  initial  lesion  being  discoverable.  This  consti- 
tutes one  of  the  varieties  of  acute  tuberculosis.  Once  established,  tubercu- 
losis spreads  by  contiguity  and  through  the  lymphatic  system  and  blood. 
In  the  former  the  tubercle  grows  by  the  addition  of  miliarj'  tubercles  at  its 
periphery.  Through  the  lymphatic  sj-stem  tuberculosis  spreads  to  the 
Ij^mphatic  glands,  and  thence  to  the  adjacent  tissues.  The  barrier  of  the 
lymphatic  glands  once  passed,  the  blood  becomes  the  medium  of  a  general 
infection.  In  the  vast  majority  of  cases  generalization  takes  place  from  a 
focus  of  tubercle  somewhere  in  the  system,  as  the  lungs,  or  a  tubercular 
lymphatic  gland,  from  which  the  bacilli  start  their  migration. 

The  favorite  seats  of  tuberculosis  are  the  lymphatic  glands,  lungs,  liver, 
kidne3^  spleen,  intestinal  canal,  urogenital  mucous  membranes,  the  brain 
(especially  its  membranes  and  blood-vessels),  bones  and  joints.  In  fact, 
no  tissue  or  organ  is  exempt,  the  salivary  glands  and  pancreas  being  least 
frequently  invaded. 

A  primary  tubercle  is  really  in  the  beginning  an  infectious  granuloma. 

The  first  effect  according  to  Adami  of  the  lodgment  of  a  tubercle  bacillus 
is  its  absorption  by  an  endothelial  cell;  but  if  numerous  bacilU  are  in  position 


'  The  Significance  of  Tuberculous  Deposits  in  the  Tonsils.     "Journal  of  the  Am.   Med.  Assoc."  read 
at'5Sth  Annual  Session,  1904. 


TUBERCULOSIS  277 

at  the  same  time  in  too  great  num.bers  to  be  absorbed,  they  are  immediatel)' 
surrounded  by  swollen,  enlarged  endothelial  cells. 

There  are  thrown  out  with  these  endothelial  cells  a  rather  small  number 
of  leukocytes,  first  polymorphonuclear  and  later  lymphocj^tes.  This  col- 
lection of  cells,  the  result  of  inflammatory'  reaction,  occludes  the  capillaries 
in  the  neighborhood  so  that  the  tubercle  becomes  extravascular.  Some- 
times the  large  endothelial  cells  immediateh'  surrounding  the  bacilli  fuse, 
forming  the  so-called  giant  cell  having  the  baciUi  in  the  center.  As  the 
bacilli  multiply  and  as  some  of  their  toxins  are  liberated,  they  act  as  intoxi- 
cants to  the  cells  in  the  immediate  neighborhood,  causing  their  death. 
To  use  Adami's  exact  words,  "The  typical  giant  cell  comes  to  exhibit  a 
central,  badly  staining,  necrosed  area,  around  which  other  endothelial  cells 
have  fused,  the  typical  tuberculous  giant  cell,  which  exhibits  on  section  a 
peripheral  circle  or  crescent  of  nuclei  surrounding  a  more  or  less  hyaline 
necrosed  mass,  the  tubercle  bacilli  being  fovind  more  partictdarly  at  the 
edges  of  the  necrosed  area." 

Caseation  occurs  in  the  tubercle  by  the  increase  in  growth  of  the  bacilli, 
causing  a  larger  and  larger  central  area  of  necrosis  until  finallj'  a  cheesy 
mass  fills  the  center. 

As  the  central  area  of  necrosis  increases,  the  giant  cells  increase,  the 
active  cells  increase  until  the  mass  may  be  seen  by  the  naked  eye. 

Several  such  tubercles  as  this  may  occiu*  around  a  central  necrotic  area, 
these  give  rise  to  other  tubercles,  which  conglomerate  into  a  mass,  the 
center  becoming  necrotic.  If  such  a  conglomerate  mass  involved  the  walls 
of  a  vessel  or  a  bronchus,  it  may  rupture  forming  a  so-called  tuberculous 
ulcer,  which  favors  the  spread  of  the  bacilli.  On  the  other  hand  the  tissues 
may  become  surrounded  by  a  definite  connective-tissue  capsule;  under 
these  circumstances,  the  activity  of  the  bacilli  become  arrested,  and  if  the 
tubercles  are  small,  they  may  undergo  absorption,  or  the  larger  caseous 
masses  may  calcify  causing  actual  calcaseous  nodules  surrounded  by  a  fibrous 
capsule. 

The  bacilU  in  these  fibrous  nodules  may  remain  alive  for  a  long  while, 
and  if  the  resistance  of  the  individual  is  lessened,  they  may  be  the  focus 
from  which  the  disease  may  extend. 


II.  Acute  Tuberculosis. 

Synonyms. — Dif^lse  General  Tuberculosis;  Acute  Miliary  Tuberculosis. 

Definition. — The  simtdtaneous  comparatively  sudden  irruption  of 
miliarj'  tubercles  in  different  parts  of  the  body  as  the  result  of  the  spread 
of  bacilli  through  the  blood  and  lymphatic  systems.  It  is  the  most  emphatic 
expression  of  the  infectious  nature  of  tuberculosis.  The  infection  is  in 
almost  every  instance  an  auto-inoculation,  of  which  the  source  is  a  nodule 
of  softening  tubercle  in  some  part  of  the  body.  In  300  cases  of  miliary 
tuberculosis  examined  by  Buhl  such  a  soiirce  was  found  in  all  but  ten, 
while  Simmonds  in  100  cases  found  the  caseating  focus  in  every  instance. 
The  most  common  seat  of  such  a  nodule  is  the  lungs,  next  a  tubercular 
lymphatic  gland,   especially  a  tracheobronchial  gland.     After  this  there 


278  IX FECI  10 US  DISEASES 

is  less  constancy,  but  tubercular  joints,  a  tubercular  pleurisy,  tubercular 
peritonitis,  and  even  a  skin  tuberculosis  may  be  held  responsible.  Such  a 
nodule  may  break  directly  into  a  vein,  furnishing  an  instance  of  true  embolic 
infection. 

Acute  tuberculosis  occurs  most  frequently  in  young  persons  between 
12  and  2o  years  of  age,  but  adults  are  not  exempt.  Any  tissue  or  organ 
may  be  involved,  but  very  seldom  do  we  find  all  the  organs  of  the  body 
affected,  though  it  is  quite  common  to  find  lesions  in  more  than  two,  as, 
for  example,  the  lungs,  the  pleura,  the  membranes  of  the  brain,  and  the 
peritoneum.     The  first  three  are  favorite  locations. 

Clinical  Varieties. — Three  principal  clinical  forms  of  acute  tuberculosis 
arc  recognized,  one  presenting  easih'  recognizable  pulmonary  symptoms, 
another  signs  of  acute  general  infection  without  special  localization,  and  the 
third,  cerebral  and  spinal  symptoms. 


I.  Pulmonary  Form  of  Acute  Miliary  Tuberculosis. 

Symptoms. — This  form  succeeds  in  adults  on  chronic  tuberculosis  of  the 
lung,  on  prolonged  bronchitis,  on  whooping-cough  or  on  measles  in  children. 
An  irruption  of  miliary  tuberculosis  the  result  of  infection  takes  place 
throughout  the  lung  with  or  without  bronchopneumonia.  The  tubercles  may 
be  scattered  throughout  the  lung,  distributed  by  the  blood,  and  may 
be  found  in  the  walls  of  the  vessels,  or  radially  arranged  around  the  primary 
focus.  It  is  this  event  which  gave  rise  to  Niemeyer's  dictum,  "The  greatest 
danger  to  most  phthisical  patients  is  the  development  of  the  tubercle." 
To  the  previous  cough  and  physical  signs  are  added  higher  fever,  increased 
cough,  and  extreme  dyspnea  associated  with  marked  cyanosis.  The  last 
symptom  is  very  striking. 

Physical  Signs. — The  physical  signs  may  not  be  altered;  there  may 
be  sonorous  and  sibilant  riles  or  there  may  be  signs  indicating  deeper  in- 
volvement of  the  lung,  including  small  areas  of  impaired  resonance,  crepi- 
tant riles,  and  bronchial  or  bronchovesicular  breathing  (bronchopneumonic 
foci).  On  this  account  there  may  be  rusty  expectoration,  rarely  hemoptysis. 
The  dull  areas  may  alternate  with  areas  of  hyperresonance — hyperresonance 
due  to  relaxation  (the  Skodaic  type) — or  it  may  be  due  to  localized  emphy- 
sema. On  the  front  of  the  chest  there  may  be  unusual  resonance.  Oc- 
casionally this  Skodiac  resonance  continues  to  the  end.  As  the  disease 
progresses  moist  rales  become  general  all  over  the  chest.  Again  there  may 
be  friction  crepitation  due  to  tubercular  pleurisy. 

Diagnosis. — The  diagnosis  is  made  by  recalling  the  symptoms  detailed. 
Choroidal  tubercle  should  be  looked  for.  Especially  important  are  the  dis- 
proportionate dyspnea  and  cyanosis  associated  with  the  signs  of  difluse 
bronchitis.     Leukocytosis  "is  here  present. 

Prognosis  and  Treatment. — The  disease  is  often  rapidly  fatal  and  treat- 
ment is  of  little  avail  toward  cure.  It  must  consist  in  efforts  to  make  the 
patient  comfortable,  but  as  the  diagnosis  can  perhaps  never  be  made  with 
absolute  certainty  the  treatment  to  be  detailed  later  for  the  cure  of  chronic 
tuberculosis  should  be  carried  out. 


TUBERCULOSIS  279 

2.  General  or  Typhoid  Form  of  Acute  Miliary  Tuberculosis. 

Symptoms. — The  general  or  typhoid  form  of  acute  tuberculosis  has 
long  been  recognized  as  resembling  in  a  startlingly  close  manner  the  symp- 
toms of  typhoid  fever,  and  many  mistakes  have  been  made  in  diagnosis 
because  of  this  resemblance.  Since  the  use  of  the  clinical  thermometer  in 
diagnosis,  however,  such  mistakes  have  been  less  frequent. 

As  in  typhoid  fever,  a  prodrome  of  several  days,  and  even  weeks,  of 
ill-defined  sickness  often  precedes  the  taking  to  bed.  Fever,  with  its  height- 
ened temperature  and  frequent  pulse,  is  present,  as  are  also  the  dry  tongue, 
hebetude,  and  delirium  of  typhoid.  Yet  afebrile  cases  are  reported  by  Rein- 
hold  and  Eichhost.  It  differences  are  sought  in  the  fever  of  the  two  dis- 
eases, it  will  be  found  that  the  pulse  and  respiration  may  be  unduly  fre- 
quent as  compared  with  typhoid  fever,  but  above  all,  the  temperature 
will  be  found  to  differ  in  its  course  from  that  of  typhoid  fever.  There  is  an 
absence  of  the  characteristic  "tidal  wave"  rise  of  temperature  of  typhoid. 
There  is  an  evening  rise  and  a  morning  fall;  and  an  occasional  inversion, 
with  lower  evening  and  higher  morning  temperature,  takes  place,  which  is, 
however,  not  characteristic.  The  range  is  between  ioi°and  103°  F.  (38.3° 
and  39.4°  C),  but  may  reach  104°  or  105°  F.  (40°  or  40.5°  C).  The  coun- 
tenance is  apt  to  be  more  dusky  than  in  typhoid. 

Excessive  sweating  is  a  symptom  more  characteristic  of  acute  tuber- 
culosis than  of  typhoid  fever,  and  may  result  in  sudamina,  which  also  char- 
acterize the  latter  disease.  Herpes  is,  however,  often  present,  while  it  is 
rare  in  typhoid.  These  two  symptoms — i.  e.,  sweating  and  herpes,  together 
with  the  intermitting  fever — constitute  a  resemblance  to  malarial  fever. 
Waller  and  Eichhorst  have  fotmd  rose-colored  spots  on  the  abdomen  and 
breast,  but  they  are  certainly'  infrequent,  and  they  do  not  occur  in  crops  as 
in  typhoid  fever.  Enlargement  of  the  spleen  is  often  present  and  even  hemor- 
rhage from  the  bowels  has  been  noted.  Sleight  albuminuria  is  a  frequent 
symptom,  not  due,  as  might  be  expected,  to  a  tubercular  involvement  of  the 
kidney,  but  to  the  fever  process. 

Repeated  examinations  of  the  lungs  in  early  stages  faU  to  discover 
physical  signs  indicating  disease  of  these  organs,  and  thus  the  conclusion 
that  there  is  no  lung  involvement  is  apparently  confirmed.  Later,  however, 
pulmonary  symptoms  may  set  in,  also  meningeal  symptoms,  the  dtiration 
of  which  may  lead  to  a  suspicion  that  the  disease  is  not  typhoid  fever. 

There  may  be  pleural  or  pericardial  friction  and  other  symptoms  of 
pericarditis  and  pleurisy,  as  well  as  those  of  peritonitis  and  meningitis. 

Tuberculosis  of  the  choroid  coat  of  the  eye  has  been  frequently  met  in 
acute  miliary  tuberculosis,  more  particularly  in  cases  where  there  has  been 
the  widest  dissemination. 

In  rare  instances  bacilli  have  been  found  in  the  blood.  BacilU  are 
rarely  found  in  the  sputum  in  acute  general  tuberculosis,  because  in  this 
form  of  tuberculosis  the  tubercles  are  not  softened  and  the  bacilli  not  dis- 
charged into  the  bronchial  tubes  are  situated  not  in  the  open  air-passages  so 
much  as  in  the  interstitial  tissue  of  the  lung  and  in  the  blood-vessel  walls. 

Diagnosis. — As  stated,  acute  miliary  tuberculosis  resembles  especially 
typhoid  fever,  but  a  carefully  kept  temperature  chart  will  soon  exhibit  a 


280  INFECT  10  US  DISEA  SES 

difference  in  the  two  diseases  from  this  point  of  view.  If  tubercles  are 
found  in  the  choroid  the  question  is  settled  at  once.  Examination  of  a 
blood  culture  will  frequently  show  tj'-phoid  bacilli  in  typhoid  cases.  The 
duration  of  the  disease,  though  short,  is  usually  longer  than  that  of  typhoid 
fever.  The  Widal  reaction  in  typhoid  fever  and  its  absence  iia  tuberculosis 
are  valuable  aids  in  the  diagnosis. 

It  is  well  known  that  typhoid  fever  is  characterized  by  a  negative  leuko- 
cytosis, that  is,  a  diminution  rather  than  an  increase  of  leukocytes  in  the 
blood.  Observations  show  that  in  true,  uncomplicated  miliary  tuberculosis, 
there  is  also  wanting  an  increase  in  the  colorless  corpuscles  of  the  blood 
over  the  normal.  So  soon,  "however,  as  there  becomes  associated  with  the 
tuberculosis  any  catarrhal  or  suppurative  conditioii  of  the  parts  involved;  a 
leukocytosis  presents  itself..  A  Von  Pirquet  reaction  should  be  always 
made.  When  the  individual  is  young,  a  positive  reaction  is  of  the  greatest 
possible  importance.  A  positive  reaction  here  usually  means  the  condition 
is  tuberculous. 

The  resemblance  to  intermittent  fever  has  been  noted.  Here,  too,  a 
close  study  of  the  temperature  will  soon  show  the  difference,  while  a  search 
for  the  hematozoon  of  malaria  shoiild  be  made.  The  failure  of  quinin  to 
cure  will  settle  the  question  against  a  malarial  cause  for  the  fever. 

Prognosis. — The  course  is  invariably  toward  an  unfavorable  issue. 
Scarcely  ever  less  than  four  weeks  in  duration,  it  is  often  eight  and  even 
longer,  although  cases  are  reported  to  have  terminated  at  the  end  of  two 
weeks  and  even  twelve  days.  Such  must,  however,  be  extremely  rare. 
The  relative  shortness  of  duration,  nevertheless,  constitutes  it  one  of  the 
forms  of  galloping  consiunption.  Acute  miliary  tuberculosis  always  ter- 
minates fatally  sooner  or  later,  although  delusive  improvements  often  raise 
hopes  that  are  not  realized. 

Treatment. — Treatment  for  acute  miliary  tuberculosis  can  only  be 
symptomatic.  To  our  present  loiowledge  a  cure  has  never  been  accom- 
plished. Antipyretics  may  be  used  in  moderate  doses;  three  to  five  grains 
of  antipyrin,  antifebrin,  or  phenacetin,  the  last  probably  the  best,  frequently 
repeated,  abate  the  fever.  Anodynes  to  quiet  cough  are  also  necessary. 
Supporting  food  and  stirnvdants  are  indicated. 


3.  Meningeal  Form  of  Acute  ]\Iiliary  Tuberculosis.     Tuberculous 
Meningitis. 

Synonyms. — Tuberculous  Leptomeningitis;   Basilar  Meningitis;  Acute 
Hydrocephalus;  Water  on  the  Brain. 

Definition. — An  acute  inffammation  of  the  pia  mater  due  to  an  irruption 
of  miliary  tubercles  on  this  membrane  and  on  the  blood-vessels  proceeding 
from  it,  extending  also  at  times  to  the  corresponding  membrane  of  the 
spinal  cord. 

Etiology. — The  disease  consists  essentially  in  an  irruption  of  miHary 
tubercles  on  the  pia  mater,  with  resulting  inflammatory  product.  To  this 
end  there  must  be  somewhere  in  the  body  a  tubercular  focus  whence  the 
bacilli  start.     Tuberculous  bones  and  joints  may  furnish  such  a  focus,  but 


TUBERCULOSIS  281 

it  is  most  frequently  located  in  the  bronchial  or  mesenteric  glands.  Such 
focus  cannot  always  be  found,  even  when  present.  The  bare  possibility- 
of  a  primary  tubercular  meningitis  may,  however,  be  admitted,  in  which 
event  the  cribriform  plate  of  the  ethmoid  is  the  most  likely  route  of  badlli 
inhaled  from  the  external  atmosphere  through  the  nose  to  the  brain.  The 
disease  is  most  common  in  children  between  the  second  and  fifth  years, 
though  it  is  not  very  rare  in  adults,  long  subjects  of  tuberculosis. 

Morbid  Anatomy. — The  pia  mater  at  the  base  of  the  brain  is  the  most 
frequent  seat,  whence  the  common  term  basilar  meningitis.  Particularly 
are  the  neighborhood  of  the  optic  chiasm,  the  Sylvian  fissure,  the  inter- 
peduncular space  and  pons  varolii  involved.  In  addition  to  the  miliary 
tubercles  are  seen  turbidity  of  the  membrane  increasing  to  opacity,  the  whole 
smeared  over  with  fibrin  and  pus.  The  medulla  oblongata  and  base  of  the 
cerebellum  may  be  covered.  More  rarely  the  inflammation  may  extend  to 
the  lateral  and  convex  surfaces  of  the  brain.  Especially  do  we  find  the 
adventitia-sheaths  of  the  blood-vessels  invaded  by  the  tubercles,  which  are 
seen  in  the  bead-like  rows  when  the  vessels  are  withdrawn  from  the  sub- 
stance of  the  brain.  These  vessels  are  better  examined  when  spread  on  a 
dark  background,  with  a  low  magnifying  power.  Sections  of  blood-vessels 
should  be  made  also,  because  there  may  be  tubercular  infiltration  of  the 
intima,  causing  narrowing  and  obliteration  of  the  vessel.  The  cerebral 
convolutions  are  softened  to  a  slight  depth  by  the  invasion,  the  blood- 
vessels dragging  a  portion  of  the  brain-substance  when  drawn  out.  Thus 
there  is  really  a  meningo-encephalitis. 

The  lateral  ventricles  contain  a  varying  quantity  of  limpid  or  tiu-bid 
fluid,  a  dram  to  several  ounces,  the  ependyma  is  softened  and  swollen;  the 
septum  lucidum  and  fornix  are  disrupted.  The  convolutions  may  be  flat- 
tened because  of  the  pressure  exerted  between  the  dilated  ventricles  and 
unyielding  cranium.  More  rarely  there  is  a  chronic  process  like  that  de- 
scribed, but  slower  in  its  course.  As  already  mentioned,  the  pia  mater  of 
the  cord  may  be  involved,  resulting  in  the  same  turbid  picture. 

Symptoms. — The  symptoms  of  tuberctdar  meningitis  are  varied  and 
irregular  in  their  course.  At  times,  the  beginning,  at  least  to  the  superficial 
observer,  is  sudden.  At  others,  there  are  many  weeks  of  ill  health  with  ill- 
defined  symptoms  that  go  to  make  the  child  unhappy,  restless,  and  an  evi- 
dent sufferer.  In  the  course  of  such  weeks  the  child's  appetite  is  poor,  its 
tongue  coated,  its  bowels  are  constipated  or  the  reverse,  and  it  loses  weight. 
Such  a  chUd  may  have  been  convalescent  from  measles,  whooping-cough, 
bronchitis,  or  other  ills  of  childhood. 

An  attempt  has  been  made  with  more  or  less  success  to  divide  the  symp- 
toms of  the  disease  into  stages,  of  which  the  first  may  be  called  irritative; 
the  second,  that  of  subsiding  irritation;  the  third,  paralysis. 

I.  Irritative  Stage. — The  symptoms  most  constant  in  the  irritative 
stage  are  vomiting,  headache,  and  fever.  As  has  been  stated,  convulsions 
may  usher  in  the  attack,  and  these  convulsions  may  intermit  and  be  sepa- 
rated by  periods  of  some  length.  Sometimes  an  accident,  as  a  fall,  may 
be  an  exciting  cause,  and  the  first  vomiting  may  be  excited  by  a  meal  of 
food  unsuited  to  the  child's  age.  The  three  symptoms  mentioned  as  more 
constant  grow  in  severity,  especially  the  headache,  which  becomes  more 


282  INFECTIOUS  DISEASES 

or  less  incessant  and  intense,  so  that  the  child  is  never  free  from  it.  Yet 
there  may  be  a  lull  in  the  pain  as  the  result  of  treatment  or  other  cause, 
followed  by  an  acute  exacerbation,  which  probably  causes  the  peculiar  short 
cry  known  as  the  "hydrocephalic  cry."  In  other  cases  there  is  constant 
screaming,  which  points  to  the  degree  of  suffering.  The  child  rarely  sleeps 
more  than  a  few  minutes  at  a  time,  unless  imder  the  influence  of  powerful 
anodynes.  There  is  always  jever  in  this  stage,  though  it  may  not  be  very 
high,  103°  F.  (39.4°  C.)  being  commonly  the  maximum.  There  is  more  or 
less  delirium.  The  pulse  is  rapid,  even  rapid  disproportionately  to  the 
temperature,  while  breathing  rate  is  little  altered,  furnishing  a  symptom  of 
some  diagnostic  value.  Evidences  of  nervous  irritation  may  occur  early, 
more  commonly  late  in  this  stage.  The  convulsion  has  been  alluded  to. 
The  pupils  may  be  contracted,  irregular  of  oscillating,  there  may  be  stra- 
bismus and  nystagmus,  or  twitching  of  the  muscles  of  the  face  from  in- 
volvement of  the  facial  nerve. 

2.  Stage  of  Subsiding  Irritation. — In  the  second  stage  delirium  yields  to 
coma,  though  conviolsions  may  continue.  There  may  be  localized  rigidity 
of  the  muscles  of  one  limb  or  of  half  the  bod^^  The  head  may  be  retracted 
and  the  spine  arched,  due  to  rigidity  of  the  muscles  of  the  neck  and  back. 
Headache  is  not  complained  of,  though  the  child  still  may  occasionally  cry 
out.  The  pupils  are  dilated  or  irregular,  and  squint  is  more  marked  from 
oculomotor  or  third-nerve  irritation;  a  purulent  conjunctivitis  occurs; 
the  bowels  are  constipated;  the  abdomen  is  retracted — scaphoid.  The 
temperature  tends  to  be  lower,  but  is  variable.  There  is  often  a  patchy 
redness  of  the  skin  and  tdche  cerebrale  may  be  brought  out  by  drawing  the 
finger-nail  across  the  sldn. 

3 .  Stage  oj  Paralysis. — The  stupor  increases  and  may  be  profound.  Con- 
\Tilsions,  however,  still  occur.  They  may  be  localized  in  a  group  of  muscles 
or  those  of  one  limb,  or  they  may  be  unilateral.  On  the  other  hand,  there 
may  be  absolute  paralysis  of  the  oculomotor  nerves,  and  even  hemiplegia. 
As  a  result  of  the  former  the  pupils  are  dilated,  the  eyelids  partiall}-  closed, 
and  the  e3'e  turned  upward.  Hemiplegia  is  more  apt  to  occur  when  the 
fissure  of  Sylvius  is  invaded,  when,  too,  there  may  be  aphasia.  Optic  neu- 
ritis is  sometimes  present  in  this  stage,  usually  occurring  late,  due  to  inva- 
sion of  the  optic  nerve  within  the  skull.  The  facial  nerve  maj'  be  involved 
in  basilar  cases,  producing  slight  facial  paralysis;  so  may  the  fifth,  produc- 
ing anesthesia,  and  atrophic  changes  in  the  cornea  if  the  Gasserian  ganglion 
be  involved.  Hyperesthesia  of  the  special  senses  may  also  be  present, 
though  this  is  rather  a  symptom  of  the  first  stage.  Toward  the  end  a 
typhoid  state  may  supervene,  characterized  by  dry  tongue,  muttering 
delirium,  and  involuntary  discharge  of  urine  and  feces.  The  temperature 
at  this  stage  may  be  subnormal,  falling  as  low  as  93°  F.  (33.9°  C),  On  the 
other  hand,  the  temperature  sometimes  rises  just  before  death  to  106°  F. 
(41.1"  C.)  or  more.  The  entire  duration  of  the  disease  is  from  two  to  three 
weeks.     The  blood  examination  fails  to  find  a  characteristic  leukocytosis. 

Diagnosis. — In  the  diagnosis  we  have  first  to  recognize  the  presence  of 
a  meningitis,  and,  second,  to  separate  the  tubercular  meningitis  from  menin- 
gitis due  to  other  causes.  The  former  is  commonly  easy,  yet  mistakes  are 
often  made  because  so  many  of  the  head  symptoms  are  simulated  by  head 


TUBERCULOSIS  283 

symptoms  in  dyscrasic  conditions,  of  which  cholera  infantum  is  a  type,  whUe 
retraction  of  the  head  may  result  from  rheumatism  of  the  muscles  of  the 
back  of  the  neck;  but  optic  neuritis  and  paralytic  symptoms  are  confined 
to  meningitis.  The  presence  of  tuberculosis  elsewhere  strengthens  other 
signs.     Examination  of  the  spinal  fluid  will  show  tubercle  bacilli. 

The  other  varieties  of  meningitis  that  may  give  similar  symptoms  are 
meningitis  due  to  internal  ear  disease,  traumatic  meningitis  due  to  blows 
and  injuries,  syphilitic  meningitis  and  cerebrospinal  fever,  meningitis 
due  to  any  infecting  organism.  In  meningitis  due  to  ear  disease  the  history 
of  the  case  should  prevent  a  mistake.  Traumatic  meningitis,  especially 
with  abscess,  might  simulate  the  symptoms  described,  but  here,  too, the  history 
of  the  accident  would  be  helpful,  but  in  absence  of  a  knowledge  of  the  cause 
there  might  be  confusion.  Syphilitic  meningitis  is  usually  chronic,  involv- 
ing chiefly  the  convexity,  whence  cortical  symptoms,  especially  focal  con- 
vulsions. It  may,  however,  invade  the  base  of  the  brain,  when  it  is  more 
apt  to  be  limited  in  area  and  confined  to  one  side.  Basal  headache  and  signs 
pointing  to  localization  are  then  present.  Often  the  history  does  not  help 
us,  because  the  patient  denies  the  existence  of  the  specific  cause.  Cerebro- 
spinal fever  fiimishes  sometimes  identical  symptoms.  In  cerebrospinal 
fever  retraction  of  the  head  and  back  is  more  marked  and  there  is  more 
pain  in  the  trunk  muscles,  in  a  word,  more  symptoms  of  involvement  of 
the  spinal  membranes.  The  diagnosis  of  tuberculous  meningitis  is  most 
conclusively  established  by  spinal  puncture.  The  fluid  is  usually  clear,  con- 
tains lymphocytes,  does  not  reduce  Fehling's  solution  and  gives  a  globulin 
reaction.  Tubercle  bacilli  can  be  demonstrated.  In  cerebrospinal  fever  the 
fluid  is  usually  turbid  with  polymorphonuclear  cells  containing  meningo- 
cocci. 

Prognosis.- — The  prognosis  of  tuberculous  meningitis  well  established  is 
invariably  fatal.  On  the  other  hand,  the  chances  of  error  in  diagnosis  are 
so  many  that  it  is  not  wise  to  be  too  confident.  It  has  happened  more 
than  once  that  cases  in  children  recover  where  the  disease  has  been  thought 
present,  but  where  the  ultimate  result  proved  the  diagnosis  erroneous. 

Treatment. — Curative  treatment  is,  therefore,  futile,  but  for  the  same 
reason  should  be  persevered  in.  Spinal  puncture  may  be  practised  everj^ 
second  or  third  day  as  a  therapeutic  measure.  It  will  often  relieve  con- 
vulsions and  irregular  breathing.  Hexamethylenamine  should  be  adminis- 
tered in  doses  of  one  to  two  grains  .06  to  .12  every  two  or  three  hoiirs. 
In  addition  to  this  all  supporting  measures  possible  should  be  used  with 
such  treatment  of  symptoms  as  will  secure  the  least  suffering  to  the  little 
patient.  Where  the  suffering  is  great  morphin  should  be  used  hypoder- 
maticaUy.     Bromide  of  potassium  will  often  control  the  convulsions. 

Acute  Tuberculosis  of  the  Lungs. 
(6)  Pneumonic  Phthisis — Bronchopneimionic  Phthisis. 

This  more  unusual  form  of  tuberculosis  of  the  lungs  constitutes  one 
variety  of  ' '  galloping  consumption, ' '  or  phthisis  florida.  In  it  the  tubercular 
infiltration  is  by  a  rapid  peripheral  invasion  inciting  to  active  inflammation. 
This  is  manifested  as  a  bronchopneumonia,  by  which  the  air- vesicles  and 


284  INFECTIOUS  DISEASES 

bronchioles  are  variously  blocked  with  cheesy  matter.  The  result  is  the 
dissemination  through  extensive  areas  of  lung  tissue  of  opaque,  white  foci 
one-fifth  to  one-half  inch  (s  to  1 2  mm.)  in  diameter.  These  areas  are  usually 
separated  by  others  of  a  more  or  less  congested  but  still  crepitating  tissue, 
contrasting  strongly  with  the  white  of  the  tubercular  bronchopneumonic 
foci.  These  bronchopneimionic  foci  tend  to  soften  with  varying  rapidity, 
resulting  sometimes  in  nimierous  little  abscess  ca\'ities  throughout  the  lung. 
At  other  times  the  bronchopneumonic  foci  are  more  widely  separated  or  may 
be  limited  to  the  apices.  In  more  rare  instances  the  condition  may  succeed 
on  croupous  pneimionia,  forming  continuous  areas  which  may  also  extend 
throughout  a  lobe  or  entire  limg.  The  process  is  truly  pneumonic;  the 
results  resemble,  indeed,  more  a  limg  in  the  second  stage  of  croupous 
pnevunonia.  As  in  it,  too,  the  lung  is  heavy  and  airless,  sinking  rapidly  in 
water.  There  is,  however,  a  greater  tendency  to  disintegration  than  in 
croupous  pneumonia,  and  cavities  form  rapidly  in  the  apices  and  elsewhere. 

There  may  also  be  enlargement  of  the  bronchial  glands  in  either  of  these 
forms,  but  more  particularly  in  the  first — the  rapid  peripheral  extension. 

Symptoms. — The  bronchopnetunonic  form  of  constunption  occurs  most 
frequently  in  children  as  a  sequel  to  measles  or  whooping-cough.  In  such 
seemingly  ordinary  cases  of  bronchitis,  with  fever,  obstinate  cough,  and 
shortness  of  breath,  physical  examination  will  reveal  submucous  and  sub- 
crepitant  rales  throughout  the  chest  with  or  without  limited  areas  of  con- 
solidation. Tubercle  bacilli  and  elastic  tissue  appear  in  the  sputum.  The 
fever  continues  and  may  become  hectic,  with  sweats.  The  child  emaciates 
rapidly,  and  death  ensues  in  from  three  to  eight  weeks.  Other  cases 
originate  more  suddenly  and  with  less  apparent  cause  as  cases  of  simple 
bronchial  catarrh,  which  assume  the  graver  picture  described.  Such 
children  may  inherit  a  predisposition  to  phthisis. 

In  adults  the  attack  begins  as  an  ordinary  cold  in  a  person  -ndth  a  pre- 
disposition to  tuberculosis,  though  apparently  healthy,  or  run  down  with 
overwork.  The  cough  is  harassing,  and  soon  becomes  loose,  expectoration 
mucopurulent.  There  are  high  fever  and  rapid  wasting,  and  hemorrhage 
may  set  in  to  the  surprise  of  everyone  concerned.  Then  there  may  be  a 
lull  in  the  storm,  but  for  a  short  time  only.  The  symptoms,  and  especially 
the  burning  fever,  wear  out  the  patient.  Bacilli  and  elastic  tissue  will  now 
be  found  in  the  sputum  and  the  diagnosis  is  settled.  The  patient  may 
perish  in  three  weeks.  On  the  other  hand,  a  reactive  effort  toward  improve- 
ment may  take  place  and  after  a  time  be  followed  again  by  decline  and 
perhaps  again  by  improvement,  with  the  effect  of  prolonging  the  disease, 
but  not  of  altering  the  termination.  The  physical  signs  are  the  same  as  in 
children,  submucous  and  subcrepitant  rales  throughout  the  chest  -nath  or 
without  limited  areas  of  consolidation. 

The  pure  pneumonic  form  succeeding  what  seemed  to  be  croupous 
pneumonia  is  more  an  affection  of  adults.  More  rare,  still,  than  the  bron- 
chopneumonic form,  it  may  be  also  rapid  in  its  course.  It  begins  with  a 
chill  followed  by  fever,  often  after  exposure  to  cold,  wnth  pain  in  the  side, 
cough,  dyspnea,  mucous  and  rusty  sputum,  impairment  of  resonance, 
bronchial  breathing,  increased  vocal  fremitus — in  fact,  all  the  symptoms  of 
a  pneumonia  of  the  whole  or  a  part  of  a  lung,  which  may  be  an  upper  or  lower 


TUBERCULOSIS  285 

lobe.  If  the  lower  lobe,  it  is  probably  regarded  as  a  pneumonia  until  the 
absence  of  the  signs  of  resolution  call  attention  to  the  fact  that  something 
unusual  is  going  on.  Later,  softening  and  the  signs  of  a  ca\'ity  may  present 
themselves  at  the  apex,  and  baciUi  and  elastic  tissue  be  found  in  the  sputum. 
The  case  may  last  for  three  weeks  or  three  months,  or  even  pass  over  into  a 
chronic  phthisis. 

Diagnosis. — In  the  bronchopneumonic  form  it  is  difficult  to  make  the 
diagnosis  early  from  simple  bronchitis  and  bronchopneumonia.  The 
'temperature  in  phthisis  is  probably  more  irregular  and  higher.  Where  the 
disease  lasts  more  than  three  weeks,  the  sputum  should  be  examined  care- 
fully for  bacUli.  The  diagnosis  in  the  pnemnonic  form  can  never  be  made 
in  the  beginning,  because  the  symptoms  of  the  first  and  second  stages 
of  this  form  are  identical  with  those  of  the  first  and  second  stages  of  true 
pneumonia,  and  it  is  only  when  the  type  of  the  latter  disease  is  departed 
from  that  phthisis  can  be  suspected.  The  fever  in  true  pneumonia  should 
abate  by  the  ninth  day  or  twelfth  day  at  latest,  and  if  it  continue  after  that 
time  acute  tuberciilosis  should  be  suspected  and  the  expectoration  should 
be  examined  for  bacilli. 

Prognosis. — The  prognosis  is  very  urufavorable  in  this  form  of  con- 
sumption, death  being  frequent  in  from  a  few  weeks  to  a  few  months. 

Treatment. — Treatment  of  the  acute  stage  is  symptomatic:  fresh  air 
and  absolute  rest  are  most  important.  After  the  acute  stage  it  is  that  of 
chronic  phthisis. 


Chronic  Pulmonary  Tuberculosis. 

Synonyms. — Phthisis   pulmonalis;  Pulmonary   Consumption;   Consumption 
of  the  Lungs. 

(a)  Chronic  Tuberculosis  of  the  Lungs. 

Morbid  Anatomy. — This  most  usual  fonh  of  consumption,  beginning 
with  the  tubercle  and  associated  with  more  or  less  infiltration  of  the  apex, 
extends  thence  slowly  downward.  The  deposit  in  the  beginning  is  not 
actually  in  the  very  apex,  but  a  little  below  it,  and  usually  the  first  point  at 
which  physical  signs  are  found  is  on  the  middle  of  the  clavicle  or  just  below 
it.  Sometimes,  however,  the  extension  is  rather  backward,  so  that  the 
physical  signs  are  first  manifested  in  the  supraspinous  fossa,  whence  the 
importance  of  always  insisting  on  the  posterior  examination. 

From  this  initial  focus,  usually  toward  the  anterior  face  of  the  lung, 
the  disease  extends  more  or  less  throughout  the  lobe,  or  it  may  pass  to 
another  lobe.  If  the  disease  be  on  the  right  side,  from  the  upper  it  may 
extend  to  the  middle  lobe,  and  thence  into  the  lower  lobe  about  an  inch 
below  its  apex,  corresponding  also  to  a  point  on  the  surface  opposite  the  fifth 
dorsal  spine.  On  the  left  side,  the  extension  is  directly  from  the  upper  to 
the  lower  lobe.  From  its  previous  focus  the  tubercular  infiltrate  travels 
centripetally  along  the  bronchi  from  smaller  to  larger  as  a  tuberculous  peri- 
bronchitis. Larger  and  larger  branches  become  implicated  with  the  in- 
termediate parenchyma,  but  usually  it  does  not  extend  beyond  the  cartilage- 


286  INFECTIOUS  DISEASES 

ringed  bronchi  of  the  second  order,  forming  tubercular  masses  of  correspond- 
ing size. 

The  infiltration  is  not  limited  to  peribronchial  tissue.  It  extends  also 
inward  toward  the  lumen  of  the  tube,  invading  the  submucous  tissue,  where 
it  may  be  seen  as  whitish  or  cloudy  patches  on  slitting  up  the  bronchi  and 
washing  off  the  adherent  mucopus.  Thus  uncovered,  the  mticous  mem- 
brane is  found  also  red  and  inflamed,  contrasting  strongly  with  the  whitish 
patches  referred  to.  As  we  penetrate  deeper,  these  enlarge  and  intrude  upon 
the  lumen  of  the  tube,  while  the  hyperemic  areas  grow  smaller.  Such 
intrusion  becomes  finally  complete  invasion,  associated,  sooner  or  later, 
with  an  excoriation  or  rupture  of  the  mucous  membrane.  This  is  the 
beginning  of  idceration,  which  assumes  an  important  place  in  facilitating 
subsequent  destructive  process,  and  is  the  foundation  of  the  term  adopted 
for  this  form  of  phthisis,  chronic  ulcerative  phthisis. 

The  pathological  process  referred  to,  and  the  destructive  effects  of 
which  they  are  the  cause,  give  to  the  lung  in  a  state  of  chronic  phthisis  a 
varied  picture  that  is  not  always  found  in  a  single  case,  nor,  indeed,  would 
the  lesions  of  two  or  more  cases  always  cover  this  picture.  They  include 
the  following: 

1.  The  caseous  tubercular  masses.  They  embrace  single  or  compound 
peribronchial  foci  perforated  by  the  central  bronchiole,  itself  plugged  with 
cheesy  matter.  Thus  constituted  they  form  grayish-yellow  masses  from  a 
couple  millimeters  to  four  or  five  centimeters  (1/12  to  2  inches)  in  diameter. 
They  have  the  composition  already  described.  Though  usually  massed 
toward  the  apices  of  the  lung,  they  may  also  be  disseminated  through  the 
remainder  of  the  organ,  and  around  them  there  maj^  also  be  found  scattered 
true  miliary  tubercles. 

2.  The  second  anatomical  feature  of  the  phthisical  lung  is  the  cavity. 
As  soon  as  a  tuberculous  area  reaches  a  certain  size,  the  tendency  to  break 
down  is  increased,  though  such  tendency  does  not  depend  altogether  on 
extent.  The  bronchial  wall,  weakened  by  the  tubercular  infiltration  and  the 
ulceration  referred  to,  is  the  initial  invitation.  The  wall  yields  to  the 
pressure  which  it  formerly  easily  resisted — the  inspiratory  and  expirator\- 
strain  incident  to  coughing — the  bronchus  dilates,  the  gap  of  the  ulcer  widens 
and  the  texture  of  the  bronchus  gradually  yields.  The  free  access  of  air  to 
the  already  necrotic  caseous  matter  causes  it  to  soften,  break  down,  and  a 
cavity  results.  Small  foci  unite  with  others  and  thus  larger  cavities  form, 
occupying  the  greater  part  of  a  lobe,  or  even  a  whole  lung  in  very  rare 
instances. 

Large  cavities  have  usually  smooth  walls  and  are  lined  by  the  so-called 
pyogenic  membrane,  into  which,  however,  often  protrude  blood-vessels  of 
large  size,  as  thick  as  a  crow-quill,  exliibiting  also  at  times  and  aneurysmal 
dilatations.  Rarely  such  vessels  pass  directly  across  a  cavity,  and  when 
eroded  they  may  give  rise  to  fatal  hemorrhage  toward  the  end  of  a  case  of 
chronic  phthisis.  On  the  other  hand,  these  vessels  may  also  become  thor- 
oughly occluded  by  an  obliterating  endarteritis.  The  surface  of  these 
smooth-walled  cavities  is  constantly  producing  pus,  while  muco-pus  is  being 
added  by  communicating  bronchi.  Such  cavities  may  be  more  or  less 
completeh'   emptied  by  expectoration.     They  are  also   surrounded  by  a 


TUBERCULOSIS  287 

consolidated  lung  tissue,  which  gives  a  dull  percussion  note  and  thus  often 
prevents  the  tympany  natural  to  a  cavity.  Small  cavities  have  rough  and 
ragged  walls,  from  which  there  is  constant  breaking  down,  adding  elastic 
tissue,  pus,  grandular  debris,  and  bacilli  to  the  matter  expectorated.  There 
may  be  a  number  of  these  small  cavities,  and  if  under  the  pleura  one  may 
rupture  into  the  pleural  sac,  producing  pneumothorax. 

Other  cavities  form  by  the  softening  of  the  center  of  a  caseous  area. 
Others  stUl  may  be  purely  bronchiectatic,  being  limited  by  bronchial  walls. 
It  is  more  particularly  the  bronchi  of  medium  size  that  are  thus  involved, 
weakened  also  by  tubercular  infiltration.  The  form  of  dilatation  may  be 
cylindrical  or  globular.  The  small  tubes  especialh^  may  be  the  seat  of 
cylindrical  dilatation. 

3.  Pleurisy  is  constantly  associated  with  tuberculosis  of  the  lungs.  It  is 
found : 

(a)  As  an  adhesive  pleurisy  in  the  immediate  neighborhood  of  tuber- 
cvdar  infiltration. 

(h)  There  may  be  perforation  from  a  cavitj'  into  the  pleural  sac,  exciting 
a  piirulent  pleurisy  or  a  pyopneumothorax. 

(c)  Finally,  the  pleura  may  be  the  seat  of  a  tubercular  plevuisy,  result- 
ing in  a  thickened  membrane,  which  may  be  limited  or  may  encase  the  whole 
lung  and  cement  the  lobes  in  a  continuous  inseparable  mass. 

4.  Pulmonary  concretions  are  also  found  in  the  phthisical  lung,  usuall}' 
about  half  as  large  as  a  pea,  smooth  or  lobulated.  They  represent  calcareous 
infiltration  of  alveoli^  of  the  lung,  filled  with  tubercular  bronchopneumonia 
products.  They  are  a  medium  of  one  form  of  healing  of  tuberculosis. 
Those  retained  in  the  lung  are  com.monly  surrounded  by  a  ring  of  hyper- 
plastic connective  tissue.  At  times  they  are  expectorated,  being  released  by 
a  sequestrating  supptiration  into  an  adjacent  bronchus,  whence  they  are 
brought  up  by  coughing.  Sometimes  a  good  many  are  coughed  up.  They 
are  something  different  from  bronchial  calculi,  which  are  always  smooth, 
spherical,  or  elliptical,  and  are  found  in  small  bronchiectatic  cavities. 

5.  Other  evidences  of  attempts  at  healing  seen  in  the  phthisical  lungs 
are  of  the  nature  of  reactive  infiammation.     They  may  occur : 

(a)  In  the  initial  stage  as  the  i;esult  of  treatment  and  favorable  hygienic 
surroundings,  when  the  initial  granule  is  replaced  by  a  cicatricial-like  pucker- 
ing of  fibrous  tissue  or  a  hard  cartilaginous  mass  of  coimective  tissue. 

{b)  There  may  be  a  sequestration  or  encapsulation  of  a  cheesy  nodule, 
which  may  or  may  not  undergo  calcareous  infiltration. 

(c)  Even  a  cavity  of  moderate  size  may  heal,  in  which  event,  the  cavity 
being  cleared  out,  its  walls  unite  by  adhesive  infiammation  and  thus  a  band 
of  cicatricial  tissue  takes  the  place  of  the  ca\'ity.  Larger  cavities  may  be 
reduced  in  size  by  a  contraction  of  the  cicatricial  tissue  surrounding  them, 
or  several  small  cavities  may  be  thus  surrounded.  Quite  small  cavities 
surrounded  by  connective  tissue  and  communicating  with  a  bronchus  were 
called  cicatrices  fistuleuses  by  Laennec. 

6.  The  neighborhood  of  a  tuberciilar  infiltration  is  often  the  seat  of  a 
pneiamonia  which  may  be  simply  reactive  or  due  to  the  irritative  effect  of 

.  t 

*  If  macerated  in  hydrochloric  acid,  the  lime  salt  can  be  dissolved  out,  and  the  actual  elastic  tissue 
framework  of  an  alveolus,  with  its  infundibula  and  attached  air-vessels,  be  left. 


288  INFECTIOUS  DISEASES 

the  bacillus — i.  e.,  a  tubercular  bronchopneumonia.  The  area  is  hyperemic, 
hard,  consolidated,  and  the  air-vesicles  filled  with  exfoliated  epithelium. 
The  latter  may  exhibit  various  stages  of  fatty  degeneration.  It  may  be 
complete  when  an  appearance  indistinguishable  from  that  of  tubercular  in- 
filtration is  present.  In  fact,  it  is  tubercular  infiltration  plus  catarrhal 
pneumonia. 

7.  When  a  subject  dies  of  tubercular  phthisis,  other  organs  should  be 
searched  for  tubercles.  Tuberculosis  of  the  larynx  is  common  and  is  not 
infrequently  associated  with  destruction  of  the  cords  and  epiglottis.  The 
bronchial  glands  are  usually  involved,  swollen,  inflamed,  or  tubercular,  and 
when  tubercular  may  become  caseous  and  sometimes  calcareous.  Other 
glands  are  also  affected,  such  as  the  cervical,  mediastinal,  and  postperito- 
neal.  After  the  bronchial  glands  the  organs  most  affected  are  the  intestine; 
next,  the  spleen,  kidneys,  and  brain  in  nearly  equal  proportion;  then  the 
liver  and  the  pericardium. 

8.  The  only  remaining  morbid  states  which  may  be  considered  as  hav- 
ing any  essential  relation  to  tuberculosis  of  the  lungs  are  the  amyloid  and 
Jatty  infiltration.  The  former  is  found  affecting  the  kidneys,  liver,  spleen, 
and  mucous  membrane  of  the  intestines;  the  latter,  especially,  the  liver 
and  kidney. 

Symptoms. — The  onset  of  tuberculosis  of  the  lungs  is  by  no  means 
uniform.  Notwithstanding  the  fact  that  its  insidious  nature  is  well  recog- 
nized, its  initial  stage  is  often  overlooked.  The  \'ictim  is  scarcely  appreci- 
ably ill.  Yet  he  may  lose  flesh  and  strength  continuously.  He  may  even 
say  that  he  had  no  cough,  while  close  questioning  will  ascertain  that  he  has 
had  a  slight  hacking  cough  for  some  time,  worse  in  the  morning.  Soon  the 
symptoms  are  plainer,  there  is  evident,  wasting  an  intermittent  fever,  a  bright 
eye,  and  the  cough  with  expectoration  is  a  conspicuous  symptom.  Yet 
during  all  this  the  patient  is  cheerful  and  denies  that  there  is  much  the  matter 
with  him. 

In  another  instance  an  indi\adual  is  "subject  to  cold";  he  takes  cold 
repeatedly,  and  each  attack,  while  passing  away,  yields  more  stubbornly 
than  the  previous  one,  and  finally  one  comes  that  persists.  There  is  daily 
fever  which  abates  to  return  again,  emaciation  is  evident,  and  the  bright  eye 
and  burning  cheeks  and  night-sweats  again  attest  the  arrival  of  the  dread 
disease. 

Another  case  maj'  begin  with  hoarseness,  due  probably  to  tuberculosis 
of  the  larynx. 

Again,  after  a  stubborn  attack  of  bronchitis  in  a  person  pre\'iously 
healthy  a  hemorrhage  of  the  lungs  unexpectedly  makes  its  appearance,  or 
such  a  hemorrhage  may  set  in  without  previous  warning,  although,  again, 
careful  inquiry  may  find  that  cough  has  been  present  for  some  time.  The 
patient  has,  perhaps,  previously  been  overworked,  or  lived  under  unfavor- 
able hygienic  surroundings,  or  may  possess  a  hereditary  tendency. 

In  still  another  instance  a  patient  may  consult  the  physician  without 
suspecting  that  he  is  very  ill,  and  the  signs  of  advanced  disease  of  the 
apices  will  be  found  present,  and  there  may  be  but  a  few  more  months  life 
remaining  to  the  unsuspecting  victim. 

A  certain  number  of  cases  of  consumption  begin  as  tuberculous  pleurisy. 


TUBERCULOSIS  289 

which  invades  the  lung  by  contiguity  or  by  blood  infection.  One  of  the 
most  convincing  facts  in  favor  of  the  infectious  theory,  which  seemed 
established  prior  to  the  discovery  of  the  bacillus,  was  the  frequent  occurrence 
of  pleurisy  as  a  forerunner  of  phthisis.  It  was  held  that  the  caseous  product 
of  the  pleurisy  furnished  the  infectious  virus,  which,  entering  the  blood, 
caused  tubercle  formations  in  various  parts  of  the  body.  Thus,  one-third 
of  the  90  cases  of  pleurisy  followed  up  by  Bowditch  terminated  in  phthisis. 

Inveterate  dyspepsia  is  associated  with  many  cases  and  is  as  often  a 
predisposing  cause  as  a  symptom.  A  great  loss  of  appetite  and  indisposi- 
tion to  take  food  are  often  symptomatic,  and  their  presence  does  much  to 
diminish  the  efficiency  of  remedies  and  nutriments  so  essential  to  success- 
fully combat  the  disease.  Anemia  is  a  constant  early  symptom.  Dyspnea 
is  common  as  an  early  sign,  usually  the  result  of  weakness  rather  than  large 
involvement  of  the  lungs. 

Physical  Signs.- — Given  the  suspicion  of  the  existence  of  tubercular  con- 
sumption from  the  presence  of  the  above  symptoms,  whatever  others  may 
be  superadded,  or  whatever  modification  may  occur  in  them,  the  diagnosis 
is  completed  by  a  physical  examination.  An  evening  rise  of  temperature 
with  anemia  and  while  it  is  not  always  easy  to  separate  the  clinical  history 
of  a  case  of  consumption  into  three  sets  of  symptoms  corresponding  to  the 
three  separate  stages  in  the  morbid  anatomy,  the  physical  signs  corre- 
sponding with  these  stages  are  tolerably  definite.     They  are: 

1.  The  incipient  stage,  or  beginning  deposit. 

2.  Stage  of  complete  consolidation. 

3.  Stage  of  softening  and  cavity  formation. 

1.  Inspection,  in  the  incipient  stage,  is  as  often  negative  as  not.  A 
slightly  diminished  expansion  in  the  infraclavicular  space,  as  compared  with 
the  opposite  side,  may  be  present,  and  more  rarely  a  slight  flattening  of  the 
same  region.  The  clavicle  becomes  correspondingly  conspicuous.  The 
body  may  continue  well  nourished  or  slightly  emaciated,  or  the  heart-beat 
in  the  normal  position  may  be  soraewhat  accelerated,  while  the  respirations 
are  likely  to  be  more  frequent  than  in  health. 

Palpation  may  recognize  increased  vocal  fremitus  in  the  same  situation, 
although  not  always,  while  the  physiological  difference  in  favor  of  the  right 
side  is  to  be  remembered.  Percussion  in  this  stage  gives  slightly  higher 
pitch  and  impairment  of  resonance,  which  may  be  noted  above,  on,  or  below 
the  clavicle.  Usually  the  resonance  on  the  affected  side  does  not  extend 
as  high  above  the  clavicle  as  it  does  on  the  normal  side.  It  sometimes  hap- 
pens that  increased  resonance  is  obtained  by  percussion  in  the  earliest  stage 
of  pulmonary  tuberculosis.  This  arises  in  the  following  way:  The  lung 
is  engorged  and  in  consequence  relaxed,  in  which  condition  the  air  within 
the  vesicles  vibrates  more  freely,  the  result  being  a  full  clear  note  (Skodaic 
reasonance) . 

To  auscultation  above  or  below  the  clavicle,  we  have  the  first  evidence 
of  abnormality  in  a  prolongation  of  the  expiratory  murmur  and  harshness  in 
the  inspiratory  sound.  Theoretically,  this  should  be  preceded  by  a  di- 
minished intensity  in  the  inspiratory  sound,  owing  to  the  interference  of  the 
newly  deposited  tubercles  with  the  entrance  of  air  into  the  air-vesicles,  but 

19j 


290  INFECTIOUS  DISEASES 

practically  such  diminished  intensity  is  rarely  encountered,   and  even  if 
present  is  not  of  distinctive  significance. 

Increased  vocal  resonance  is  a  constant  accompaniment  of  these  modi- 
fications in  the  normal  breathing-sounds,  but  it,  as  well  as  the  vocal  fremitus, 
may  be  masked  by  a  pleuritic  thickening,  and  the  physiological  difference  so 
often  referred  to  must  be  remembered.  J.  M.  DaCosta  also  called  attention 
to  the  fact  that  in  a  certain  number  of  cases,  at  this  stage,  there  is  a  blowing 
sound  in  the  subclavian  or  pulmonary  artery,  and  that  a  murmur  is  some- 
times present  in  these  vessels  before  any  other  physical  sign  is  noted. 
There  are  frequently  concurrent  with  these  signs  those  of  a  bronchitis  more 
or  less  acute.  It  must  not  be  forgotten  that  the  signs  of  early  infiltration 
may  begin  in  any  portion  of  the  lung. 

2.  In  the  second  stage  the  changes  discoverable  by  inspection  are  more 
easily  recognized.  There  is  evident  loss  of  flesh,  depression  of  surface,  and 
impaired  range  of  respiratory  movement.  The  hectic  flush  is  intermittingly 
present.  Palpation  may  even  discover  an  increased  warmth  of  sldn.  The 
increased  vocal  fremitus  is  now  plainly  recognized  unless  obscured  by  a 
thickened  pleural  membrane.  Dullness  on  percussion  is  positive  and  easily 
elicited. 

To  auscultation  there  is  increased  vocal  resonance.  The  bronchial 
factor  in  the  breathing  now  becomes  conspicuous,  showing  itself  by  the 
harshness  and  relative  shortening  of  the  inspiratory  element,  with  the 
decidedly  prolonged  and  blowing  expiration;  also  a  gradual  diminution  of 
the  vesicular  factor,  until  the  latter  disappears  entirely,  when  we  have  the 
typical  bronchial  breathing  of  extended  areas  of  tubercular  infiltration. 
This  sign  will  now  be  found  in  the  supraspinous  fossa  posteriorly  as  well  as 
anteriorly.  The  conduction  of  the  normal  heart  sounds  to  the  area  of  in- 
filtration, if  at  either  apex,  is  a  very  frequent  and  significant  sign.  The 
high  degree  of  vocal  resonance  known  as  bronchophony  in  also  superadded 
as  a  valuable  confirmation  of  the  presence  of  complete  consolidation.  The 
auscultation  signs  of  a  concurrent  bronchitis  may  also  be  present  in  this 
and  in  the  next  page. 

3.  In  the  third  stage  the  information  furnished  by  inspection  is  still 
more  positive.  Emaciation  is  marked,  breathing  and  the  pulse  are  rapid, 
and  the  face  is  often  flushed.  There  is  flattening  over  the  affected  area,  and 
the  excursion  of  respiratory  movement  is  still  more  limited.  In  this  stage 
the  superficial  veins  over  the  involved  area  maj'  be  prominent,  partly  from 
emaciat  ion  and  partly  from  obstructed  circulation.  To  palpation  the  vocal 
fremitus  is  still  more  marked,  and  even  remains  distinct  over  cavities,  be- 
cause of  the  consolidation  around  them,  unless  there  be  some  obstruction 
to  the  entrance  of  air  into  the  bronchus  leading  to  the  involved  area.  The 
skin  is  hot  and  dry,  unless  succeeding  one  of  the  sweats  that  characterize 
this  stage,  when  it  may  be  moist  and  clammy. 

Dullness  on  percussion  is  always  to  be  found  in  the  third  stage,  but  to 
it  is  often  added  some  one  of  the  varieties  of  tympanitic  note — viz.,  pure 
tympany,  the  "cracked-pot"  sound,  or  amphoric  resonance,  due  to  cavities. 
These  require  sufficient  size  and  superficial  situation  on  the  part  of  the 
cavity.  On  the  other  hand,  resonance  may  even  be  normal  over  a  cavity 
some  distance  from  the  surface,  especially  if  the  percussion  be  lightly  made, 


TUBERCULOSIS  291 

while  the  consolidated  tissue  which  almost  invariably  surrounds  a  cavity 
often  permits  only  a  dull  sound  to  be  elicited.  Wintrich's  change  of  note 
should  be  sought — a  change  of  note  produced  during  percussion  over  a  cavity 
on  opening  and  closing  the  mouth,  the  pitch  being  higher  when  the  mouth  is 
open. 

Auscultation  in  this  stage  may  continue  to  recognize  the  bronchial 
breathing  of  the  second,  but  to  it  are  superadded  first  small  bubbling  sounds 
or  subcrepitant  rS,les  indicating  liquefaction;  later,  may  be  added  the  dis- 
tinctive signs  of  a  cavity.  These  signs  are  cavernous  breathing,  cavernous 
voice,  pectoriloquy,  either  whispering  or  loud  speaking,  amphoric  breathing, 
and  amphoric  voice.  To  these  are  often  added  the  large  bubbling  soimds 
known  as  gurgling,  caused  by  the  air  bubbling  through  fluid  in  a  cavity. 
Metallic  tinkling  may  be  added  to  these  phenomena,  caused  by  the  bursting 
of  bubbles  in  a  cavity  with  amphoric  conditions. 

"Cavernous  breathing,"  generally  speaking,  is  any  modification  of  the 
normal  breathing  sounds  due  to  the  air  passing  in  and  out  of  a  cavity. 
When  high  pitched  it  becomes  tubal  or  amphoric.  The  amphoric  sound  is 
supposed  to  occur  in  cavities  with  firm  walls  that  best  secure  the  "echo- 
ing," which  is  the  condition  of  amphoric  breathing  and  amphoric  percussion. 
Over  more  yielding  walls  the  breathing  is  lower  pitched,  and  to  this  the 
term  "cavernous"  is  especially  applied. 

Special  Symptoms. — The  cough  of  consumption  varies  greatly.  It  is 
at  first  very  slight,  and  may  continue  so  even  in  advanced  stages.  As  a 
rule,  however,  it  grows  in  severity  with  the  progress  of  the  disease.  It  is 
caused  by  the  irritation  of  interciurrent  bronchitis  or  bronchopneumonia  or 
the  accumulated  contents  of  cavities.  When  a  cavity  becomes  more  or  less 
filled  with  secretion  it  must  be  emptied,  and  a  spell  of  coughing  comes  on 
and  continues  until  the  cavity  is  cleared  but,  whence  the  paroxysmal 
character  so  often  assumed  by  the  cough  when  this  stage  is  reached. 

The  expectoration  of  tuberculosis  varies  with  the  stage  of  the  disease. 
At  first  scanty,  and  in  no  waj'  characteristic,  it  grows  more  copious  and 
becomes  puriform  as  the  disease  progresses.  A  more  or  less  circular  shape 
is  finally  assumed,  which  is  somewhat  distinctive,  and  is  called  "num- 
mtdar,"  from  its  resemblance  to  a  coin.  The  quantity  of  expectoration 
varies  greatly,  from  1/2  ounce  (15  c.c.)  to  1/2  pint  (250  c.c.)  in  the  24 
hours.  It  generally  has  a  sweetish,  unpleasent  odor,  but  is  rarely  offensive. 
It  is  sometimes  tinged  with  blood,  and  may  contain  Charcot's  crystals 
(p.  297). 

Minutely,  the  expectoration  is  made  up  chiefly  of  pus-corpuscles,  among 
which  may,  however,  be  found  epithelial  cells  from  the  mouth  and  lung 
alveoli,  elastic  tissue  from  the  air-vesicles,  more  rarely  from  the  bronchial 
tubes  or  blood-vessels,  bacilli,  oil  drops,  particles  of  food,  generally  innumer- 
able tubercle  bacilli,  and  at  times  blood-disks.  The  elastic  tissue  is  most 
easily  demonstrated  by  boiling  the  sputum  in  a  test-tube  with  an  excess  of 
solution  of  potash  or  soda,  the  effect  of  which  is  to  thin  the  sputum  and 
permit  the  elastic  tissue  to  fall  to  the  bottom  of  the  tube;  whence  it  is  easily 
carried  by  the  pipet  to  the  glass  slide  and  recognized  under  the  microscope 
by  its  wreath-like  or  circular  shape,  if  derived  from  the  air-vesicles.  Care 
must  be  taken  to  eliminate  fibers  of  elastic  tissue  that  may  be  derived  from 


292  INFECTIOUS  DISEASES 

food.  To  this  end  the  mouth  should  be  carefully  rinsed  before  collecting 
sputum  for  examination,  and  it  is  further  to  be  remembered  that  particles 
of  food  containing  such  tissue  may  remain  in  the  mouth  for  two  or  three  days. 
The  clastic  tissue  from  the  bronchi  occurs  in  the  shape  of  elongated  or 
reticular  fibers.  That  from  blood-vessels  is  similar;  more  rarely  it  is 
fenestrated  membrane.  The  alveolar  epithelial  cells  are  round  and  oval, 
mononucleated,  highly  granular,  nearly  twice  the  diameter  of  a  pus- 
corpuscle. 

The  bacilli,  which  are  an  unfailing  sign  of  tuberculosis,  are  demon- 
strable only  by  special  staining  methods,  of  which  that  by  carbol-fuch- 
sin,  with  or  without  Gabbet's  counter  stain  of  methyl-blue  is  recommended. 

One  of  the  most  impleasant  consequences  of  the  cough  is  the  vomiting 
which  it  induces,  more  especiall)'  in  the  last  stages  of  the  disease.  It  is  not 
unusual  to  throw  up  a  meal  immediately  after  it  is  taken.  Such  vomiting 
is  probably  a  reflex  act,  excited  by  irritation  of  the  pharynx  in  coughing. 
Fortunate  is  the  patient  who  can  immediately  thereafter  take  another 
meal,  since  this  meal  is  generally  retained,  because  the  accumulated  muco- 
pus  which  caused  the  coughing  spell  is  also  thrown  up  with  the  food  in  the 
first  act  of  vomiting,  and  the  cough  ceases  for  a  while. 

Pain  is  not  inherent  to  tuberculosis — that  is,  the  seat  of  a  tubercular 
infiltration  is  not  usually  a  seat  of  pain.  Pain  is,  however,  a  frequent  sec- 
ondary symptom.  It  is  most  severe  as  the  result  of  a  concurrent  pleurisy, 
when  it  is  usually  sharp  and  cutting  at  the  site  of  the  pleurisy.  Pain  also 
results  from  inveterate  cough. 

Fever  is  a  symptom  of  all  stages  of  pulmonary  consumption.  At  the 
onset  there  may  be  fever  of  an  irritative  kind,  due  to  deposition  of  the 
tubercle  and  to  inflammation.  This  is  a  fever  of  a  continued  type  with 
slight  evening  increments,  often  overlooked,  until  it  becomes  associated 
with  hectic  fever,  which  is  a  septic  fever  occurring  during  softening  and 
cavity  formation.  Hectic  fever  is  one  of  the  most  interesting  symptoms  of 
consumption,  adding  often  a  picturesqueness  that  increases  the  sadness  of 
the  situation.  Coming  on  usually  toward  the  end  of  the  day,  the  maximum 
point  is  reached  at  no  fixed  hour,  but  generally  occurs  between  2  and  6  P.M., 
though  it  may  be  as  late  as  10  P.M.  The  minimum,  usually  noted  between 
2  A.  M.  and  6  A.  M.,  may  occur  as  late  as  12  noon.  Hence,  frequent 
observations  of  temperature  should  be  made  during  the  day  and  night, 
two  in  24  hours  being  inadequate.  Once  in  four  hours  is  not  infrequently 
desirable,  and  where  careful  study  is  desired,  once  in  three  hours  may  be 
necessary.  The  chart  (Fig.  95),  on  page  293,  shows  extreme  range  of 
temperature  in  hectic  fever. 

There  is,  however,  no  greater  mistake  than  to  suppose  that  every  case 
of  tuberculosis  of  the  limgs  must  have  fever  throughout.  It  probably 
always  has  fever  in  the  beginning — the  fever  of  onset;  but  with  the  disease 
once  established  it  frequently  happens  that  there  is  no  fever  in  any  part  of 
the  24  hours.     Appended  is  a  chart  of  such  a  case  (Fig.  96). 

In  the  course  of  a  case  of  consumption  it  constantly  happens  that 
periods  occur  of  various  dtu-ation,  from  one  to  seven  daji-s,  in  which  the 
fever  is  higher  than  usual  with  moderate  remissions,  say  of  one  degree,  and 
attended  with  increased  localized  pain.     These  are  explained  by  the  occur- 


TUBERCULOSIS 


293 


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294 


INFECTIOUS  DISEASES 


rence  of  new  patches  of  bronchopneumonia,  which  may  be  either  simple  or 
tubercular. 

The  fever  of  hectic  is  generally  followed  by  sweating,  sometimes  lim- 
ited to  the  head  or  the  neck.  The  occurrence  of  sweats  in  the  night,  or 
rather  toward  morning,  has  given  rise  to  the  term  "night-sweat."  They 
are  not,  however,  confined  to  the  night,  but  may  occur  at  any  time,  especially 
during  sleep. 

The  pulse  is  always  frequent  in  tuberculosis  of  the  lungs  and  gradually 
grows  feebler  as  the  disease  progresses. 

Hemorrhage  from  the  lungs  is  a  symptom  everywhere  associated  with 
the  idea  of  tuberculosis  of  the  lungs.  There  are  two  periods  in  which  it 
occurs — one  early  and  one  late.  The  early  hemorrhages  are  usually 
moderate  and  are  due  to  the  rupture  of  blood-vessels  weakened  by  tuber- 
cular infiltration.  They  are  sometimes  the  very  first  annoimcement  of 
the  presence  of  the  disease,  at  others  they  are  a  means  of  relief  to  a  certain 


). — Temperature  Chart  of  a  Case  of  Tubercular  Consumption  without  Fever,  long  under 
treatment  at  the  Hospital  of  the  University  of  Pennsylvania. 


feeling  of  oppression  in  the  chest  which  precedes  them.  A  great  danger  is 
production  of  an  insufflation  pneumonia  by  the  inspiration  of  small  par- 
ticles of  clot  that  act  as  irritants.  In  such  cases  the  blood  probably  comes 
from  the  mucous  membrane  of  the  bronchial  tubes.  The  hemorrhages 
late  in  the  disease  are  commonly  large,  sometimes  enough  to  cause  imme- 
diate death.  The  amoimt  of  blood  lost  in  such  a  fatal  case  has  reached  four 
potmds  (1.8  kilos) .  Yet  enormous  hemorrhages  are  sometimes  survaved. 
They  are  due  to  tilceration  into  a  large  blood-vessel,  often  one  of  those 
described  as  traversing  the  wall  of  a  cavity,  bridging  it  from  side  to  side. 

Diarrhea  is  a  frequent  symptom  late  in  the  disease.  It  is  commonly 
due  to  tuberctilosis  of  the  bowel  and  is  often  exceedingly  obstinate.  Not 
every  diarrhea,  however,  in  tuberculosis  is  tubercular. 

The  club-finger  was  noted  by  Hippocrates,  and  has  long  been  asso- 
ciated with  tuberculosis — though  not  peoiliar  to  it.  It  is  a  condition 
found  in  other  chronic  diseases,  as  emphysema,  chronic  bronchitis,  chronic 


TUBERCULOSIS  295 

cardiac  disease,  and  aneurysm.  The  end  of  the  finger  is  bulbous,  quite  like 
a  club,  and  the  nail  curves  over  the  end.  It  maj'  in-\'olve  some  of  the  fingers 
only. 

Tubercidotis  meningitis  may  be  added  toward  the  close  of  the  disease. 
The  symptoms  vary  a  good  deal  with  the  seat  of  the  involvement,  and  have 
been  considered  in  detail  when  treating  of  tubercular  meningitis.  If  the 
inflammation  is  in  the  fissure  of  Sylvius,  there  may  be  aphasia  and  even 
hemiplegia;  if  at  the  base,  retraction  of  the  head  and  palsies  of  the  cranial 
nerves  from  pressure,  also  optic  neuritis;  if  on  the  convexity,  delirium  is  more 
decided,  and  there  may  be  local  convulsions  with  hemiplegic  weakness. 
Ventricular  effusion — acute  hydrocephalus — adds  little  to  the  specializa- 
tion of  symptoms.  There  may  be  co-involvement  of  the  membranes  of 
the  brain  and  spinal  cord,  producing  symptoms  of  cerebrospinal  meningitis. 

The  relation  of  pulmonary  consumption  to  cardiac  disease  has  always 
been  an  interesting  one.  It  was  formerly  thought  that  affections  of  the 
heart  and  lungs  are  never  concurrent.  This  is  a  mistake ;  such  concurrence  is 
observed,  but  whether  such  relation  is  any  but  an  accidental  one  is  doubtful. 
Osier  reports  12  instances  of  endocarditis  in  216  autopsies  on  cases  of 
consimiption.  The  rarity  of  lung  tuberculosis  succeeding  chronic  valvular 
heart  disease  must  still  be  admitted.  It  has  been  ascribed  to  hypertrophy 
of  the  unstriped  muscular  structure  about  the  smaller  bronchioles  and  their 
acinous  terminations,  which  keeps  the  alveoli  evacuated  of  such  secretions  as 
favor  the  development  of  phthisis. 

Chronic  nephritis  and  amyloid  kidney  are  frequent  complications  of 
chronic  phthisis.  From  these  causes  albuminuria  may  result.  There  may 
be  simple  febrile  albumintuia.  Or  albuminiiria  may  be  due  to  pus,  if  there 
is  tuberculosis  of  the  bladder  or  kidney.  Tubercle  bacilli  should  be  sought 
for  in  purulent  urine. 

The  liver  is  often  enlarged  from  fatty  infiltration. 

Diagnosis. — Early  diagnosis  is  the  key-note  to  successful  treatment. 
Fever,  anemia,  loss  of  strength  and  of  weight  must  never  be  considered 
lightly.  Tuberculosis  must  always  be  kept  in  mind,  and  physical  signs 
constantly  searched  for.  The  same  may  be  said  of  neurasthenia.  Many 
tuberctdous  patients  have  neurasthenia  as  their  first  symptom.  The 
diagnosis  of  tuberculosis  of  the  Itings  may  be  difficult  in  the  early  stages, 
but  later,  when  the  physical  signs  have  developed,  it  is  easy.  In  any  stage 
the  finding  of  the  bacillus  removes  all  doubt.  Occasionally,  however,  the 
sputum  is  very  scanty  and  difficult  to  get  or  it  may  be  abundant  and  contain 
few  bacilli.  If  such  an  examination  is  not  possible,  or  furnishes  negative 
results,  some  time  may  elapse  before  a  positive  diagnosis  is  obtained,  never- 
theless every  doubtful  case  should  have  frequent  sputum  examinations.  A 
positive  finding  is  worth  any  trouble;  for  the  physical  signs  in  the  early 
stages  cannot  always  be  relied  on,  while  there  occur  cases  in  which,  even 
months  after  baciUi  have  been  found  in  the  sputum,  the  physical  signs  are 
confusing  and  inconclusive.  Due  regard  must  be  paid  to  the  fact  that  in 
health  the  expiratory  sound  below  the  right  clavicle  is  longer  and  rougher 
than  in  a  corresponding  position  on  the  opposite  side,  while  the  percussion 
note  may  also  be  somewhat  higher  pitched.  The  presence  of  fever  more  or 
less  constant,  the  bright  eye,  and  crimson  flush  in  the  cheek,  the  anemia, 


296  INFECTIOUS  DISEASES 

with  or  without  emaciation,  should  excite  suspicion  and  lead  to  careful 
physical  exploration  and  examination  of  the  sputum,  if  not  already  made. 
The  search  of  the  sputum  for  elastic  tissue  is  relatively  less  valuable,  because 
bacilli  are  usually  found  much  earlier. 

The  A'-ray  is  of  the  greatest  value  in  locating  tubercular  lesion  especially 
where  the  physical  signs  are  meager. 

In  doubtful  cases  the  tuberculin  test  may  be  made.  This  is  of  value  in 
cases  tinder  the  age  of  puberty,  but  of  little  value  after  that  age.  The 
majority  of  adults  react  to  tuberculin  whether  they  have  active  tubercles 
or  not.  A  positive  reaction  means  tuberculosis,  but  does  not  necessarily 
mean  the  condition  from  which  the  patient  suffers  is  tuberculosis. 
One  milligram  of  pure  tuberculin  is  injected  hypodermicalh%  and  if  there 
be  no  febrile  reaction  in  lo  to  12  hours,  twice  this  quantity  is  used  two  or 
three  days  later,  and  gradually  increased  at  intervals  until  five  milligrams 
have  been  injected  at  a  dose.  If  there  be  no  rise  in  temperature  within 
10  to  12  hours  the  patient  may  be  considered  free  from  tuberctdosis.  The 
usual  rise  is  from  two  to  four  degrees  F.  The  test  is  valueless  when  the 
patient  already  has  fever. 

The  Tuberculin  Ophthalmo-reaction  of  Tuberculosis. — Suggested  by  Wolff, 
Eisner  and  Vallee,  it  was  left  to  Calmette'  to  elaborate  this  test  of  the  pres- 
ence of  tuberciilosis.  It  is  an  excellent  test,  but  certain  accidents  have  fol- 
lowed its  use.     It  has  now  fallen  out  of  common  practice. 

Von  Pirquet's  tubercvlin  skin  reacuion  is  much  more  safe  than  the  opthal- 
mic  test  and  should  always  be  used.  It  is  made  in  the  same  way  vaccination 
against  smallpox  is  done  with  some  variation. 

The  forearm  or  arm  over  biceps  is  carefully  cleared,  two  small  drops 
of  Koch's  old  tuberculin  are  placed  about  s  cm.  apart — upon  the  cleaned 
skin.  A  sterile  needle  is  then  used,  a  small  area  2  mm.  in  diameter  is  then 
scarified  in  the  sound  skin  between  the -drops  of  tuberculin.  Scarifica- 
tions is  then  done  through  the  two  drops  of  tuberculin.  If  the  reaction  is 
positive  the  two  spots  where  the  tuberciilin  was  used  will  become  red  and 
swollen  in  from  24  to  48  hours,  no  reaction  takes  place  in  the  spot  where 
there  is  no  tuberculin. 

The  physical  examination  must  be  made  early  and  repeated  frequently 
in  the  study  of  a  case.  Especially  is  this  true  of  cases  in  which  there  is  a 
hereditary  tendency.  It  goes  without  saying,  that  the  physical  signs  of 
incipient  tuberculosis  may  easily  escape  detection  when  an  examination 
is  made  with  the  clothing  on,  while  they  would  be  easily  recognized  if  the 
patient  were  stripped  to  the  skin.  Too  frequently,  also,  an  examination  is 
deferred  because  of  a  fear  that  the  patient  will  be  needlessly  alarmed  thereby. 
So-called  "hemorrhages  from  the  throat"  should  be  carefully  investigated, 
as  should  also  any  continued  hack-ing  cough.  Many  of  these  coughs  are 
now  known  to  be  due  to  tonsillar  trouble,  but  this  shoiild  not  be  taken  for 
granted,  and  a  careful  examination  of  the  throat  should  be  associated  with  a 
physical  examination  of  the  chest.  A  habitually  frequent  pulse  and  rapid 
breathing  should  also  excite  suspicion.  We  should  not  omit  either  to 
examine  the  posterior  part  of  the  chest  in  the  supraspinous  fossae,  for  it 


'  Calmette:     Acaddmie  des  Sciences,  17  juin,  1907,  vol.  c.xliv,  No.   24,  p.   1324-     "Presse  Medicale," 
No.  49.  19  juin,  1907,  p.  388-389. 


TUBERCULOSIS  297 

sometimes  happens  that  physical  signs  are  here  detected  before  they  are 
recognizable  in  front. 

Prognosis. — The  prognosis  of  chronic  tuberculosis  of  the  limgs  varies 
greatly  with  different  cases.  Many  cases  will  recover  if  the  diagnosis  is 
made  early.  Its  duration  ranges  in  individual  cases  from  a  few  months 
to  years. 

The  modern  treatment  has  been  followed  by  great  improvement  in  re- 
sults. Not  only  is  the  disease  arrested  in  its  course  in  many  instances,  but 
in  many  actual  cures  result.  Indeed,  many  instances  of  recovery  un- 
doubtedly happened  before  the  modern  treatment  was  instituted.  It 
is  difficult,  indeed  impossible,  with  the  present  statistical  methods  to  as- 
certain the  proportions  of  recoveries,  but  one  can  form  an  idea  of  the  general 
situation  from  the  number  of  deaths  from  this  cause  as  compared  with  others. 
Thus  in  Philadelphia  in  1882,  there  were  3.28  deaths  from  consumption  per 
1000  of  population.  In  1907,  25  years  later,  the  rate  was  2.10 — a  decided 
falling  off.  In  1882  there  were  2809  deaths  from  tuberculosis  of  the  lungs 
to  17,250  deaths  from  all  other  causes  or  i  to  6.1.  In  1907  there  were  3157 
deaths  from  tuberculosis  and  24,305  deaths  from  other  causes  or  i  to  7.6. 
The  per  cent,  death  rate  in  Pennsylvania  is  i .  5  per  1000  of  population. 

ih)  Fibroid  Phthisis. 

Definition. — This  term  is  applied  to  a  form  of  pulmonary  consumption 
in  which  the  lung,  in  addition  to  being  the  seat  of  tuberculosis,  is  permeated 
by  an  overgrowth  of  fibroid  tissue.  Its  course  is  much  slower,  and  while  it 
often  begins  as  an  inhalation  bronchitis  in  those  exposed  to  the  inhalation 
of  fine  particles  of  dust  from  various  sources,  it  may  also  begin  as  an  ordinary 
ulcerative  or  catarrhal  phthisis. 

Symptoms. — Its  symptoms,  on  the  whole,  are  less  aggravated  than  those 
of  ordinary  phthisis.  The  cough  is  less  severe,  less  exhausting,  though 
more  apt  to  be  paroxysmal,  and  the  patient  has  less  fever  and  emaciates 
less  rapidly.  He  is  often  able  to  pursue  some  occupation.  Bacilli  are  less 
numerous  and  are  often  found  with  greater  difficulty.  Expectoration  is 
often,  however,  as  copious,  usually  arising  from  cavities  or  dilated  bronchi, 
and  is  more  frequently  fetid.  It  may  contain  fat  crystals  and  Charcot's 
acicular  crystals.  There  may  also  be  hemorrhage.  Apart  from  these  symp- 
toms and  the  presence  of  bacilli  in  the  sputum,  the  clinical  history  is  scarcely 
different  from  that  of  simple  nonspecific  cirrhosis  of  the  lung,  from  which  it 
is,  indeed,  often  separated  with  difficulty.  As  in  this  affection  there  may 
be  hypertrophy  of  the  right  ventricle,  induced  by  the  extra  effort  demanded 
of  the  right  heart  to  move  the  blood  through  the  fibroid  lung.  Fibroid 
phthisis  is  especially  characterized  by  its  prolonged  course,  which  may 
extend  over  years. 

Physical  Signs. — The  degree  of  retraction  of  the  chest  wall  as  noticed 
by  inspection  is  greater  than  in  the  ulcerative  form,  more  easily  recognized, 
and  not  always  confined  to  the  vicinity  of  the  apices  of  the  lungs.  The 
heart  may  be  dislocated  and  its  apex  correspondingly  awry,  sometimes  to  an 
extreme  degree.  If  on  the  left  side,  owing  to  retraction  of  the  lung,  there 
may  sometimes  be  seen  a  distinct  cardiac  pulsation  in  the  second,  third,  and 


298  INFECTIOUS  DISEASES 

fourth  interspaces.  The  intercostal  spaces  are  often  narrowed  and  the 
diaphragm  may  be  drawn  up.  Modifications  of  vocal  fremitus  as  revealed 
to  palpation  are  not  nearly  so  constant,  being  masked  by  retraction  of  the 
lung  and  pleuritic  complications,  and  may  be  absent.  There  is  often  little 
or  no  elevation  of  temperature. 

Percussion  is  more  constant  in  its  results,  there  being  marked  dullness 
and  a  wooden-like  resistance.  The  hyperthrophy  of  the  right  ventricle 
referred  to  may  extend  the  normal  cardiac  dullness  in  positive  degree 
beyond  the  right  edge  of  the  sternum. 

Auscultation  most  frequently  notes  bronchial  breathing  and  exaggerated 
voice  sound,  but  both  of  these  may  be  lessened  in  intensity  by  a  thickened 
pleura.  A  dilated  bronchus  is  frequently  present,  yielding  the  signs  of  a 
cavity,  which  may  be  found  in  the  middle  or  even  at  the  base  of  the 
lung. 

To  the  signs  of  the  fibroid  state  in  one  part  of  a  lung  are  frequently 
added  those  of  emphysema  in  the  remainder  or  in  the  other  lung. 

Prognosis. — This  is  perhaps  no  better,  so  far  as  cure  is  concerned  than 
for  the  chronic  ulcerative  phthisis,  but,  as  has  already  been  stated,  the 
duration  of  the  disease  is  much  longer,  and  under  favorable  circumstances 
much  more  can  be  done  for  the  patient  by  the  same  treatment. 

Treatment  of  Chronic  Tuberculosis  of  the  Lungs. — There  is  no  disease 
of  like  importance  in  which  treatment  must  for  various  reasons  differ  so 
much  in  different  cases.  This  is  owing  partly  to  the  fact  that  curative 
measures  must  be  adapted  more  or  less  to  the  circumstances  of  the  patient, 
and  partly  to  the  varying  peculiarities  of  the  patient  himself.  In  the  follow- 
ing pages  we  will  advise  first,  regardless  of  the  patient's  circumstances,  the 
treatment  which  experience  has  shown  to  be  most  efficient,  then  recommend 
such  measures  as  are  useful  or  necessary  under  any  circumstances. 

The  fundamental  principle  of  a  successful  treatment  of  a  case  of  tuber- 
cular consumption  is  early  diagnosis  and  corresponding  promptness  in  the 
application  of  remedial  measures,  together  with  the  cooperation  of  the  patient 
supported  by  the  belief  that  consumption  is  a  curable  disease.^  To  these 
necessary  points  must  be  added  fresh  air,  rest,  food,  a  certainty  of  the 
fact  on  the  part  of  the  patient  that  he  can  recover. 

Fresh  Air.- — It  is  not  necessary  that  a  patient  be  removed  from  his  home 
in  order  to  get  fresh  air.  Hmnan  beings  are  still  afraid  of  drafts,  cold  air, 
hot  air,  night  air,  indeed  of  any  kind  of  air  except  that  to  be  found  in  a 
superheated  room.  This  is  slowly  being  changed  for  it  is  a  fact  that  a  patient 
may  sleep  in  a  room  with  wind  blowing  over  him,  or  outside,  in  a  tent  or 
on  a  porch,  in  cold  weather  or  hot  weather,  dry  weather  or  wet  weather, 
provided  he  is  protected  by  proper  clothing. 

A  patient  in  any  stage  of  tuberculosis  should  spend  the  entire  24  hours 
in  the  open  air  or  in  a  room  which  allows  a  free  passage  of  air  from  one  side 
to  another.  He  should  sleep  out  of  doors  or  in  such  a  room  winter  and  sum- 
mer. He  should  either  have  an  occupation  outside  or  have  just  as  free  access 
of  air  to  his  working  room  as  to  his  sleeping  room.  Window  tents,  sleeping 
porches,  tents  outside  the  home  any  and  all  should  be  utilized.      These 

'  For  evidence  of  the  correctness  of  this  dictum  see  the  annual  report  of  the  Adirondack  Sanatorium 
for  1912. 


TUBERCULOSIS  299 

helps  can  be  found  in  the  proper  books  and  advertisements.  Sleeping  bags 
and  caps  can  be  used  in  very  cold  weather. 

Rest. — No  patient  with  active  tuberculosis  should  do  any  sort  of  work 
which  exhausts  him,  which  causes  a  rise  in  his  temperature  or  causes  in- 
creased cough. 

Every  patient  with  a  continued  evening  temperature  of  ioo°  or  over 
should  be  absolutely  still  in  bed  in  the  open  air  until  the  temperature 
remains  normal  the  whole  twenty-four  hours.  Neglect  of  this  precaution 
is  likely  to  bring  disaster. 

Work. — Every  patient  with  a  normal  temperature  is  the  better  for  some 
employment.  This  should  be  varied  for  each  individual  case  and  should 
be  prescribed  by  the  physician  with  even  more  care  than  the  drugs.  It 
should  occupy  but  not  exhaust  the  patient.  It  must  be  increased  accord- 
ing to  the  strength  of  the  patient. 

Climate. — No  climate  is  a  specific  for  tuberculosis.  A  patient  may  get 
well  in  any  climate  if  he  is  early  taught  to  follow  the  above  rules. 

No  patient  should  ever  be  allowed  to  change  to  another  place  of  living 
unless  in  going  to  another  climate  he  can  have  aU  the  comforts  of  home. 
Unquestionably  a  patient  who  is  able  to  live  all  the  year  round  in  such  a 
climate  as  southern  California,  Colorado  Spring,  or  the  valleys  of  Switzer- 
land can  spend  his  time  out  of  doors  more  comfortably  than  in  the  usual 
changeable  climate  of  the  middle  and  eastern  United  States,  but  he  must 
remember  that  he  must  be  out  of  doors  or  he  wiU  not  recover. 

Artificial  Pneumothorax. — The  injection  of  nitrogen  into  the  chest  cavity 
is  lately  coming  into  vogue.  A  pneiuno thorax  cannot  always  be  made  because 
of  pleural  adhesions,  but  in  certain  cases  especially  where  there  is  hemor- 
rhage it  can  be  tried;  rather  flattering  reports  are  being  made.  A  special 
apparatus  is  employed  which  generates  nitrogen.  This  is  introduced 
between  the  chest-waU  and  the  lung  under  a  measured  pressure. 

Food. — Food  shoiild  be  abundant  and  of  the  best  and  most  nutri- 
tious kind.  Eggs,  meats,  including  especially  fats,  poultry,  game,  oysters, 
fish,  rich  animal  broths  prepared  in  the  most  tempting  way  should  be  pro- 
vided, because  the  quantity  taken  shovdd  be  as  large  as  can  be  digested 
and  assimilated.  Milk  and  cream,  cheeses,  and  the  like  are  eminently 
suitable.     Koumiss  or  zoolak  may  be  substituted  for  milk. 

Eggs  and  milk  are  the  favorite  food  for  consumptives,  from  six  to  12 
eggs  and  two  or  four  quarts  of  milk  daily,  with  as  much  additional  food  as 
the  patient  can  assimilate.  Care  must  be  taken  however  that  the  food 
does  not  disagree  with  the  patient.  Many  think  they  cannot  take  nulk. 
Actually  most  persons  can  take  it  if  it  is  drank  slowly,  is  taken  in  moderate 
quantities  at  one  time,  or  is  charged  to  suit  the  taste. 

Specific  Treatment. — Treatment  by  tuberciilin  offers  the  most  scientific 
method  of  any  system.  Unfortunately  it  cannot  as  yet  be  safely  used  in 
general  practice  except  under  certain  conditions.  The  patient  must  be 
carefully  watched. 

Perhaps  the  last  word  so  far  said  is  contained  in  the  report  of  the  National 
Association  for  Study  and  Prevention  of  Tuberculosis  for  1912. 

Brown  says,  the  tuberculin  should  be  injected  under  the  skin.  Koch's 
original   tuberculin,   T.R.  or  B.F.  may  be   used   indifferently,   a   dose   of 


;500  INFECTIOUS  DISEASES 

o.oooooi  or  o.ooooi  being  given  and  very  slowly  increased.  A  small  dose  is 
given  which  is  gradually  increased  until  a  tolerance  is  established.  The 
interval  is  three  or  four  days.  Another  method  is  to  give  larger  doses  at 
longer  intervals.  He  believes  that  usually  incipient  cases  do  better  with 
it  than  wathout  it. 

Sanatorium  Treatment. — These  resorts  are  of  the  greatest  value  where 
they  can  be  used.  Their  chief  use  is  education  of  the  patient  by  precept, 
as  to  what  is  meant  by  fresh  air,  rest,  work,  and  food. 

Necessarily  a  patient  cannot  always  live  in  Ihcm,  and  only  a  few  can 
ever  be  accommodated. 

They  can  take  the  hard-worked,  underfed  individual,  or  the  hampered 
patient  out  of  himself  and  give  him  time  for  mental  and  physical  rest,  plenty 
of  food  and  continuous  fresh  air.  When  so  used  they  are  of  the  utmost 
value  in  many  cases. 

Medicinal  Treatment. — Medicines  have  long  since  ceased  to  be  thought 
specific  for  tuberculosis.  They  are  now  looked  upon  as  materials  to  be 
used  for  symptomatic  treatment.  As  such  they  are  most  useful  in  many 
instances. 

Cod-liver  Oil. — When  cod-liver  oil  is  well  borne  it  may  be  administered 
in  tuberculosis  of  the  lungs  as  a  food,  but  it  is  perhaps  no  more  valuable 
than  cream. 

The  various  compound  preparations  and  emulsions,  consisting  of  cod- 
liver  oil,  other  tonic  substances,  gums,  and  flavors  to  cover  up  the  taste, 
are  no  better  borne  than  the  pure  oil,  and  are  frequently  harmful. 

Creasote  is  not  a  specific  for  consvimption,  but  it  relieves  the  catarrhal 
symptoms  and  diminishes  the  cough  and  expectoration.  It  may  be  used 
in  pill  form  one  or  two  grains  three  times  a  day,  or  in  drops  two  to  three 
drops  three  times  a  day  in  milk. 

Creasotal  or  Carbonate  of  Creasote. — It  has  the  great  advantage  of 
being  unirritating  and  can  therefore  be  given  in  larger  doses. 

Iron  is  indicated  in  cases  of  tuberculosis  where  there  is  anemia.  It  is 
best  given  in  the  form  of  Blaud's  pUl.  Five  grains  of  the  mass  being  given 
three  times  a  day. 

Arsenic  is  often  useful  in  tuberculosis  and  may  be  combined  with  iron 
or  alternated  with  it.  Many  consider  arsenic  more  beneficial  than  iron.  It 
is  not  desirable  to  give  very  large  doses,  and  s  minims  of  Fowler's  solu- 
tion are  a  sufficient  maximum  dose.  It  is  especially  useful  in  small  doses 
where  there  are  gastric  symptoms,  and  may  be  continued  in  moderate  doses 
for  a  long  time. 

Strychnin  is  a  drug  that  is  very  valuable  in  pulmonary  consumption, 
more  especially  as  a  heart  tonic.  It  should  also  be  continued  over  long 
periods  in  doses  of  1/30  to  1/20  grains  (0.0022  to  0.0032  gm.)  three  or  four 
times  a  day.  Quinin  is  also  at  times  very  usefid,  especially  when  there  is 
fever. 

Antitubercular  Serum  Therapy. — Notwithstanding  many  attempts  to 
produce  an  effective  antitoxic  serum  for  tuberculosis,  no  satisfactory 
experimental  or  clinical  results  have  been  attained  in  any  degree  comparable 
to  the  success  with  diphtheria  antitoxin.  The  existence  of  a  true  antitoxin 
in  the  serum  of  treated  animals  is  in  doubt,  although  certain  antibodies  have 


TUBERCULOSIS  301 

been  demonstrated.  The  necessity  for  repeated  injections  of  sera  in  such  a 
protracted  disease  as  tuberculosis  involves  some  unpleasant  consequences 
due  to  the  serum  itself.  The  occasional  development  of  some  symptoms 
of  "serum  disease"  (urticaria,  joint  pains  and  even  collapse),  make  the  sub- 
cutaneous use  of  serum  sometimes  undesirable. 

The  principal  area  for  which  claims  are  made  at  present  are  those  of 
Maragliano  and  Marmorek.  Of  late  the  latter  has  found  favor  in  some 
quarters  by  rectal  administration  in  doses  of  s  to  20  c.c.  It  is  at  least 
unobjectionable  when  thus  given.  The  dose  of  Maragliano 's  serum  is  from 
I  to  s  c.c.  subcutaneously.     It  is  also  given  per  os  or  rectum. 

Antistreptococcus  or  streptolytic  serum  has  been  used  to  combat  the 
supposed  mixed  infection  from  this  bacterium  in  certain  cases.  Its  effi- 
ciency is  doubtful,  but  Bonney  and  Pottenger  claim  good  results  in  some 
desperate  cases.     The  rectal  administration  is  perferable  and  safe. 

Bacterial  Vaccine  Therapy. — The  inoculation  of  sterile  bacteria  pre- 
pared according  to  A.  E.  Wright's  methods  from  cultures  obtained  from 
the  sputum  is  a  recent  and  promising  method  of  treatment  for  chronic 
mixed  infections  in  pulmonary  tuberculosis.  Its  application  is  too  recent 
to  warrant  an  opinion  as  to  its  usefulness. 

Prophylaxis  against  Tuberculosis. — Sputum,  feces  and  urine  are  the 
chief  means  by  which  tuberculosis  is  spread.  If  every  particle  of  sputum, 
all  the  feces  and  all  the  iirine  of  tuberculous  individuals  were  thoroughly 
destroyed,  tuberculosis  would  disappear  as  an  impotant  disease  in  one 
generation.  Unquestionably  ceriain  cases  come  from  the  use  of  milk  and 
meat  of  tuberculous  cattle.  Sputum  the  chief  offender  is  frequently, 
indeed  constantly,  expectorated  on  the  floor,  on  handkerchiefs  or  clothing 
in  the  street,  this  is  full  of  danger. 

Under  no  circumstances  should  the  patient  be  allowed  to  expectorate 
upon  the  floor,  in  cars  or  other  public  conveyances,  or  even,  if  possible  to 
prevent  it,  in  the  street.  In  order  to  meet  these  necessities  as  well  as  those 
of  other  situations  in  the  house  paper  cups  which  can  be  burned  after  use 
should  be  used,  or  porous  paper  can  be  used  to  be  similarly  disposed  of. 
The  so-called  Japanese  handkerchiefs  answer  the  purpose  admirably.  An 
important  instruction  is  that  no  piece  of  paper  should  be  used  twice.  The 
sputum  should  be  deposited  in  the  paper  and  the  paper  should  then  be 
deposited  at  once  in  some  such  a  receptacle  as  an  ordinary  paper  bag.  Bag 
and  papers  containing  the  sputum  can  all  be  burned  at  convenient  intervals. 

The  pasteboard  spit-cups,  supported  in  a  rim  of  steel,  recommended  by 
the  New  York  City  Health  Department,  intended  to  be  biu-ned  after  use, 
are  correspondingly  inexpensive  and  answer  the  purpose  very  well.  There 
is  also  a  paper  envelope  upon  the  market  which  can  be  easily  carried  in  the 
pocket.     This  is  also  inexpensive. 

To  the  same  end,  diminution  of  the  possibility  of  harboring  dried  bacilli, 
unwashable  curtains  and  superfluous  upholstering  should  be  banished  from 
the  rooms  occupied  by  tuberculous  patients.  There  should  either  be  no 
carpets,  or  they  should  be  replaced  by  rugs  that  can  be  frequently  taken  up 
and  shaken.  The  sleeping-car,  with  restricted  air  space  per  caput,  its  costly 
upholstery  and  curtains,  used  year  after  year,  becomes  a  possible  source  of 
infection,  especially  in  routes  toward  health  resorts,  but  is  less  serious  than 


302  IXFECTIOUS  DISEASES 

i1  might  be  because  of  the  short  time  that  it  is  generallj'  occupied  b)'  the 
tuberculous  and  healthy  alike.  The  state-room  of  the  ocean  steamer  stands 
a  greater  chance  of  being  a  medium  of  infection  from  its  longer  occupation. 
Both  these  useful  means  of  travel  should  be  disinfected  after   each   trip. 

When  it  is  remembered  how  easy  it  is  with  ordinary  intelligence  and 
simple  means  to  render  completely  innocuous  the  bacillus  of  tuberculosis,  it 
becomes  a  question  how  far  the  surveillance  of  boards  of  health  can  be 
helpful.  For  the  well  to  do  who  can  afford  to  employ  an  intelligent  phy- 
sician it  would  seem  unnecessary.  For  the  poor  it  should  be  associated 
with  material  assistance,  and  carried  out  with  great  tact  and  consideration. 
For  statistical  purposes,  at  least,  every  case  of  tuberculosis  should  be  re- 
ported by  physicians  to  the  proper  authorities  in  order  that  intelligible 
records  may  be  kept  by  which  the  disease  may  be  traced  and  followed 
from  its  first  recognition  to  its  termination,  whenever  desired. 

Persons  affected  with  tuberculosis  should  not  kiss  other  individuals. 
Tuberculous  mothers  should  not  nurse  their  children.  When  a  tuberculosis 
patient  coughs  he  should  shield  his  mouth  with  a  paper  handkerchief  which 
must  at  once  be  destroyed  as  the  paper  contains  sputvun. 

The  second  source  of  infection,  the  milk  of  the  tuberculous  cow  is 
avoided  by  boiling  the  milk,  which  is  thus  rendered  thoroughly  sterile. 
There  are,  however,  objections  to  boiling  milk.  In  the  first  place,  the  taste 
of  boiled  milk  is  not  always  agreeable,  but  of  greater  importance  is  the 
fact  that  it  gives  rise  to  certain  diseases  of  childhood — scurvy  and  the  like — 
especially  when  it  is  the  only  food,  as  in  the  case  of  children.  Pasteuriza- 
tion has  therefore  taken  the  place  of  boiling  milk.  Practically,  the  use 
by  adults  of  raw  milk  mixed  wdth  other  food  cannot  be  regarded  as  danger- 
ous, but  with  children  fed  exclusively  on  milk  precautions  shoiild  be  taken 
to  render  it  sterile  by  cooking  or  if  it  must  be  used  tmcooked  it  should  be 
the  mixed  milk  of  a  number  of  cows.  The  milk  of  a  cow  known  to  be 
tuberculous  should  be  invariably  condemned  and  the  animal  slaughtered. 
The  products  of  milk — that  is,  butter  and  cheese — are,  of  course,  not 
amenable  to  the  treatment  to  which  milk  can  be  subjected.  Safety  from 
infection  from  these  sources  can  only  be  secured  by  a  rigid  inspection  of 
cows,  and  by  measures  to  prevent  the  development  of  tuberculosis  in  these 
animals. 

Infection  by  tuberculous  meat  is  still  rarer.  In  the  first  place,  the 
flesh  pi  tuberculous  animals  may  not  itself  be  -tuberculous,  and,  in  the 
second  place,  the  cooking  to  which  meat  is  subjected  must  kill  bacilli.  On 
the  other  hand,  that  the  communication  of  tuberculosis  by  tuberculous 
meat  when  carelessly  used  is  possible  is  shown  by  the  fact  that  tuberculosis 
has  been  produced  in  animals  by  the  introduction  of  the  juice  of  the  meat  of 
other  tuberculous  animals  and  even  from  tuberculous  human  beings.  The 
use  of  raw  or  half-cooked  meat  should  therefore  be  prohibited. 

In  consequence  of  what  has  been  said  of  the  experimental  production 
of  tuberculosis  by  the  inoculation  of  sputum  as  well  as  the  increased  possi- 
bilities of  getting  into  the  mouth  portions  of  tuberculous  sputum,  no  one 
should  sleep  with  a  tuberculous  patient.  Dishes  and  utensils  used  by  such 
patients  should  not  be  used  by  others  unless  first  scrupulously  cleaned,  and 
this  is  best  accomplished  by  thorough  boiling.     The  patient  shoiild  himself 


TUBERCULOSIS  303 

be  taught  to  prevent  his  hands,  face,  and  bedding  from  becoming  smeared 
with  sputum. 

Precautions  against  autoinfection  are  scarcely  less  important  than 
those  against  infection  of  others.  It  has  been  said  that  if  it  were  not  for 
autoinfection  most  cases  of  tuberculosis,  except  those  within  the  cranium, 
would  get  well.  Be  this  as  it  may,  it  is  certain  that  new  foci  of  tuberculosis 
are  constantly  being  developed  in  the  same  patient,  which  aggravate  his 
complaint  and  hasten  his  death.  Such  a  focus  is  tuberculosis  of  the 
intestine,  which  probably  often  has  its  origin  in  swallowed  sputum.  Patients 
should  therefore  be  enjoined  against  the  practice  of  swallowing  sputum. 

The  close  dependence  of  tuberculosis  upon  predisposition,  hereditary 
or  acquired,  chiefly  the  former,  has  long  been  recognized.  Treatment 
early  in  life  as  will  correct  any  possible  constitutional  taint,  to  be  directed 
against  the  dangers  of  infection.  Under  the  circumstances  a  due  amount 
of  attention  paid  to  both  factors  cannot  be  amiss. 

Children  born  of  tuberculous  parents  should  follow  the  following  rules. 

Outdoor  life  should  be  sought  under  all  circvmistances.  Riding  and 
driving  should  be  practised.  Judicious  athletics,  such  as  develop  all  parts 
of  the  body  in  good  proportion  and  especially  such  as  secure  expansion  of  the 
lungs,  should  be  encouraged.  Frequent  inflation  of  the  lungs  should  be 
practised  several  times  a  day.  Practice  with  dumb-bells  and  clubs  of 
moderate  weight  is  pre-eminently  calculated  to  empty  the  deeper  recesses  of 
the  lungs  of  retained  mucus,  and  to  cause  the  blood  to  move  more  rapidly 
through  the  more  remote  parts  where  the  circiilation  is  naturally  sluggish. 

The  treatment  of  acute  tuberculosis  of  the  lungs  is  supporting  and  stimu- 
lant, symptomatic  and  palliative.  There  is  no  advantage  to  be  derived  by 
taking  the  patient  away  from  home.  Food  and  stimulants  are  required  to 
combat  the  exhausting  effect  of  the  disease  and  its  fever.  The  fever  itself 
may  be  lowered  by  sponging  and  the  cautious  use  of  such  apyretics  as 
phenacetin,  acetanilid,  and  the  like,  because  in  this  form  of  the  disease  it  is 
more  apt  to  be  continuous  and  exhaustive  in  character.  The  cough  must  be 
controlled  by  opiates,  and  such  other  measures  must  be  taken  as  will  make 
the  patient  comfortable  and  mitigate  the  sadness  with  which  an  inevitable 
fatal  prospect  is  more  or  less  associated.  If  it  should  happen  that  the 
disease  assumes  an  unexpected  chronicity,  it  may  fall  into  a  class  of  cases 
in  which  the  treatment  laid  down  for  the  more  chronic  forms  of  consumption 
is  available. 

Treatment  of  Special  Symptoms. — Cough,  there  is  no  symptom  that  re- 
quires more  judgment  in  its  management.  A  slight  cough  is  often  best 
let  alone,  because  it  is  an  effort  to  remove  secretion,  the  retention  of  which 
may  be  harmful.  If  a  cough  becomes  harassing,  so  as  to  keep  the  patient 
awake  or  otherwise  wear  him  out,  it  should  be  controlled.  Fresh  air  as 
already  advised  is  the  very  best  remedy  for  cough  at  our  command. 

As  to  cough  medicines,  creasote  and  creasotal  may  be  classed  among 
the  curative  measures  for  this  symptom,  as  they  diminish  secretion  and  thus 
relieve  cough.  Moderate  cough  is  often  easily  controlled  by  simple  syrupy 
remedies,  such  as  syrup  of  wild  cherry  and  syrup  of  tolu,  to  which  some 
dilute  hydrocyanic  acid  may  be  added,  2  to  4  minims  (0.12  to  0.24  c.c.) 
to_the  dose.     If  these  measures  are  not  sufficient,  an  opiate  becomes  indis- 


304  IXFECriOUS  DISEASES 

])ensablc.  It  does  not  matter  much  what  preparation  is  used.  A  teaspoon- 
ful  of  paregoric  in  the  beginning  is  often  sufficient,  acting  like  a  charm,  or 
deodorized  tincture  of  opium,  if  a  stronger  preparation  be  needed,  will 
answer  better  because  of  its  smaller  bulk.  For  this  reason,  too,  sooner  or 
later,  the  alkaloids  of  opium  are  indicated.  Codein  is  the  best  of  these  to 
start  out  with  in  doses  of  1/4  grain  (0.0165  gm.)  increased.  Heroin  is  the 
most  recent  and  is  much  commended.  It  is  given  in  doses  of  1/20  grain 
(0.0033  gm.)  or  more.  Morphin,  however,  becomes  ultimately  the  best 
remedy  in  the  majority  of  cases.  When  this  stage  is  reached  the  wiser 
course  is  not  to  order  it  at  stated  intervals,  but  at  such  times  as  the  cough 
needs  especially  to  be  controlled,  as  at  night  on  going  to  bed,  or  once  during 
the  night.  The  dose  essential  for  the  purpose  named  must  vary,  any- 
thing from  1/24  to  1/4  grain  (0.00275  to  0.0165  gm.).  Proprietary  cough 
remedies  should  never  be  used. 

In  the  morning  the  patient  should  be  allowed  to  cough  for  a  time  to  get 
up  the  accumulated  mucus.  If  he  has  to  contend  with  a  cavity  fuU  of  pus 
it  is  better  to  give  him  a  tablespoonful  of  whisky  or  a  milk  punch,  to  aid  in 
coughing  up  the  accumulated  matter,  than  to  give  a  sedative  cough  mixture. 

The  ammonium  preparations,  chlorid  and  carbonate,  are  rarely  useful 
in  the  cough  of  consumptives,  while  their  eflfect  is  to  derange  the  stomach 
and  destroy  the  appetite.  Sometimes,  however,  where  there  is  much  loose 
phlegm,  the  use  of  the  former  for  a  short  time  may  be  beneficial.  Under 
the  same  circumstances  terebene  is  one  of  the  best  medicines  given  in  doses 
of  5  to  10  minims  (0.3  to  0.6  c.c).  It  taxes  the  stomach,  however,  some- 
what severely.  Terpin  hydrate  may  be  substituted  in  doses  of  3  to  6  grains 
(0.2  to  0.4  gm.). 

The  fever  of  tuberculosis  rarely  demands  special  measures.  Should 
the  temperatiu-e  exceed  103°  F.  (39.4°  C.)  there  is  no  more  satisfactory  or 
harmless  measure  than  sponging,  allowing  to  remain  on  the  surface  a  thin 
film  of  water,  the  evaporation  of  which  produces  the  refrigerating  effect. 
Or  3  grains  of  antipyrin  or  acetanilid  or  5  of  phenacetin  (0.2  to  0.33  gm.) 
may  be  given,  the  effect  watched,  and  the  drug  repeated  two  or  three  times 
if  necessarv.  The  high  fever  of  phthisis  rarely  lasts  long  and  of  itself  does 
little  or  no  harm.  It  is  merely  a  symptom  of  a  more  uncontrollable  septic 
process. 

Night-sweats  demand  special  measures.  By  far  the  most  reliable  ther- 
apeutic agent  is  atropin;  i/ioo  to  1/60  grain  (0.00066  to  0.00 11  gm.)  at 
bedtime  usually  suffices.  It  may  be  combined  with  morphin,  if  the  latter  is 
necessary.  Sponging  at  bedtime  with  a  saturated  solution  of  alum  in 
alcohol  may  be  efficient  when  atropin  fails,  or  sponging  with  simple  hot 
water  may  answer. 

Agaricin  or  agaric  acid  in  doses  of  1/8  to  1/4  grain  (0.0082  to  0.0165 
gm.)  is  a  modem  remedy  for  night-sweats.  Camphoric  acid,  20  to  30  grains 
(1.32  to  2  gm.)  in  a  capsule  at  bedtime,  is  another  remedy  highly  recom- 
mended. So  are  muscarin,  5  minims  (0.3  c.c.)  of  a  one  per  cent,  solution,  and 
picrotoxin,  1/60  grain  (o.ooii  gm.).  An  old  remedy  is  the  aromatic  sul- 
phiuic  acid,  and  it  is  certainly  a  good  tonic,  which,  administered  in  doses  of 
10  to  20  drops  (0.6  to  1.3  c.c.)  before  meals,  may  also  aid  in  checking  the 
sweats.     Or  the  following  lotion  may  be  used :     Balsam  of  Peru,  i  part ;  for- 


TUBERCULOSIS  305 

inic  acid,  5  parts;  chloral  hydrate,  5  parts;  trichloracetic  acid,  i  part; 
absolute  alcohol,  100  parts. 

Hemorrhage  is  an  alarming  symptom  and  must  be  treated,  although  it 
is  probable  that  most  hemorrhages  stop  of  their  own  accord.  The  patient 
should  be  immediately  put  in  bed  at  rest,  with  the  shoulders  raised.  Ice 
suitably  encased,  may  be  applied  to  the  chest,  or  cloths  wrung  out  in  cold 
water.  A  hypodermic  injection  of  1/4  grain  (0.016  gm.)  of  morphin  to  an 
adult  is  a  useful  measure  to  secure  quiet.  Indeed,  treatment  should  begin 
with  it. 

Strapping  is  very  highlj^  recommended  by  William  Oilman  Thompson. 
He  directs  that  pads  of  cheese-cloth  be  placed  in  the  axillae  and  over  the 
femoral  veins,  and  buckle-straps  dra^\'n  over  them  tight  enough  to  prevent 
venous  return,  but  not  to  prevent  arterial  flow.  It  is  best  to  strap  but 
three  extremities  at  one  time,  loosening  one  strap  every  15  minutes  and 
reapplying  it  to  the  unstrapped  limb.  Care  should  not  to  loosen  all  the 
straps  at  one  time. 

Lawrason  Brown'  advises  the  nitrites  and  morphin,  guiding  their  use 
by  frequent  observation  of  the  blood  pressure.  If  the  patient  is  seen 
early,  while  bleeding,  amyl  nitrite  is  given  by  inhalation.  If  he  be  nervous 
1/8  grain  of  morphin  is  injected  hypodemlicall}^  This  effect  is  maintained 
by  nitroglycerin  or  sodium  nitrite  at  such  intervals  as  will  keep  the  blood 
pressure  between  115  and  120  mm.  of  mercury.  This  is  easily  done  with 
sodium  nitrite,  of  which  is  given  one  grain  only  at  a  dose  repeated  often. 
In  severe  hemorrhages  of  long  duration  the  injection  of  normal  human  or 
horse  serum  is  perhaps  the  best  curative  remedy. 

The  diarrhea  of  consumption  does  not  generally  become  troublesome 
until  tuberculosis  of  the  bowel  develops.  Slight  degrees  seem  often  to 
relieve  the  cough.  When  there  is  tubercidosis  of  the  bowel  it  is  exceedingly 
difScult  to  control.  Sufficient  doses  of  bismuth  are  on  the  whole  the  best 
remedy — sufficient,  because  at  first  the  smaller  quantities,  say  10  grains 
(0.66  gm.),  answer,  while  later  much  larger  doses  are  necessarJ^  Opium  is, 
however,  often  necessary'',  and  sometimes  the  mineral  astringents,  as  the 
acetate  of  lead,  nitrate  of  silver,  and  oxid  of  zinc,  act  well  in  combination 
with  it.  Tannic  acid  is  also  efficient  in  combination  with  opium.  In 
severe  hemorrhages  of  long  dtrration  the  injection  of  normal  human  or 
horse  serum  is  the  best  remedy  here  as  in  hemoptysis. 


IV.  Tuberculosis  of  Lymphatic  Olands. 
Synonym. — Tuberculous  Lymphadenitis. 

Etiology.!— Even  before  the  discovery  of  the  bacillus  of  tuberculosis  by 
Koch  in  1882,  it  was  generally  conceded  that  what  has  been  known  as 
scrofula,  or  the  King's  Evil,  was  a  true  tuberculosis  of  lymphatic  glands. 
The  minute  study  of  these  glands  showed  the  presence  of  miliary  tubercles, 
and  since  Koch's  announcement  the  bacillus  has  been  found  in  them. 

Tuberculous  lymphadenitis  is  most  common  in  children  and  young 
adults,  but  ma}^  occur  at  any  age. 

I  A  Suggestion  in  the  Treatment  of  Hsemoptysis.     "Amer.  Jour.  Med.  Sciences,"  Aug.,  1906, 


:3U(i  IXFECTIOUS  DISEASES 

Symptoms. — The  lymphatic  glands  most  frequently  affected  are  those 
of  the  neck,  which  appear  in  various  degrees  swollen  and  tender,  in  many 
instances  suppurating  and  rupturing  when  not  opened  by  the  surgeon's 
knife.  The  cervical  glands  in  the  anterior  triangle  are  usually  the  first 
involved,  but  those  in  the  posterior  cervical  triangle  are  also  frequently 
invaded  on  one  or  both  sides,  though  commonly  on  one  side  more  than  the 
other.  The  cervical  and  axillary  glands  may  be  conjointly  involved,  form- 
ing a  continuous  chain  behind  the  clavicle  and  pectoral  muscles.  The 
bacillus  usually  attacks  the  glands  nearest  its  point  of  entrance,  and  pre- 
sumably the  cervical  glands  are  infected  by  bacilli,  which  enter  by  the  wa>- 
of  the  nasal  or  naospharyngeal  passages.  The  vulnerability  of  these  mu- 
cous membranes  to  the  bacilli  is,  of  course,  increased  by  any  inflammator\' 
state  present.  As  a  rule,  there  is  little  or  no  constitutional  sympathy  in 
such  a  degree  of  invasion.     There  may,  however,  be  slight  fever. 

More  rarely  there  is  involvement  of  all  the  lymphatic  glands  of  the  body. 
Such  cases  are  sometimes  met  among  negroes.  In  them  are  swelling, 
pain,  and  tenderness  of  all  the  visible  glands,  including  the  cervical,  sub- 
maxillary, inguinal  and  axillary  glands,  while  autopsy  discloses  the  involve- 
ment of  bronchial,  mesenteric,  and  retroperitoneal  glands.  In  such  cases 
there  is  more  or  less  continuous /ei'^r,  but  death  is  usually  the  result  of  some 
intercurrent  disease,  or  of  pressure  upon  the  respiratory  passages. 

In  addition  to  the  visible  pictures  described,  the  bronchial  glands  arc 
often  involved  without  visible  enlargement,  the  condition  being  first  found 
at  autopsy,  when  it  may  or  may  not  be  associated  with  lung  tuberculosis. 
The  enlargements,  may  however,  reach  such  a  size  as  to  form  a  recognizable, 
mediastinal  tumor,  which  may  or  may  not  produce  the  signs  of  pressure. 
The  bacilli  which  invade  these  glands  filter  through  the  respiratory  passages. 

Tahes  Mesenterica. — When  the  mesenteric  or  retroperitoneal  glands  arc 
especially  involved  the  disease  is  called  tabes  mesenterica.  These  cases 
occur  among  children.  The  trunk  and  limbs  are  pun}-,  wasted,  and  anemic, 
while  their  little  bellies  are  prominent,  partly  because  of  the  enlarged  glands 
and  partly  from  tympany,  producing  a  striking  picture.  The  tympanitic 
distention  often  predominates,  making  it  difficult  to  feel  the  enlarged  glands. 
In  these  cases,  too,  there  is  often  diarrhea,  with  thin,  offensive  stools,  yet 
the  bowels  are  not  generally  the  seat  of  tuberculosis.  There  may  be 
tuberculosis  of  the  peritoneum,  which  may  also  give  rise  to  an  uneven, 
nodular,  tender,  and  painful  enlargement  easily  recognized  b)-  palpation. 
The  disease  prevails  among  poorly  fed  children  in  the  slums  and  badly 
drained  and  ill-ventilated  houses  of  the  poor.  There  are  fever,  fretfulness,  and 
a  general  aspect  of  abject  misery.  Death  generally  takes  place  through 
exhaustion,-  or  some  acute  intercurrent  disease,  such  as  enteritis,  carries 
off  the  little  sufferers.  More  rarely  adults  may  be  affected  with  tabes  mesen- 
terica, either  as  a  primary  disease  or  as  secondary  to  pulmonary  tuberculosis. 
Tyson  remembers  a  case  associated  with  peritoneal  tuberculosis  in  which  the 
diagnosis  between  this  condition  and  carcinoma  was  difficult,  the  autopsy 
determining  the  question  in  favor  of  the  former. 

While  tubercvdous  glands  of  the  neck,  and  even  of  the  axilla,  tend  to 
suppurate,  the  retroperitoneal  and  mesenteric  glands  more  frequentl)- 
caseate  without  suppuration,  and  especially  characteristic  is  a  tendency  in 


TUBERCULOSIS  307 

the  latter  to  calcify.  The  bronchial  glands  are  also  less  prone  to  suppurate, 
but  caseate  and,  at  times,  liquefy.  The  easier  accessibility  of  the  external 
glands  to  the  pyogenic  organisms  may  explain  the  greater  frequency  of 
suppuration  in  them. 

Diagnosis. — The  diagnosis  of  tuberculous  lymphadenitis  requires  its 
differentiation  from  Hodgkin's  disease,  lymphatic  leukemia;  from  sarcoma 
and  carcinoma.  The  affected  glands  in  tubercular  lymphadenitis  are 
usually  more  tender  than  those  in  Hodgkin's  disease,  they  are  more  closely 
adherent  to  each  other  and  the  adjacent  tissues,  and  are,  therefore,  more 
fixed  and  immovable  than  the  glands  in  Hodgkin's  disease.  Again,  tuber- 
culosis rarely  invades  more  than  one  group  of  glands,  is  associated  with  _ 
caseation  and  suppuration,  while  the  lymphadenoid  growths  do  not  suppu- 
rate. Notwithstanding  this,  the  tuberciilar  process  is  slower.  Tuberculosis 
affects  the.  young — those  of  either  sex  under  20 — while  Hodgkin's  disease 
occurs  at  any  age,  is  less  frequent  in  the  young,  and  is  more  common  in 
males.  The  examination  of  an  excised  gland  shotvs  the  presence  of  the 
typical  picture  described  by  Longcope. 

From  lymphatic  leukemia  tuberculosis  of  lymph-glands  is  easily  recog- 
nized by  the  absence  of  leukocj^tosis  characteristic  of  the  former  and  b>' 
the  differential  blood  count. 

Sarcoma  involves  groups  of  glands,  and  spreads  rapidly,  invading  also 
adjacent  tissues,  while  carcinoma  is  always  secondary  to  primary  cancer 
somewhere  else. 

Prognosis. — The  prognosis  except  in  tabes  mesenterica  is  generally 
favorable  unless  systemic  infection  occur.  Recovery  being  sometimes  spon- 
taneous. This  is  favored  by  suitable  conditions  to  be  mentioned  under 
treatment.  The  condition  is  a  menace  because  of  the  danger  of  systemic 
infection  through  it,  three-fourths  of  the  cases  of  acute  tuberculosis  ow- 
ing their  existence  to  it.  Under  the  circumstances,  we  must  regard  cases 
of  recovery  from  tubercular  lymphadenitis  in  childhood  as  instances  of 
a  siu-vival  of  the  fittest.  Certainly  our  present  knowledge  demands  a 
prompter  attempt  to  eradicate  the  local  condition  than  was  formerh- 
practised. 

Treatment. — The  general  management  of  a  case  of  tuberculosis  of  the 
lymphatic  glands  is  similar  to  that  of  a  case  of  tuberculosis  of  the  lungs. 
The  patient  should  be  surrotmded  by  the  most  favorable  hygienic  conditions, 
have  the  best  of  food,  take  cod-liver  oil  and  the  iodid  of  iron.  .  At  the 
present  day  tubercular  lymphatic  glands  are  frequently  removed  by  the 
surgeon.     Tuberculin  is  of  value  in  these  cases. 

When  suppuration  has  set  in  it  is  best  to  open  an  exposed  abscess  with 
the  knife,  because  if  allowed  to  open  itself  there  is  apt  to  result  an  unhealthy 
sinuous  ulcer,  very  slow  to  heal,  and  when  healed  causing  marked  disfigura- 
tion by  unsightly  cicatrices.  The  access  of  air  permitted  by  the  opening 
seems  also  to  be  antagonistic  to  the  life  of  the  bacillus,  for  with  the  heal- 
ing of  the  abscess  the  tubercular  process  stops  in  that  particular  gland. 

V.  Tuberculosis  of  the  Serous  Membranes. 

General  tuberculosis  of  the  serous  membranes  is  a  rare  condition, 
and  is  recognized  chiefly  by  the  signs  of  tuberculosis  of  the  peritoneum  and, 


308  INFECTIOUS  DISEASES 

so  far  as  they  exist,  of  the  pleura,  these  being  the  two  serous  membranes  of 
greatest  extent  and  importance. 

Tuberculosis  of  the  Pleura. 

Tuberculosis  of  the  pleura  may  be  suspected  when,  along  with  the  phys- 
ical signs  of  tuberculosis  elsewhere,  there  appear  the  signs  and  symptoms 
of  a  dry  pleurisy,  with  or  without  effusion. 

Tuberculosis  of  the  pleura  manifests  itself — 

1.  As  an  acute  primary  inflammation  characterized  by  a  serofibrinous 
or  purulent  exudate.  The  onset  of  such  an  inflammation  may  be  like  that 
of  ordinary  acute  pleurisy  or  it  may  be  insidious  in  its  development,  like  that 
of  the  latent  form  of  pleurisy  to  be  described  under  diseases  of  the  pleura. 
It  may  immediately  precede  pidmonary  tuberculosis,  be  associated  with  it, 
or  succeed  it. 

2.  As  an  acute  pleurisy  the  result  of  extension  from  an  adjacent  tuber- 
culous lung,  and  as  such  it  may  be  circumscribed,  adhesive,  or  may  con- 
stitute an  extensive  serofibrinous  or  purulent   pleurisy. 

3.  A  chronic,  adhesive,  proliferative,  tuberculous  pleurisy  characterized 
by  great  thickening  and  adhesion  of  the  pleurae,  with  tuberculous  infiltration 
of  the  thickened  product. 

The  symptoms  and  physical  signs  are  in  no  way  different  from  those  to 
be  described  in  connection  with  the  nonspecific  forms  of  pleurisJ^ 

Treatment. — Some  time  often  elapses  before  an  absolute  diagnosis 
is  made,  after  which,  if  the  disease  is  at  all  extensive  and  a  purulent  effusion 
exists,  its  treatment  is  mainly  surgical,  consisting  in  drainage  secured 
by  the  excision. 

In  addition  all  of  the  restorative  and  hygienic  measures  employed  in 
tuberculosis  of  the  lungs  should  be  carried  out.  These  hygienic  measures 
are  of  even  greater  value  in  the  ]:)leuritic  cases  because  of  their  natural 
tendency  toward  recovery. 

Tuberculosis  oj  the  Peritoneum. 
Synonyms. —  Tuberculous  Peritonitis. 

Tubercidosis  invades  the  peritoneum  in  two  ways : 

1.  As  acute  miliary  tubercidosis. 

2.  As  a  tubercular  peritonitis  when  the  tubercular  deposit  is  associated 
with  an  inflammatorj-  proliferation  more  or  less  abundant.  In  a  simpler 
\'ariety  of  the  latter,  the  diffuse  adhesive,  the  peritoneal  cavitj^  is  obliterated, 
the  coils  of  intestine  being  matted  together  and  adherent  to  the  abdominal 
walls.  In  a  second  variety  known  as  proliferative  peritonitis,  there  is 
marked  thickening  of  the  peritoneal  layer  with  less  tendency  to  adhesion  and 
obliteration  of  the  cavitj'.  The  omentum  is  sometimes  an  inch  in  thickness 
and  composed  of  tuberculous  tissue  in  various  stages  of  degeneration.  The 
mesenter}'  is  similarly  infiltrated  and  shrunken,  drawing  the  intestines  to- 
gether into  a  ball-like  mass  or  tumor  as  large  as  a  child's  head.  The  coats 
of  the  bowel,  especially  the  large  gut,  also  show  localized  areas  of  similar 
morbid  changes.     In  this  condition  there  is  generally  much  liquid.     Tuber- 


TUBERCULOSIS  309 

culous  peritonitis  is  sometimes  associated  with  cirrhosis  of  the  liver,  whose 
capsule  and  that  of  the  spleen  may  be  infiltrated  to  enormous  thickness. 
There  is  often  in  this  form  considerable  effusion,  which  may  be  serous  or 
purulent,   at   times  bloody. 

Symptoms. — Acute  miliary  tuberculosis  may  begin  as  an  acute  peri- 
tonitis the  origin  of  which  cannot  be  discovered,  or  it  may  be  mistaken 
for  a  peritonitis  due  to  inflammation  of  some  viscus  such  as  the  appendix 
or  the  gall-bladder. 

Cases  are  constantly  mistaken  for  typhoid  fever  because  of  the  abdom- 
inal distress  and  distention  with  fever.  In  the  latent  forms  the  onset  "is 
slow,  frequently  distention  of  the  abdomen  with  ill  health,  is  the  first 
symptom  which  attracts  the  patient's  attention.  Ascites  is  frequent,  it 
may  be  either  bloody  or  pvuulent.  Often,  the  fluid  is  sacculated.  In  prac- 
tically all  the  cases,  irregular  fever  is  prevent.  In  other  cases  a  tumor 
is  present  due  usually  to  a  puckered,  thickened  omentum. 

Diagnosis. — The  history  of  the  patient,  his  appearance,  the  condition 
of  the  lungs  and  the  presence  of  tuberculosis  there  and  elsewhere,  particu- 
larly in  the  pleura  and  bowel,  whence  extension  t.o  the  peritoneum  is  easy 
by  the  lymphatic  vessels  are  of  importance.  Four-fifths  of  all  cases  of 
tuberculous  peritonitis  are  said  to  succeed  primary  tuberculosis  of  the 
limgs.  In  children  tuberculous-  peritonitis  is  frequent  as  a  part  of  a  general 
miliary  tuberculosis.  The  character  of  the  liquid  and  the  presence  of  the 
tuberculin  test  will  help  to  distinguish  these  cases  from  carcinoma  of  the 
peritoneum.  The  mass  may  simulate  also  an  ovarian  cyst.  Tuberculosis 
in  other  organs  should  help  to  distinguish  the  cases. 

Treatment. — The  treatment  for  tubercular  peritonitis  is  the  general 
treatment  for  tuberculosis,  with  such  operative  interference  as  may  be 
deemed  appropriate  after  a  careful  study  of  each  case.  The  results  of  opera- 
tion thus  far  have  been  quite  sufficiently  satisfactory  to  justify  its  repeti- 
tion in  suitable  cases. 

VI.  Tuberculosis  of  the  Genito-urinary  Organs. 

This  includes  tuberculosis  of  the  kidney  and  its  pelvis  tuberctilosis  of 
the  ureters,  bladder,  ovaries  and  testes. 

Tuberculosis  of  the  Kidney. 

Morbid  Anatomy. — Tuberculosis  presents  itself  in  the  kidney  in  two 
forms: 

1.  In  the  shape  of  miliary  tubercles,  which  are  a  part  of  a  general 
tuberculosis,  giving  rise  to  no  special  local  symptoms ;  as  secondary  invasion 
confined  to  the  kidney,  or  rarely  as  primary  in  the  kidney. 

2.  As  secondary  foci  of  localized  tuberculosis ,  which  in  time  may  fuse  to 
form  larger  areas  that  undergo  caseation  and  liquefaction,  transforming  the 
whole  kidney  a  series  of  cysts  containing  cheesy  matter  or  at  times  into  a 
sac  of  punilent  or  chessy  matter  or  such  tuberculosis  may  begin  in  the 
kidney  or  may  start  in  the  prostate  gland,  bladder,  ureter,  or  pelvis  of  the 
kidney,  and  may  extend  also  into  the  testicle  and  epididymis  in  men  and 
the  ovary  and  Fallopian  tubes  in  women. 


310  INFECTIOUS  DISEASES 

Symptoms. — The  first  form  is  without  special  symptoms.  In  the 
second  class  there  may  be  none  at  all  or  they  may  simulate  closely  those  of 
■nephrolithiasis.  Tenderness  to  pressure  should  be  especiallj-  sought. 
Frequently,  subjective  symptoms  are  reflected  to  the  bladder,  and  the\- 
include  frequent  micturition,  pain,  and  tenderness  in  the  region  of  the 
l^ladder.  There  is  also  purulent  urine,  but  commonly  this  differs  from  that 
of  cystitis.  It  is  more  imiformly  acid  in  reaction,  and  contains  pus  less 
admixed  with  mucus.  Blood  is  much  more  frequent  than  in  simple  cystitis, 
and  correspondingly  albumin.  Tubes  casts  are  very  rarely  found.  Cheesy 
masses  are  sometimes  present  in  the  urine  and  with  them  the  tubercle 
iDacillus,  which  is  a  pathognomonic  sign.  It  should  always  be  sought. 
It  should  not  be  confounded  with  the  bacillus  found  in  smegma.  Hence, 
a  negative  result  does  not,  however,  exclude  tuberculosis.  Only  the  urine 
from  catheteirzed  ureters  should  be  examined  for  bacilli.  If  bacilli  are 
absent  guinea-pigs  should  be  inoculated  with  the  same  urine. 

A  phenolsulphoepthallein  test  should  always  be  made  before  any 
operative  interference  with  the  kidneys. 

Diagnosis. — In  the  absence  of  such  conclusive  proof  as  bacilli  in  the 
urine  and  a  pig  test  the  presence  of  tubercle  elsewhere,  as  in  the  lungs  or 
nearer  parts,  as  the  testicles  and  prostate  in  men  or  the  ovaries  and  Fallo- 
pian tubes  in  women,  affords  suggestive  evidence.  The  latter  may  be  in- 
\'estigated  through  the  vagina  and  rectum.  Catheterization  of  the  ureters 
may  also  be  practised  and  stenosis  of  the  ureter  due  to  tubercular  infiltra- 
tion of  the  pyeloureteral  wall  thus  recognized.  In  other  cases  where  the 
lungs  are  not  primarily  tuberculous  they  may  be  secondarily  invaded. 
Hydronephrosis  may  resvUt  from  complete  obstruction  of  the  ureter  b\- 
tubercular  infiltration.  A  cystoscopic  examination  including  catheteriza- 
tion of  the  ureters  should  always  be  made.  The  urine  by  these  catheters 
can  be  examined  for  tubercle  bacilli.  Colargol  can  be  injected  through  the 
ureters  and  cavities  in  the  kidney  substance  demonstrated  by  X-rays, 
as  shown  by  Keene  and  others. 

Treatment. — Beyond  the  general  restorative  and  palliative  treatment 
useful  in  general  tuberculosis  there  is  no  medical  treatment  of  tuberoilar 
Iddney.  As  soon  as  the  diagnosis  is  made  of  tuberculosis  of  a  single  kidney 
and  the  general  condition  of  the  patient  justifies  an  operation,  the  surgeon 
should  be  called  and  nephrectomy  done. 

Tuberculosis  of  the  Pelv-is  of  the  Kidney,  Ureters,  and  Bladder. 

It  is  difficult  to  separate  tuberculosis  of  these  parts  of  the  urinary 
tract.  So  far  as  symptomatology  is  concerned,  outside  of  the  bacterio- 
logical examination,  the  symptoms  of  tuberculosis  are  those  of  simple 
inflammation.  If  the  disease  is  advanced  there  is  tenderness,  but  this  is 
the  case  also  when  there  is  impacted  stone  or  pyelitis  from  other  causes. 
The  invasion  of  the  bladder  produces  symptoms  like  those  of  cystitis,  in- 
cluding frequent  micturition  and  punilent  urine  in  which  there  may  be  a 
small  amount  of  blood.  These  symptoms,  again,  are  not  peculiar  to  tuber- 
culosis, and  the  examination  for  bacilli  again  becomes  necessary.  The 
diagnosis  is  largely  one  for  a  surgeon,  though  the  medical  man  should  see 


TUBERCULOSIS  311 

that  the  methods  are  carried  out.  Cystrocopic  examination  will  show 
whether  the  bladder  is  the  seat  of  lesion  or  not.  Catheterization  of  one 
or  both  ureters  will  show  whether  the  kidneys  and  pelves  are  normal  or  not. 

Tuberculosis  of  the  Ovaries,  Fallopian  Tubes,  and  Uterus. 

The  ovaries  may  be  the  seat  of  miliary  tubercles  or  may  contain  large 
cheesy  masses.  Ovarian  tuberculosis  is  commonly  associated  with  tuber- 
culosis of  the  Fallopian  tubes.  The  symptoms  of  the  former  are  in  no  way 
different  from  those  of  ovaritis  from  other  causes.  Fallopian  salpingitis 
produces  a  hard  and  thick  infiltration  of  the  Fallopian  tubes,  which  may  be 
recognized  by  the  usual  methods  of  examination  for  the  disease  of  these 
organs.  The  uterine  ends  are  commonly  closed,  while  the  intervening 
portion  may  be  dilated  and  contain  mucus,  pus,  and  cheesy  material. 
Tubal  tuberculosis,  is  commonly  double. 

Tuberculosis  also  invades  the  uterus,  infiltrating  it  by  miliary  tubercles, 
which  coalesce,  soften,  and  break  down,  producing  metritis  and  ulceration, 
discharges  from  which  may  contain  the  bacilli.  The  symptoms  of  the  result- 
ing metritis  are  the  same  as  those  of  metritis  from  other  causes. 

Tuberculosis  of  the  Testes,  Prostate  Gland,  and  Seminal  Vesicles. 

Tuberculosis  of  the  testis  and  prostate  in  not  infrequent.  It  presents 
itself  as  cheesy  infiltration,  which  more  frequently  does  not  liquefy.  More 
rarely,  the  vesiculse  seminales  are  invaded.  The  enlarged  vesiculae  semi- 
nales  may  be  felt  through  the  rectum.  The  symptoms  of  this  form  of 
prostatic  disease  are  in  no  way  different  from  those  of  other  diseases  of  the 
prostate  with  enlargement  until  rupture  takes  place. 

Tuberculosis  of  the  testis  is  not  such  a  rare  affection.  It  is  commonly 
secondary  to  that  of  the  bladder  and  prostate,  whence  the  bacUli  travel  along 
the  vas  deferens  into  the  epididymis,  which  may  be  converted  into  a  cheesy 
mass  surrounding  the  testicle.  With  the  invasion  of  the  testicle  further 
enlargement  results  with  softening,  ulceration,  and  fistulous  burrowing. 
The  walls  of  these  fistulae  are  infiltrated  with  tubercles.  This  malady  is 
characteristically  painless. 

The  treatment  of  these  conditions  is  maiiily  surgical,  although  the  gen- 
eral measures  usual  in  tuberculosis  elsewhere  are  also  suitable. 

Tuberculosis  of  the  Liver. 

In  acute  miliary  tuberculosis,  the  liver  is  frequently  the  seat  of  miliary 
tubercles.  Large  tubercles  rarely  occur,  but  they  may  be  present  and 
be  multiple.  Tuberculosis  of  the  gall-ducts  occurs.  There  are  no  distinc- 
tive symptoms,  but  in  general  tuberculosis  with  hepatic  involvement  one 
or  the  other  of  these  forms  may  be  suspected  to  exist. 

Tuberculosis  of  the  Mammary  Glands. 

The  mammary  gland,  though  rarely  invaded  by  tuberculosis,  is  neverthe- 
less an  occasional  seat,  it  may  occur  at  any  age  and  in  both  sexes.  Warden 
having  collected  58  authentic  cases  in  literature,  nearly  90  per  cent,  of  whom 
were  females.     Three  forms  are  recognized  by  Adami,   the  acute  miliary. 


312  INFECTIOUS  DISEASES 

the  discrete  and  the  confluent.  In  the  discrete  form  the  breast  is  not  nec- 
essarily enlarged,  the  nodules  may  be  one  or  many,  and  may  be  immovable. 
The  skin  is  intact,  each  nodule  on  section  shows  a  central  grayish  material 
or  it  may  be  pyriform  in  character.  The  confluent  form  gives  rise  to  con- 
siderable enlargement  of  the  breast,  there  is  a  single  large  mass.  On 
section  the  mass  is  found  to  be  filled  with  cavitis  of  irregular  size  and  shape. 
Radiating  from  the  central  area  are  rays  of  fibrous  tissue.  These  cavities 
may  communicate  with  the  exterior  by  a  sinus.  Sometimes  this  form 
terminates  in  a  cold  abscess.  The  bacilli  causing  the  disease  are  carried  by 
the  blood  in  the  acute  miliary  form. 

Tuberculosis  of  the  Heart  and  Blood-Vessels. 

Tuberculosis  of  the  Heart  and  Pericardium. — Tuberculosis  of  the  myo- 
cardium sometimes  occurs — usually  as  extension  from  a  tuberculous  affec- 
tion of  the  pericardium  they  are  difficult  to  differentiate  from  syphilis — 
presents  itself  in  the  shape  of  miliary  tubercles  scattered  throughout  the 
substance  of  the  heart.  Tuberculous  pericarditis  may  be  acute  or  chonic, 
more  commonly  acute,  caused  by  sudden  invasion.  Both  are  usually  a 
part  of  a  general  tuberculosis.  Very  rarely  the  acute  form  is  primar^^ 
Tuberculous  pericarditis  is  followed  by  exudation  of  fibrin,  and  sometimes 
of  blood  and  pus.  It  is  found  sometimes  in  old  persons  in  whom  it  promptly 
causes  death.  Such  pericarditis  is  also  commonly  adhesive,  and  is  not 
distinguishable  by  physical  signs  and  symptoms  from  the  other  foi-ms  of 
pericarditis. 

In  cardiac  tuberculosis  it  is  supposed  that  the  bacilli  arise  from  long 
latent  foci  of  tuberculosis  of  the  bronchial  or  mediastinal  lymphatic  glands. 
The  latter,  on  the  other  hand,  may  be  secondarily  invaded  from  the  cardiac 
tuberculosis. 

Tubercles  are  sometimes  found  on  the  valves  of  the  heart. 

Tuberculosis  of  Blood-vessels. — May  arise  from  infection  through  the 
blood  or  it  may  also  invade  the  blood-vessels  of  a  part  attacked.  Both  the 
intima  and  adventitia  may  be  effected.  Sometimes  the  tubercles  caseate 
and  rupture  into  the  vessel  and  in  tubercidosis  of  the  lungs  hemorrhages 
are  commonly  due  to  such  invasion,  which  weakens  the  vessel  and  ultimately 
perforates  it. 

LEPI^OSY. 

/ 
Synonym. — Elephantiasis  Grcecorum. 

Definition. — Leprosy  is  an  infectious  disease,  due  to  the  bacillus  leprcB, 
characterized  by  a  subcutaneous  and  submucous  nodular  infiltrate,  or  by 
similar  infiltration  of  nerve-trunks.  The  former  constitutes  tubercular 
leprosy;  the  latter,  anesthetic  leprosy. 

Etiology. — The  bacillus  of  leprosy  was  discovered  by  Hansen  in  187 1, 
and  subsequently  clearlj^  described  by  Neisser,  and  is  especially  character- 
ized by  its  close  resemblance  to  the  tubercle  bacillus,  both  in  morphology 
and  in  its  reaction  to  stains.  Duval  has  recently  been  able  to  cultivate  it 
on  mature  green  bananas.    So  far  as  is  known  it  does  not  exist  normally  outside 


LEPROSY  313 

the  human  body  and  they  are  discharged  only  by  secretions  of  the  diseased 
individuals.  They  are  for  the  most  part  found  in  the  interior  of  cells, 
rarely  outside  of  them.  Some  of  these  cells  are  of  large  size  and  known  as 
lepra  cells.  In  the  interior  of  these  cells  the  bacilli  often  form  clumps. 
They  are  exceedingly  numerous  in  leprous  tissue. 

While  the  disease  is  contagious,  its  spread,  even  under  the  most  favor- 
able circumstances,  is  exceedingly  slow,  the  most  intimate  contact,  as  that 
between  parent  and  child,  being  often  unattended  by  inoculation.  Experi- 
mental inoculation  was,  however,  successfully  performed  on  a  Hawaiian 
convict  by  Arning,  as  well  as  in  rabbits  by  Melcher  and  Artmann.  Accord- 
ing to  Morrow,  in  the  majority  of  cases  the  disease  spreads  by  sexual  inter- 
course, but  cracks  and  fissures  in  the  skin  also  favor  the  lodgment  of  the 
bacillus.  In  certain  countries,  especially  the  tropical,  its  spread  is  more 
rapid.  Such  are  India,  where  there  are  said  to  be  250,000  lepers,  and  the 
Sandwich  Islands,  where,  in  1889,  there  were  iioo  in  the  settlement  at 
Molokai. 

In  this  country  the  cases  are  for  the  most  part  isolated  ones  that  enter 
by  the  seaports  of  the  Pacific  and  Atlantic  coasts.  In  Tracadie,  on  the 
Gulf  of  St.  Lawrence,  there  is,  however,  a  leper  settlement,  the  disease  having 
been  brought  from  Norway  in  the  latter  part  of  the  eighteenth  century. 
The  number  of  cases  is  being  gradually  reduced,  there  being  in  1S96  but  18 
as  compared  to  40  a  few  years  previous.  This  is  apparently  the  result  of 
segregation,  which  is  now  generally  practised  where  possible.  A  few  cases 
have  been  reported  from  Texas  and  there  is  a  settlement  in  Louisiana  and 
Florida.  The  commission  appointed  in  1899  reported  278  cases  in  the 
United  States. 

All  ages  and  sexes  are  liable  to  this  disease.  Animals  are  not  subject 
to  it,  although  guinea-pigs  have  been  successfully  inoculated.  A  curious 
impression  has  arisen  that  the  disease  is  caused  by  eating  spoiled  fish  or 
vegetables.  To  this  belief  Jonathan  Hutchinson  has  given  the  weight  of 
his  opinion.  In  view,  however,  of  the  acknowledged  bacillary  origin  of  the 
disease,  this  can  only  be  considered  as  a  predisposing  cause  that  lowers 
vitality  by  altering  nutrition. 

Morbid  Anatomy. — Tubercular  leprosy  is  characterized  by  its  nodular 
outgrowths  on  the  skin,  especially  of  the  face,  the  extension  surfaces  of  knees 
and  elbows,  and  especially  of  the  prepuce  and  scrotvmi,  the  nodules  being 
made  up  of  a  small-celled  infiltrate  together  with  the  "lepra  cells,"  main- 
taining itself  for  a  considerable  time,  after  which  it  breaks  down  and 
ulcerates.  The  ulcers  may  heal,  producing  cicatrices.  The  mucous  mem- 
brane is  also  invaded,  particularly  that  of  the  eyelids,  the  conjunctiva, 
cornea,  and  larynx.  Lymphatic  glands,  cartilage,  liver,  lungs,  and  spleen 
are  also  at  times  affected.  The  lepra  nodes  are  vascular,  differing  in  this 
respect  from  the  nodules  of  tuberculosis. 

The  morbid  anatomy  of  the  anesthetic  variety  will  be  included  in  the 
anatomical  changes  of  the  skin  to  be  described  in  the  symptomatology  of 
that  type  of  the  disease. 

Symptoms. — Nothing  is  known  of  a  period  of  incubation.  The  outbreak 
of  the  disease  is  apt  to  be  preceded  by  an  intermittent  febrile  movement,  by 
drowsiness,  dyspepsia,  vertigo,  ^tc,  symptoms  which  have  been  mistaken  for 


314  INFECTIOUS  DISEASES 

intermittent  fever  and  which  may  last  for  one  or  two  years.  Except  for 
the  length  of  time  over  which  they  extend  they  do  not  differ  from  the  symp- 
toms which  may  precede  many  specific  diseases.  There  is  often  an  erythe- 
matous redness  of  the  skin,  which  in  places  becomes  pale  and  in  others 
assumes  a  brownish  tinge,  usually  those  areas  are  hyperesthetic.  From  this 
appearance  the  name  macular  leprosy  has  been  applied  to  certain  cases  which 
go  no  farther.  From  these  spots  the  pigment  may  also  disappear,  leaving 
perfectly  white  anesthetic  areas — lepra  alba. 

In  the  further  development  of  the  disease,  in  the  tubercular  or  more 
usual  form,  an  infiltration  of  the  skin  with  tubercular  nodules  takes  place. 
These  areas  usually  first  appear  on  the  face,  remain  for  a  long  time  intact, 
without  degenerating,  but  sooner  or  later,  as  a  rule,  though  often  only  after 
many  years,  softening  and  ulceration  takes  place.  Some  of  them,  on  the 
other  hand,  gradually  disappear  without  ulceration.  The  number  of 
nodules  varies  greatly.  Some  of  them  are  pediculated,  others  are  a  simple 
thickening  of  the  skin,  which  is  conspicuous  in  such  portions  as  the  eyelids, 
nose,  and  ears,  parts  of  which  may  disappear  by  ulceration.  Even  the 
cornea  and  conjunctiva  may  be  the  seat  of  nodules,  and  blindness  may 
result. 

The  same  development  maj^  take  place  in  mucous  membranes  produc- 
ing obstruction  of  the  respiratory  passages,  including  the  nose  and  larynx. 
There  may  also  be  leprous  deposits  in  internal  organs,  including  the  liver, 
spleen,  lungs,  and  lymphatic  glands. 

In  the  nervous  or  anesthetic  form  the  peripheral  nerves  become  infil- 
trated with  the  leprous  growth  and  are  converted  into  thickened  cords  that 
may  even  be  felt  under  the  skin.  These  are  at  first  painful,  but  later  be- 
come anesthetic.  Trophic  phenomena  of  a  striking  character  result,  pro- 
ducing dryness,  smoothness,  and  tightness  of  the  skin  with  a  total  absence 
of  nodules.  Atrophy  and  wasting  ensue  from  the  same  cause,  and  toes, 
fingers,  and  even  larger  limbs  drop  off.  Great  vesicles  also  sometimes 
form.  Subsequently  are  added  signs  of  weakness  and  exhaustion  which 
gradually  increase  untU  the  patient  succumbs. 

Diagnosis. — The  diagnosis  of  the  tubercular  form  when  full}'  developed 
is  not  difficult  though  it  might  be  mistaken  for  syphilis  or  tuberculosis. 

The  anesthetic  variety  resembles  closely  certain  forms  of  scleroderma, 
the  face  has  a  characteristic  canine  appearance,  but  the  trophic  changes  are 
more  extensive.  The  resemblance  of  the  early  stage  to  intermittent  fever 
has  been  referred  to.  The  diagnosis  may  be  made  absolute  by  the  detection 
of  lepra  bacilli  in  portions  cut  out  for  the  purpose  of  study. 

The  anesthetic  or  nervous  form  of  leprosy  and  syringomyelia  bear  a 
close  clinical  resemblance.  It  maj'  also  be  mistaken  for  peripheral  neuritis, 
l^rogressive  muscular  atrophy,  or  Raynaud's  disease,  but  the  leper  almost 
without  exception  has  discolored  areas  of  the  skin  which  are  anesthetic 
and  are  frequently  discolored. 

Prognosis. — The  course  of  the  disease  is  almost  always  prolonged,  and 
the^patient  may  die  from  intercurrent  disease.  In  some  cases  death  results 
from  the  gradual  exhaustion  of  the  sj-stem,  which  is  more  rapid  in  the  tdcer- 
ative  forms.  From  the  nervous  form  of  leprosy  recovery  does  sometimes 
take  place,  though  the  secondary  changes  resulting  remain  permanent. 


WEIL'S  DISEASE  315 

Prophylaxis. — It  is  known  that  the  disease  is  probably  spread  by  the 
discharges  of  the  patients.  Therefore  all  cases  should  be  at  once  reported 
to  the  authorities  and  strict  measures  taken  to  prevent  the  patient  from 
spreading  the  disease  by  handling  food,  clothing  and  the  like.  It  is  quite 
possible  also  that  the  disease  is  spread  through  the  agency  of  blood-sucking 
insects  and  this  should  be  taken  into  account.  Segregation  should  be 
practised  whenever  possible,  for  such  a  course  is  invariably  accompanied 
by  a  falling  off  in  the  number  of  cases,  and  the  continued  practice  of  this 
method  must  ultimately  result  in  the  disease  being  stamped  out.  In  this 
segregation,  sanatoria  should  be  established  which  would  allow  the  leprous 
family  to  live  normal  lives,  and  where  the  segregated  individuals  should 
not  be  made  to  feel  they  are  undergoing  imprisonment. 

Treatment. — Hygienic  measures  should  not  be  neglected.  The  patients 
should  live  in  the  open  as  much  as  possible,  should  have  good  nutritious  food, 
exercise  which  should  be  regulated  must  always  be  used.  As  yet  there  is 
no  specific  treatment. 

Medicines. — Innumerable  drugs  have  been  used  without  the  least  effect. 
Chaulmoogra  oil  is  now  in  the  greatest  favor.  It  is  used  internally  and 
externally.  The  dose  is  five  to  50  drop  doses  given  in  capsules  or  in  milk. 
A  purified  form  of  this  oil  is  used  called  antileptrol.  Nartin  is  another 
preparation  now  in  favor.  It  is  a  bacterial  fat,  produced  by  a  streptothrix 
isolated  from  leprous  nodules.  A  diluted  mixture  of  this  called  Nartin  B. 
is  injected  subcutaneously  in  i  c.c.  doses  once  a  week  for  five  or  six  weeks. 

Arsenic  has  been  used  as  a  general  tonic. 

Sertun  and  vaccine  treatment  so  far  have  availed  nothing. 

Salvarsan  has  been  used  with  good  results  in  a  few  instances.  Master's 
Treatment,  the  injection  of  living  cultures  of  streptothrix  leproides,  have 
been  reported  favorably  by  Deycke. 

Surgical  interference  may  be  employed   wherever   it  seems  advisable. 

Finsen  light  and  Roentgen  Ray  treatment  have  both  been  tried. 

INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE. 

ACUTE  FEBRILE  JAUNDICE. 

Synonyms. — Weil's  Disease. 

Definition. — An  acute  infectious  disease,  characterized  bj^  jaundice 
and  fever,  described  by  Weil  in  1886. 

Etiology. — The  cause  is  as  yet  undetermined,  but  it  affects  males  in 
preference  to  females,  especially  butchers,  laborers,  and  brewers,  and  its 
subjects  are  from  25  to  40  years  of  age.  Exposure  to  cold  may  be  con- 
sidered an  exciting  cause.  A  few  cases  have  occurred  in  this  country,  two 
having  been  reported  from  the  Philadelphia  Hospital  by  J.  H.  Musser  and 
John  Guiteras.  Weiss  considers  that  the  symptoms  and  lesions  most 
resemble  the  bilious  typhoid  described  by  Griesinger,  while  the  latter  has 
been  claimed  to  be  identical  with  the  typhoid  icterodes  of  Egypt. 

It  occurs  commonly  in  the  summer  months,  and  nearly  always  in  groups 
of  cases.  But  for  the  last  fact  the  disease  might  well  be  regarded  as 
catarrhal  jaundice. 


316  INFECTIOUS  DISEASES 

Symptoms. — The  illness  sets  in  suddenly,  after  exposure  to  cold,  as 
in  a  beer  vault,  most  frequently  with  a  chill  and  without  prodrome.  There 
is  fever,  with  temperature  of  102°  to  104°  F.  (38.9°  to  40°  C),  headache, 
muscular  and  joint  pain,  and  epigastric  pain,  which  is  characteristic.  There 
is  especially  tenderness  in  the  calj  muscles.  Jaundice  promptly  makes  its 
appearance.  The  fever  lasts  usually  from  ten  to  14  days,  and  is  characterized 
by  decided  remissions.  The  liver  and  spleen  are  both  enlarged;  the  former 
may  be  tender.  Associated  with  the  jaundice  are  the  usual  clay-colored 
stools  of  obstructive  jaundice.  Beyond  the  epigastric  pain,  which  maj^ 
be  hepatic  in  origin,  gastro-intestinal  symptoms  are  not  marked,  though  the 
tongue  is  coated,  and  there  may  be  vomiting  and  diarrhea.  There  may  be 
dizziness,  confusion  of  mind,  and  even  delirium.  The  urine  contains  bUiarj' 
coloring-matter;  sometimes  albumin  with  casts  and  even  blood. 

After  a  duration  of  from  eight  to  fourteen  days,  convalescence  sets  in, 
usually  slowly,  and  it  may  be  prolonged. 

Diagnosis. — The  conditions  with  which  Weil's  disease  might  be  for  a 
time  confounded  are  malaria  fever,  acute  yellow  atrophy  of  the  liver, 
phosphorus  poisoning,  and  catarrhal  jaundice.  The  first  would  be  ex- 
cluded by  the  absence  of  the  Plasmodium  of  malaria,  while  the  mildness 
and  favorable  termination  would  exclude  the  second  and  third.  Catarrhal 
jaundice  is  distinguished  by  the  absence  of  fever,  and  of  muscular,  joint, 
and  epigastric  pain,  which  characterize  Weil's  disease. 

Prognosis. — Recovery  is  usual,  but  a  few  autopsies  have  been  made, 
with  the  discovery  of  no  definite  morbid  anatomy.  There  is  cloudy  swelling 
and  even  fatty  degeneration  of  the  cells  of  the  heart,  liver,  kidney,  stomach, 
and    intestines. 

Treatment  consists  in  attention  to  the  diet  and  general  symptomatic 
treatment. 

MILIARY  FEVER. 

Synonyms. — Febris  miliaris;  Sudor  anglicus;  Sweating  Sickness;  the  Sweat- 
ing Disease  of  Picardy;  the  English  Sweat. 

Definition. — An  infectious  fever  of  unknown  cause,  characterized  by 
profuse  sweats  and  an  eruption  of  miliary  vesicles. 

Etiology. — As  to  the  specific  cause  nothing  is  known.  It  is  not  con- 
tagious nor  inoculable,  and  not  favored  by  crowding.  Most  epidemics  occur 
in  summer,  fewest  in  the  autumn;  second  in  frequency  is  the  spring;  third, 
the  winter.  Moist,  warm,  and  unchanging  weather  favors  the  disease. 
Contaminations  of  the  soil,  such  as  arise  from  neglected  drains  and  collec- 
tions of  refuse,  also  contribute  to  its  causation.  More  women  are  affected 
than  men,  and  the  vulnerable  age  seems  to  be  between  20  and  50  years. 
The  healthy  and  strong  are  as  likely  to  be  attacked  as  the  weak,  and  the 
rich  as  well  as  the  poor.     Lately  it  has  been  confined  to  Italy  and  Prussia. 

Morbid  Anatomy. — No  characteristic  anatomical  changes  have  been 
noted  in  miliary  fc\'er.  The  internal  organs  are  generally  hyperemic.  The 
spleen  is  often  enlarged.  The  most  striking  feature  is  the  tendency  to  rapid 
decomposition,  "beginning  almost  during  life,"  as  has  been  said.  The 
blood  is  thin  and  dark  in  color. 


GLANDULAR  FEVER  317 

Symptoms. — After  an  incubation  of  two  or  three  days  the  patient  goes 
to  bed  apparently  well,  and  wakes  up  in  the  night  dripping  with  sweat. 
With  this  is  a  sense  of  oppression,  and  even  pain,  in  the  precordial  region, 
tenderness  and  pain  in  the  epigastrium,  palpitation,  headache,  dizziness,  and 
muscular  cramps.  The  temperature  is  abnormally  high,  the  pulse  and 
respirations  are  frequent;  there  s  even  dyspnea,  sometimes  very  violent. 
The  perspiration  continues,  saturating  the  bed  clothing  and  diffusing  an 
unpleasant  odor  throughout  the  room. 

On  the  third  or  fourth  day,  as  a  result  of  the  profuse  sweating,  miliary 
vesicles  make  their  appearance,  at  first  so  minute  at  to  be  scarely  visible, 
though  they  may  be  felt  by  passing  the  hand  over  the  skin.  As  they  become 
larger  they  are  easily  visible  by  their  crystalline  contents,  which  later  become 
turbid  and  even  milky.  They  appear  first  on  the  neck  and  breast,  then  over 
the  back  and  extremities,  less  frequently  on  the  abdomen  and  scalp.  After 
two  or  three  days  they  burst,  dry  up,  and  form  crusts,  which  subsequently 
desquamate.  With  the  appearance  of  the  eniption  the  other  symptoms 
disappear  rather  suddenly,  but  there  is  often  noted  a  burning  and  prickling 
sensation  of  the  skin.  There  is  generally  loss  of  appetite,  sometimes  nausea, 
seldom  vomiting,  scanty  urine,  and  especially  constipation. 

The  duration  of  the  disease  is  usually  from  six  to  eight  days,  although 
it  may  be  prolonged  beyond  this,  the  eruption  being  sometimes  delayed  to 
the  seventh,  tenth,  and  even  isth  day.  Relapses  may  occur.  Sometimes 
the  disease  assumes  an  intermittent  character. 

Diagnosis. — This  is  not  diffictilt.  The  prevalence  of  an  epidemic, 
profuse  sweating,  and  rash  scarcely  permit  an  error. 

Prognosis. — The  prognosis  has  varied  greatly  in  different  epidemics, 
the  mortality  in  some  of  the  earlier  reaching  as  much  as  50  per  cent.,  while 
in  others  none  died.  The  average  may  be  put  down  at  from  eight  to  nine 
per  cent. 

Treatment. — The  treatment  is  mainly  expectant  and  symptomatic. 
Simple  febrifuges  and  acid  drinks  are  indicated.  Warm  baths  and  spong- 
ing of  the  skin  with  warm  water  are  soothing  and  comforting.  The  precor- 
dial distress  and  apnea  may  require  anodynes,  preferably  subcutaneously 
administered.  The  sweating  itself,  if  alarming,  may  be  treated  by  hypo- 
dermic injections  of  atropin,  1/200  to  i/ioo  grain  (0.00033  to  0.00066  gm.), 
p.  r.  n.,  or  this  drug  may  be  given  by  the  mouth  in  the  same  dose. 

GLANDULAR  FEVER. 

Synonym. — Driisen-Fieher. 

Definition. — An  acute  infectious  fever  of  children,  characterized  by 
inflammation  of  the  lymph  glands  of  the  neck,  especially  those  back  of  the 
sternocleidomastoid  muscle. 

Etiology. — No  responsible  bacterium  has  been  found.  The  disease 
may  be  epidemic,  as  was  that  which  occurred  in  Bellaire,  Ohio,  described 
by  West.  It  has  been  observed  to  prevail  more  commonly  between  the 
months  of  October  and  June  in  the  winter  season.  The  infection,  whatever 
it  may  be,  probably  enters  through  the  tonsils  or  the  pharyngeal  mucous 
membrane. 


318  IXFECriOUS  DISEASES 

Morbid  Anatomy.- -This  includes  the  enlargement  of  the  glands,  which 
forms  so  essential  a  part  of  the  disease.  The  enlargement  may  involve  not 
only  the  cervical  glands  referred  to,  but  the  axillary,  inguinal,  bronchial, 
and  even  the  mesenteric.  Thus,  in  West's  report  of  96  cases  occurring 
between  the  ages  of  seven  months  and  13  years,  in  three-fourths  of  them 
the  postcervical,  inguinal,  and  axillary  glands  were  involved,  with  the 
mesenteric  in  37  cases.  The  liver  and  spleen  were  also  enlarged,  the 
former  in  87  and  the  latter  in  57  cases. 

Symptoms. — The  period  of  incubation  lasts  from  five  to  eight  days. 
The  disease  is  characterized  by  sudden  onset  of  stiffness  ^\Hith  pain  on  mo^■- 
ing  the  head.  Along  with  this  there  is  fever  with  a  temperature  of  101°  to 
103°  F.  (56°  to  57°  C.)  with  sometimes  nausea  and  vomiting.  The  enlarge- 
ment of  the  glands  does  not  make  its  appearance  until  the  second  or  third 
day,  and  may  attain  a  size  from  that  of  a  pea  to  a  hen's  egg,  but  rarely  goes 
on  to  suppuration.  The  glands  are  tender  to  the  touch,  but  there  is  not 
usually  redness  of  the  sldn.  There  may  also  be  some  hyperemia  of  the 
tonsils,  or  pharyngitis.  More  rarely  there  is  invasion  of  the  tracheal  and 
bronchial  glands  which  may  be  the  occasion  of  cough.  The  swelling  persists 
from  two  to  three  weeks,  although  the  fever  does  not  last  nearly  so  long. 

Complications. — Among  these  which  may  be  named  as  possible  are 
hemorrhagic  nephritis,  postphamygeal  abscess,  and  acute  otitis  media. 

Diagnosis. — The  disease  is  to  be  distinguished  from  the  various  forms 
of  infectious  sore  throat  found  in  scarlet  fever  and  diphtheria  which  may 
cause  a  similar  affection  of  the  lymphatic  glands. 

Prognosis. — Favorable. 

Treatment. — Active  treatment  is  scarcely  needed.  The  patient  should 
be  put  to  rest.  Cold  or  warm  applications  may  be  made,  whichever  form 
is  found  more  comfortable.  An  aperient,  such  as  a  dose  of  oil  or  calomel, 
may  be  desirable  at  the  very  beginning.  West  recommended  small  doses  of 
the  latter  drug. 

LEISHMANIASIS. 

{Kala-Azar.) 

Definition. — This  is  a  condition  occurring  in  Asia,  and  particularly  in 
India,  Ceylon,  Syria  and  China.  It  is  caused  by  a  parasite  of  the  Leish- 
mania  groujD,  and  is  supposed  to  be  spread  by  the  bite  of  a  bedbug. 

Symptoms. — The  symptoms  are  enlargement  of  the  spleen,  irregular  fever 
lasting  for  a  long  while,  and  signs  of  progressive  secondary'  anemia.  Ac- 
cording to  observers  the  blood  changes  varj'  according  to  the  stage  of  the 
disease.  According  to  Leishman  there  is  always  an  anemia,  the  red  cells 
numbering  from  three  to  four  million.  Early  in  the  disease  there  is  a  slight 
leukoc^'tosis  and  then  leukopenia  is  established  in  the  later  stages,  when 
from  one  to  two  thousand  leukocytes  are  found.  Careful  examination  will 
show  the  Leishman  body  in  the  leukocyte.  Leishman  suggests  citrating 
the  blood  and  collecting  the  corpuscles  by  centrifugal  force.  A  certain 
diagnosis  can  be  made  by  puncturing  the  spleen,  because  the  Leishman 
bodies  can  always  be  found  in  the  blood  from  the  spleen.  But  this  pro- 
cedure is  not  without  danger. 


ACUTE  POLIOMYELITIS 


319 


Diagnosis. — This  may  be  mistaken  for  a  secondary  anemia  and  for  infan- 
tile splenic  anemia,  and  possibly  for  trypanosomiasis.  However,  only  the 
history  of  the  case  as  having  a  chance  of  infection  in  southern  Asia,  and 
careful  repeated  examination  of  the  blood  will  make  a  diagnosis.  Sleeping 
sickness  would  show  the  presence  of  trypanosomcs,  which  are  absent  in 
Leishmaniasis. 

ACUTE  POLIOMYELITIS. 
(Infantile  Paralysis.) 

Definition. — -Acute  poliomyelitis  is  an  infectious  disease  due  to  a  filter- 
able virus.  It  is  characterized  by  fever,  sore  throat,  pain,  prostration,  and 
usually  paralysis  of  one  or  more  limbs.  It  can  be  transmitted  from  one 
person  to  another,  probably  through  discharges  from  the  nasophar\'ngeal 
mucous  membrane. 

Etiology. — The  disease  is  often  epidemic,  and  sometimes  apparenth' 
sporadic.  Owing  to  the  difficulty  of  diagnosing  early  and  abortive  cases, 
this  form  of  the  disease  is  constantly  overlooked.  Its  portal  of  entrance  is 
probably  the  mucous  membrane  of  the  nasopharynx. 

Virus. — This  is  definitely  proven  to  be  filterable,  and  is  therefore  not  a 
known  bacterium.  Flexner  in  a  recent  communication  reports  the  cultiva- 
tion of  the  organism  which  is  an  anaerobic  body,  but  he  cannot  as  yet  clas- 
sify it.  It  is  resistent  to  glycerization ;  it  resists  freezing  2°  C.  to  4°  C.  It 
can  be  destroyed  by  heat,  by  2  per  cent,  solution  of  hydrogen  peroxide  and 
by  corrosive  sublimate. 

The  serum  of  recovered  individuals  and  recovered  monkeys  will  destroy 
the  virulence  in  vitro.  It  can  certainly  be  transmitted  from  one  human 
being  as  proven  by  Wickham.  It  spreads  along  routes  of  human  travel. 
FHes  can  be  passive  distributors  of  the  disease. 

Age. — The  disease  is  most  frequent  in  early  ages,  about  90  per  cent. 
being  in  the  first  decade,  but  220  cases  in  the  Swedish  epidemic  were  be- 
tween 10  and  over  25.  The  following  age  table  taken  from  the  Rockefeller 
report,  No.  4,  Jan.  24,  1912^  is  of  importance. 

TABLE  OF  AGE  I.N'CIDEXCE. 


UnderL        |        ,                !        '      ^  "^           „  „      ' 

g       16-1211-2:2-3  3-4I4-SI5-6  6-7[7-8  8-9;9-l0  10-15  IS-20  20-25 

Over 

Total 

Rockefeller  Institute 
Hospital,  191 1. 

j 

3          15    I  62  j  29 

i8i3!64:0!2        13           01 

0 

1      IS7 

New  York  epidemic, 
1907. 

62              '22l'l80 

10  663!  28    18      II     II       7        14            5            I 

^ 

729 

Wickman,  Sweden, 
1906. 

183 

214                       179                       229                               220 

1,025 

ndebted  to  this  : 


;  pamphlet  for  the  quotations  in  this  article  and  niany  of  the 


320  INFECTIOUS  DISEASES 

Season. — It  reaches  its  maximum  in  the  late  simimer  and  early  fall. 

Location. — It  is  a  disease  of  open  country  rather  than  of  built  up  cities. 
The  authors'  cases  have  been  largely  among  the  residents  of  the  suburbs. 

Morbid  Anatomy. — The  meninges  are  edematous  and  injected.  The 
amount  of  cerebrospinal  fluid  is  about  normal.  The  brain  and  cord  appear 
edematous.     The  gray  matter  is  swollen. 

The  first  change  in  the  meninges  most  noticeable  on  the  anterior  part 
of  the  spinal  cord,  is  an  acute  interstitial  meningitis.  There  is  a  small 
celled  infiltration  about  the  vessels  of  the  meninges.  There  are  also  minute 
hemorrhages. 

"  Cellular  exudate,  hemorrhages  and  edema,  all  dependent  upon  vascular 
changes,  are  the  first  effects  of  the  virus.  This  is  the  reason  for  the  nerve 
changes.  The  nerve  changes  are  certainly  partly  vascular,  they  may  also 
be  toxic,  and  partly  due  to  anemia. 

If  the  hemorrhages  and  exudate  are  absorbed  soon  enough,  the  cells  will 
ragain  their  power.     The  nerve  cells  either  degenerate  or  recover. 

"Of  practically  constant  occurrence  are  the  lesions  in  the  posterior  root 
ganglia.  The  histological  changes  are  similar  to  those  that  take  place  in 
the  cord  itself.  There  is  an  infiltration  of  small  round  cells  in  the  lymphatic 
spaces  surrounding  the  vessels  which  enter  the  ganglia  from  the  meninges. 
This  has  been  shown  experimentally  to  be  the  first  step  in  the  process. 
Then  follows  a  more  general,  diffuse  exudation  of  cells,  degeneration  and 
necrosis  of  the  nerve  cells,  and  finally  the  entrance  of  polj^morphonuclear 
leucocytes  into  the  necrotic  cells  and  removal  of  the  disintegrating  cells  b>' 
neurophages.  The  suggestion  has  been  made  that  these  lesions  in  the  sen- 
sory ganglia  may  in  part  account  for  the  pain  which  is  such  a  constant 
feature  of  the  acute  stage  of  the  disease.  Another  element  in  the  production 
of  pain  is  the  cellular  infiltration  which  is  found  along  the  nerve  roots." 

The  lymph  glands  and  the  tonsils  are  enlarged.    The  spleen  often  enlarges, 

The  changes  are  much  like  those  of  typhoid  fever.  This  is  particularly 
marked  in  the  liver.  "The  disease  must  be  regarded  as  a  generalized 
process  which  affects  parenchymatous  organs,  lymphoid  tissue,  and  more 
especially  the  nerA'Ous  system.  It  is  possible  that  two  distinct  effects  of 
the  disease  on  the  organism  should  be  differentiated." 

Symptoms. — The  period  of  incubation  is  varied  and  difficult  to  fix,  but 
it  is  probably  from  four  to  six  days.  The  prodromal  symptoms  are  fever, 
sore  throat,  drowsiness,  sweating,  and  muscular  pains.  Frequently  these 
symptoms  are  so  mild  that  they  are  overlooked.  Sometimes  these  symp- 
toms are  very  severe.  The  temperature  may  reach  104°.  Drowsiness  is 
common.  The  pain  is  increased  by  flexion  of  different  parts  of  the  body. 
Sometimes  there  are  symptoms  referable  to  the  respiratory  tract,  coryza, 
bronchitis,  etc. 

Gastric  and  intestinal  sj-mptoms  are  common,  vomiting  and  diarrhoea 
constantly  appearing.  These  symptoms  are  followed  in  the  first  to  the 
1 2th  day  of  the  disease  by  a  sudden  paralysis.  The  greatest  number  develop 
the  paralysis  on  the  first,  second  or  third  day  of  the  disease.  In  certain 
cases  the  paralysis  is  the  first  sign  noticed  by  the  parents. 

Other  cases  have  a  remission  for  two  or  three  days  and  then  relapse.  In 
the  more  severe  type  the  so-called  cerebral  form,  in  which  the  paralysis  is 


ACUTE  POLIOMYELITIS  321 

of  the  bulbo-spinal  type,  the  patients  are  almost  comatose.  There  may  be 
retraction  of  the  head.  .Sometimes  the  patients  are  deHrious,  after  the 
acute  symptoms  disappear.  The  patient's  general  condition  improves,  but 
the  paralysis  remains. 

Sometimes  the  paralysis  is  complete.  It  varies  from  this  to  a  mere 
weakness.  Sometimes  the  paralysis  is  very  transient,  lasting  from  two  or 
three  days  to  several  weeks,  and  entirely  disappearing.  The  parts  involved 
are  most  frequently  the  legs,  but  any  nerves,  the  cranial  included,  may  be 
involved. 

Blood. — In  the  report  above  mentioned,  there  was  a  constant  leucocy- 
tosis,  sometimes  as  high  as  30,000. 

Cerebrospinal  Fluid. — It  is  usually  clear.  Two  hundred  and  thirty-three 
fluids  were  examined  from  69  cases.  The  pressure  is  usually'  above  normal. 
They  all  reduced  Fehling's  solution.  The  number  of  cells  is  usually  in- 
creased.    The  globulin  reaction  is  marked. 

Diagnosis. — Until  the  paralysis  occurs,  this  is  most  difficult.  The  pro- 
dromal symptoms  are  exactly  like  those  of  many  infectious  diseases.  In  the 
presence  of  an  epidemic,  however,  fever,  drowsiness,  pain,  and  sore  throat 
are  very  suspicious  symptoms.     The  sudden  paralysis  is  pathognomonic. 

Prognosis. — Eight  hundred  and  sixty-eight  of  Wickham's  cases  show  a 
death  rate  of  16.7  per  cent.  The  degree  of  the  paralysis  is  not  a  criterion 
of  its  permanency.  Certain  cases  recover,  but  in  the  Massachusetts  cases 
only  16.7  per  cent,  made  complete  recoveries. 

Prophylaxis  and  Treatment. — Early  diagnosis  is  important.  Fever, 
pain,  drowsiness  at  the  time  of  epidemics  should  be  the  sign  for  isolation 
and  the  administration  of  urotropin.  The  mouth  should  be  gargled  with 
2  per  cent,  peroxide  of  hydrogen  solution,  and  the  case  at  once  isolated. 
When  the  diagnosis  is  certain,  the  case  must  be  isolated,  nurse  and  attendants 
should  wear  gowns  and  gloves. 

As  the  virus  may  exist  in  the  exudate  from  throat  and  nose  is  certain, 
all  such  exudates  should  be  disinfected.  The  child  should  be  in  bed  perfectly 
quiet.  Urotropin,  six  grain  doses  every  three  hours  should  be  administered. 
Pain  is  often  severe  in  lifting  and  changing  the  patient.  Care  should  be 
observed  in  moving  the  patient.  The  room  should  be  warm  but  well 
ventilated. 

Salicylates  are  of  value.  Bromides  and  morphine  may  be  demanded. 
In  severe  cases  where  the  respiration  fails,  artificial  respiration  must  be 
employed.  Here  the  pulmotor  should  be  employed  because  of  the  certainty 
of  its  action. 

Treatment  of  the  Paralysis. — In  the  early  stages  absolute  rest  is  impera- 
tive. This  should  last  as  long  as  there  is  pain.  On  the  disappearance  of 
pain,  passive  movements  and  massage  should  be  employed  twice  a  day. 
The  patient  must  be  encouraged  to  attempt  voluntary  movements.  This 
should  be  done  by  tempting  the  patient  to  play,  putting  it  on  a  mattress 
and  roUing  over.     Electricity  should  be  used,  both  galvanism  and  faradism. 

Splints,  an  other  orthopedic  means,  must  often  be  employed,  but  at  all 
times  until  contractions  begin  to  occur,  the  patient  must  be  cajoled  into 
attempting  voluntary  movements.  The  hope  is  that  prophylactic  serum 
may  be  employed.     This  is  not  as  yet  applicable  to  human  subjects. 


SECTION  II 

DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

DISEASES  OF  THE  MOUTH. 

THE  COATED  TONGUE. 

The  natuarl  color  of  the  tongue  at  its  anterior  two-thirds  is  a  pale  red, 
on  which  the  fungiform  papillw  stand  out  as  brighter  red  points.  The  epi- 
thelium covering  the  filiform  papilla;,  which  are  much  more  numerous  and 
uniformly  spread  over  the  dorsal  surface  of  the  tongue,  is  thicker,  and  they 
are  therefore  less  distinctly  seen.  As  the  base  is  approached,  a  grayish 
color  is  assvuned  on  account  of  the  greater  thickness  of  the  epithelium. 
At  the  base  are  seen  the  circumvallate  papillas,  arranged  in  two  rows  of 
red  circles.  In  the  furred  tongue  the  epithelium  is  abundant,  though 
it  is  doubtfid  whether  it  is  present  in  increased  quantity  or  is  simph- 
raised  by  hyperemic  swelling  of  the  paillae.  The  "fur"  is  also  contributed 
to  by  various  forms  of  fungi.  Too  much  stress  should  not  be  laid  on  the 
coated  tongue.  Some  persons  have  a  coated  tongue  and  are  perfectly 
healthy,  while  others  have  fair-looking  tongues  and  are  ailing  seriously  with 
those  derangements  which  are  commonly  attended  with  coated  tongue,  espe- 
cially gastrointestinal  disturbances.  Food  such  as  milk,  licorice  and  tobacco 
also  contribute  to  the  coating  of  the  tongue. 

The  dry,  brown  color  of  the  tongue  in  low  fevers  is  due  to  a  drying 
of  the  exfoliating  epithelium,  admixed  sometimes  with  mucus  or  saliva. 
The  tongue  may  also  be  coated  with  dried  food  and  sometimes  with  dried 
blood,  due  to  capillary  hemorrhage,  which  imparts  to  it  a  black  color — 
the  black  tongue  of  certain  malignant  fevers.  It  is  sometimes  pale  and 
anemic  in  persons  whose  blood  is  poor  and  deficient  in  red  blood-disks. 
In  other  cases  it  is  enlarged  and  flabby,  while  its  edges  are  easily  indented 
and  marked  by  the  teeth.  A  bright  red  or  even  a  raw  appearance  of  the 
tongue  is  met  with  in  certain  fevers,  particularly  in  the  early  stages,  when 
it  ma.Y  also  be  dry  and  glazed.  It  may  be  coated  at  the  beginning,  but  later 
the  epithelium  desquamates  freely  and  the  whole  surface  may  be  red;  or 
the  fungiform  papillae  may  be  hyperemic,  swollen,  and  unusually  distinct, 
constituting  the ' '  strawberry ' '  tongue  so  characteristic  of  scarlet  fever.  The 
raw-beef  appearance  of  the  tongue  is  often  seen  toward  the  close  of  exhaust- 
ing diseases,  like  tuberculosis. 

DERANGEMENTS  OF  DENTITION. 

The  most  serious  accident  of  dentition  is  what  is  known  as  the  reflex 
con\Tilsion,  which  will  be  considered  among  ner\-ous  affections.  Other 
gastrointestinal  derangements  will  be  discussed  under  diarrhea  of  infants. 

322 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  323 

These  are  not  always  reflex.  They  may  be  excited  by  toxic  qualities  of  the 
saliva,  which  is  not  only  increased,  but  altered  as  well.  Other  abnormalities 
including  anomalies  in  the  order  of  eruption  of  teeth  occur,  and  certain 
markings  on  the  teeth,  ascribed  to  stomatitis  are  met. 

The  order  of  natural  eruption  of  the  milk  teeth  is  well  shown  in  the 
accompanying  diagram.  The  first  to  appear  are  the  lower  central  incisors 
(i,i),  at  the  age  of  from  four  to  seven  months,  then  a  few  weeks  later  the 
upper  central  incisors  (2,  2),  and  next  the  upper  lateral  incisors  (2a,  2a). 
Not  until  the  beginning  of  the  second  year  come  the  lower  lateral  incisors 
(3,  3),  and  almost  simultaneously  the  four  anterior  molars  (4,  4,  4,  4).  In 
the  second  half  of  the  second  year  come  the  four  canines  (5,  5,  5,  5),  includ- 


FiG  97. — Diagram  Showing  Eruption  of  Milk  Teeth. 
I,  I.  Between  the  fourth  and  seventh  month,  followed  by  a  pause  of  three  to  nine  weeks. 
2,  2,  2a,  2a.  Between  the  eighth  and  tenth  months;  pause  of  six  to  twelve  weeks.  3,  3,  4,  4, 
4,  4.  Between  the  twelfth  and  fifteenth  months;  pause  until  eighteenth  month.  5,  5,  5,  5. 
Between  the  eighteenth  and  twenty-fourth  months;  pause  of  two  to  three  months.  6,  6,  6,  6. 
Between  the  twentieth  and  thirtieth  months — {from  Louis  Starr,  slightly  modified). 

ing  the  two  "eye,"  two  "stomach"  teeth;  and  finally  the  foiur  posterior 
molars  (6,  6,  6,  6) ;  so  that  by  the  end  of  the  second  or  beginning  of  the  third 
year  the  first  dentition  is  completed.  The  milk  teeth  begin  to  be  replaced 
by  the  permanent  set  in  the  fifth  or  sixth  year.  Before  any  of  the  mUk  teeth 
are  shed  the  first  molars  of  the  second  set  are  fully  developed.  Hence 
they  are  called  the  sis-year  molars.  About  12  years  are  consumed  in  the 
cutting  of  the  remaining  teeth,  but  the  variations  of  the  date  of  appearance 
of  each  tooth  are  so  great  that  it  is  not  worth  while  to  attempt  to  name 
the  dates.     Some  individuals  never  develop  teeth. 

In  some  children  (usually  the  rachitic,  the  feeble,  and  badly  nourished) 
the  appearance  of  the  milk  teeth  is  greatly  delayed — the  lower  incisors  do 
not  appear  until  the  nth  or  12th  month,  but  the  completion  of  dentition 
is  not  much  delayed  thereby,  though  under  these  circumstances  denti- 
tion is  sometimes  not  completed  until  the  end  of  the  third  year.  In  others 
they  appear  earlier — ^in  the  third  or  fourth  month — and  occasionally 
children  are  bom  with  them.  It  has  always  seemed  that  the  first 
appearance  of  the  teeth  is  more  apt  to  be  delayed  in  blondes  and  anticipated 
in  brunettes. 

The  diet  of  children  during  dentition  should  be  very  carefully  watched, 
as  the  whole  gactrointestinal  tract  is  sensitive  and  irritable  and  readily 


324 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


thrown  into  inflammation.  The  mouth  is  tender,  the  saliva  flows  freely, 
and  the  child  is  disposed  to  bite  on  anything  and  to  thrust  its  little  fists  into 
its  mouth.  The  term  tooth  rash  is  applied  to  certain  eczematous  eruptions 
that  sometimes  appear  during  teething.  Their  relation  to  teething  is  not 
established. 

Very  rarely  a  purulent  conjunctivitis  makes  its  appearance  during  the 
eruption  of  the  upper  canines  or  "eye  teeth,"  which  is  ascribed  to  dentition 
and  explained  by  contiguous  extension  of  inflammation  through  the  antrum 
of  Highmore  and  the  lachrymo-nasal  duct. 

Certain  markings  are  often  found  on  the  teeth  as  a  consequence  of 
stomatitis.  They  include  pittings  and  linear  depressions,  the  result  of 
defects  in  the  development  of  the  enamel.     Extreme  degrees  produce  a 


Fig.  o8.— Thin-edged  and  Broken  Teeth, 
not  Syphilitic,  from  a  Woman,  aged  Twenty. 

The  notches  in  the  upper  teeth  differ 
markedly  from  those  shown  in  Fig.  gp.  In 
these  they  result  not  so  much  from  the  soft- 
ness and  original  malformation  of  the  teeth 
as  from  their  preternatural  thinness  and 
brittleness.  Near  the  edges  of  the  lower 
set  a  horizontal  line  of  notches  is  seen  to 
e.xtend — (ajter  Hutchinson). 


Fig.  99. — The  Permanent  Front  Teeth  of 
a  Boy,  aged  Fifteen,  who  had  Taken  Much 
Mercury  in  Infancy. 

The  teeth  are  all  of  yellow  color,  some- 
what pitted  in  their  surfaces,  and  very 
thickly  coated  with  tartar.  Near  the 
edges  of  the  lower  set  a  horizontal  line 
extends  similar  to  that  in  Fig.  98 — (after 
Hutchinson) . 


honeycombed  appearance.  These,  as  well  as  the  syphilitic  teeth  of  children, 
have  been  studied  by  Jonathan  Hutchinson,  and  are  not  to  be  confounded 
with  the  latter.  (Figs.  98  and  99).  the  "honeycombed"  changes  are 
most  conspicuous  in  the  permanent  teeth,  of  which  the  first  molars,  accord- 
ing to  Hutchinson,  are  the  test  teeth,  though  he  says  the  incisors  are  almost 
as  constantly  pitted,  eroded,  and  discolored,  often  showing  a  transverse  line 
which  crosses  all  the  teeth  at  the  same  level.  These  transverse  furrows 
are  also  ascribed  by  Magitot  to  infantile  convulsions  or  other  severe  illness 
in  early  life. 

Care  of  the  Mouth. — That  severe  toxic  conditions  may  occur  from 
neglected  conditions  in  the  mouth  is  certain.  William  Hunter  was  the 
first  to  insist  upon  this.  Conditions  closely  resembling  if  not  identical  with 
acute  rheumatic  fever  occur  which  are  preceded  and  accompanied  by  severe 
septic  conditions  of  the  mouth.  In  our  experience  the  clearing  up  of  the 
mouth  condition  has  caused  an  immediate  disappearance  of  the  joint 
s>Tnptoms.  Pyorrhea  alveolaris  is  constantly  the  cause  of  not  only  the  acute 
joint  troubles  but  of  more  chronic  ones  such  as  arthritis  deformans.  Severe 
forms  of  anemia  have  resulted  caused  apparently  by  neglected  mouth 
conditions. 

Fetor  oris  is  frequently  the  result  of  carious  teeth  and  pyorrhea.  Disturbed 
digestion  may  constantly  result  from  poor  teeth  or  no  teeth.     It  therefore 


STOMA  Tins  325 

is  of  the  highest  importance  that  great  attention  be  given  to  the  mouth,  both 
as  a  prophylactic  and  as  a  method  of  treatment. 

STOMATITIS. 
Simple  Acute  Catarrhal  Stomatitis. 

Definition  and  Etiology. — A  simple  erythematous  inflammation  of 
the  mouth,  commonly  caused  by  diffuse  chemical  or  mechanical  irritants, 
such  as  overheated  food  (very  hot  drinks),  acids,  alkalies,  stimulating  con- 
diments (red  pepper,  horse-radish,  and  the  like),  by  excessive  smoking  and 
use  of  alcohol.  It  occurs  in  adults  and  children  from  the  action  of  such 
causes,  independently  of  the  state  of  health,  but  is  prolonged  when  its 
subjects  are  unhealthy  and  ill-nourished.  Dentition  is  also  a  cause,  while 
stomatitis  may  accompany  also  indigestion  and  the  acute  fevers. 

Symptoms. — The  mucous  membrane  is  reddened  wherever  the  irrita- 
tion has  reached,  but  the  redness  may  be  greater  in  certain  situations,  as  on 
the  tongue,  gums,  and  cheeks.  There  may  be  at  the  very  beginning 
dryness,  but  it  is  soon  followed  by  increased  secretion  and  slight  swelling. 
There  is  always  discomfort  that  may  amount  to  pain,  which  is  increased  by 
the  introduction  of  food  and  its  mastication.  A  corresponding  slight  febrile 
movement  may  be  present. 

Treatment. — The  treatment  of  simple  catarrhal  stomatitis  wiU  be  con- 
sidered in  connection  with  that  of  the  other  forms  of  stomatitis  to  be 
described. 

Herpetic  or  Aphthous  Stomatitis. 
Synonyms. — Vesicttlar    Stomatitis;  Aphtha;  Canker;  Follicular   Stomatitis. 

Description  and  Symptoms. — Some  confusion  attends  the  use  of  this 
term.  The  term  "aphtha"  from  the  Greek  means  "an  eruption."  Aph- 
thous stomatitis  is  sometimes  confounded  with  thrush,  but  it  is  not  a 
parasitic  disease,  as  in  thrush,  nor  is  it  a  follicular  disease.  Others  speak 
of  it  as  herpetic  or  vesicular.  J.  Emmett  Holt  adopts  this  name  because  he 
agrees  with  Forcheimer^  in  regarding  it  as  of  nervous  (neuritic)  origin. 

The  little  grayish-white  spots  which  characterize  it  consist  primarily 
of  an  exudate  of  fibrin  and  wandered-out  leukocytes,  which  pervades  the 
superficial  layer  of  the  mucous  membrane  and  is  at  first  covered  bj'  epithe- 
lium. Hence,  an  attempt  to  remove  the  spots  by  forceps  is  futile  and  fol- 
lowed by  bleeding.  They  are  small,  round,  usually  not  more  than  a  few 
millimeters  in  diameter,  and  surrounded  by  a  red  areola  of  hyperemia, 
occurring  at  times  in  successive  crops.  They  are  most  common  on  the 
cheeks  and  lips,  especially  in  the  gingival  groove  at  the  base  of  the  latter. 
They  also  occur  on  the  tip  and  edges  of  the  tongue,  more  rarely  on  the  dor- 
sum. The  epithelium  dies  and  desquamates,  leaving  a  superficial  ulcer, 
which  under  favorable  circumstances  heals  up  rapidly.  Under  more  un- 
favorable conditions  the  ulcer  grows  deeper  and  becomes  more  painfyl, 
constituting  one  of  the  forms  of  ulcerative  stomatitis.  Young  children  are 
especially  subject  to  it,  but  it  is  common  also  in  adults,  especially  at  times 

^  "Archives  of  Pediatrics,  vol.  ix.,"  p  330. 


326  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

of  temporary  physical  depression,  as  in  women  during  menstruation,  preg- 
nancy, and  lactation. 

The  aphthas  are  commonly  associated  with  a  variable  amount  of  simple 
stomatitis,  with  increased  secretion  of  saliva,  a  slight  "heaviness"  of  the 
breath,  but  without  fetor.  There  is  commonly  a  stinging  sensation,  espe- 
cially when  brought  in  contact  with  food,  and  even  when  the  tongue  and  lips 
are  moved  in  speaking.  There  is  often  some  constitutional  distrubance, 
including  fever.     Relapses  may  occur. 

A  similar  condition  is  Riga's  disease,  in  which  a  pearly-colored  mem- 
brane with  induration  forms  on  the  frenum  of  the  tongue.  It  occurs  in 
southern  Italy  in  unhealthy  and  cachectic  children  about  the  time  of  erup- 
tion of  the  temporary  teeth,  and  may  be  epidemic. 

Thrush — Mycotic  Stomatitis. 

Synonyms. — Parasitic  Stomatitis;  Soor;  Miguet. 

Definition. — Thrush  is  characterized  by  gra^dsh-white  deposits  in  the 
buccal  and  pharyngeal  mucous  membranes,  due  to  the  development  and 
interpenetration  of  the  epithelium  by  a  fungus  variously  known  as  oidium 
albicans  or  saccharomyces  albicans.  It  is  a  variety  of  yeast  fungus  made  up 
of  branching  filaments,  at  the  ends  of  which  oval  cells  develop.  It  does  not 
grow  on  the  normal  mucous  membrane.  It  forms  minute  white  and  j^eUow- 
ish  spots  scattered  copiously  over  the  palate,  tongue,  and  cheeks,  uniting 
at  times  to  form  large  areas.  It  may  extend  into  the  esophagus  and  even 
larynx.  In  severe  cases  the  entire  buccal  mucous  membrane  maybe  covered. 
Stenosis  of  the  esophagus  has  resulted  from  its  accumulation.  The  little 
areas  are  commonly  surrounded  by  an  inflammatory  areola,  and  may  be 
scraped  off,  though  with  some  difficulty,  leaving  the  mucous  membrane 
sometimes  intact  and  sometimes  slightly  excoriated  and  bleeding. 

Thrush  is  chiefly  a  disease  of  nursing  children,  and  is  favored  by  feeble 
and  dyscrasic  states  and  by  the  want  of  cleanliness,  especially  in  the  care 
of  nursing-bottles  and  nipples  when  children  are  brought  up  on  the  bottle. 
It  may  be  associated  with  any  of  the  diseases  of  children  or  may  occur  in- 
dependent of  them.  It  also  occurs  in  adults  after  long  illness  or  in  dyscrasic 
diseases  like  diabetes  mellitus  and  tuberculosis.  Thrush  is  often  un- 
attended by  other  symptoms,  though  the  mouth  may  be  sensitive  and 
nursing  painful. 

Diagnosis. — There  should  be  no  difficulty  in  diagnosis.  In  thrush  the 
spots  are  smaller  than  in  aphthous  stomatitis,  and  the  microscope  at  once 
removes  all  doubt.  The  mouth  is  dry  as  contrasted  -with  the  moist  mouth 
of  aphthous  sore  mouth,  where  there  is  free  salivation.  The  secretions  are 
commoiily  acid. 

Koplik's  sign  in  measles  is  not  likely  to  be  mistaken  for  thrush.  It  is 
described  on  p.  99. 

Other  Varieties  of  Stomatitis  Due  to  Fungi. — The  mouth  is  a  favorite 
seat  for  the  development  of  fungi,  because  of  the  warmth,  moisture,  and 
organic  matters  constantly  present.  Though  ordinarily  harmless,  in  certain 
states  of  the  system  they  may  play  an  important  role  in  producing  iilcerative 
stomatitis,  as  already  suggested.     Especially  worthy  of  mention  are  the 


STOMATITIS  327 

diplococcus  of  Frankel  and  the  pneumonia  bacillus  of  Fricdlander;  also  the 
delicate,  thread-lilce  leptothrix  buccalis,  thought  to  exert  a  significant  part 
in  the  production  of  caries. 

Ulcerative  Stomatitis. 

Synonyms. — Stomacace;  Fetid  Stomatitis;   Putrid  Sore  Mouth. 

Definition. — This  is  a  much  more  serious  disease  of  the  mucous  membrane 
of  the  mouth,  attended  with  necrosis  and  resulting  ulceration. 

Etiology. — Any  one  of  the  above-named  diseases  may  become  ulcer- 
ative. It  may  begin  as  an  aphthous  stomatitis,  taking  on  the  more  serious 
form  in  the  ill  fed  and  badly  cared  for,  or  in  those  who  are  indifferent  in 
the  care  of  their  mouths.  It  may  begin  as  thrush.  In  other  cases,  an 
abrasion  or  laceration  by  the  tooth-brush  or  a  sharp  carious  tooth,  may  be 
the  initial  lesion.  An  ulcer  may  begin,  too,  in  a  herpetic  vesicle,  which,  on 
rupturing,  leaves  a  raw  surface  that  may  remain  isolated  or  unite  with  others. 
It  is  a  frequent  attendant  of  mercurialization — mercurial  stomatitis.  The 
ulcer  sometimes  starts  in  the  mucous  follicles  of  the  mouth.  In  all  these 
cases  the  stomatitis  is  probably  the  result  of  infection  by  some  organism; 
it  may  be  the  omnipresent  streptococcus,  staphylococcus  or  diplococcus, 
to  which  the  sound  mucous  membrane  in  health  is  invulnerable,  but  which 
finds  a  nidus  in  the  abrasions  and  conditions  referred  to. 

Symptoms. — The  ulcers  may  occur  in  any  of  the  situations  already 
named,  the  lips,  cheeks,  and,  more  rarely,  the  tongue.  They  vary  in  size, 
but  are  usually  of  an  ashen-gray  color,  with  red  areolae,  and  often  exhibit  a 
tendency  to  bleed. 

Additional  symptoms  are  profuse  secretion,  exquisite  pain  and  tender- 
ness in  the  ulcers  and  vicinity,  a  fetid  odor  of  the  breath,  which  sometimes 
pervades  the  apartment.  The  gums  become  spongy  and,  in  extreme  cases, 
the  teeth  are  loosened.  There  are  proportionate  constitutional  disturbances, 
fever,  and  often  swelling  of  the  glands  at  the  angle  of  the  jaw. 

Mercurial  stomatitis,  or  mercurial  ptyalism.  This  condition  is  due  to 
mercury  administered  as  a  medicine  or  absorbed  in  the  course  of  occupations 
in  which  mercury  is  handled.  Acquired  in  the  former  way,  ptyalism,  at 
the  present  day,  is  usually  accidental  rather  than  designed,  in  persons  exhib- 
iting a  peculiar  susceptibility.  In  such  persons  even  fractional  doses  fre- 
quently repeated  sometimes  produce  salivation  in  a  day  or  two.  The  symp- 
tom first  observed  is  usually  fetor  of  the  breath,  unless  the  patient  be  closely 
watched  during  the  administration  of  the  drug,  when  tenderness  may  be 
ascertained  on  closing  the  jaws  with  some  force.  Examination  will  then 
discover  a  swelling  of  the  gums  about  the  teeth.  A  metallic  taste  may 
make  its  appearance  as  the  first  symptom.  To  these  symptoms  salivation 
is  soon  added,  and  becomes  more  or  less  profuse  according  to  the  severity 
of  the  poisoning.  In  severe  cases,  the  entire  mucous  membrane  of  the  mouth 
becomes  swollen,  as  does  also  the  tongue.  In  such  cases,  also,  ulceration 
and  loosening  of  the  teeth  take  place.  This  form  of  stomatitis  was  not 
infrequent  in  the  older  treatment  of  syphilis,  it  used  to  fill  a  hospital 
ward  with  a  sickening  fetor  at  once  recognizable.     Actual  loss  of  teeth  was, 


328  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

perhaps,  less  common  than  is  supposed  even  in  those  days,  yet  necrosis  of 
the  jaw  has,  in  rare  instances,  resulted. 

Parrot's  ulceration  is  a  form  of  ulceration  occurring  in  new-born  children, 
consisting  of  small,  symmetrically  placed  ulcers  on  the  hard  palate  on  both 
sides  of  the  median  line.  Bednar's  aphthce,  two  symmetrically  placed  ulcers, 
also  occurring  on  the  hard  palate  on  either  side  of  the  medial  line  near  the 
velvim,  are  similar,  though  not  regarded  as  identical.  This  variety  is  thought 
to  be  traumatic  in  origin,  at  least  in  most  cases,  either  the  result  of  pressure 
of  an  artificial  nipple  against  the  hard  palate,  or  of  undue  pressure  in 
washing  the  mouth.  Both  are  described  as  usually  harmless,  but  in  poorly 
cared  for  children  may  be  converted  into  extensive  and  deep  ulcers.  Es- 
pecially is  this  the  case  in  the  form  described  by  Parrot,  which  may  invade 
the  adjacent  bone. 

Diagnosis. — This  is  made  by  inspection  of  the  mouth  and  the  history  of 
the  case.  Scurvy,  though  a  general  disease,  happily  rare  of  late,  is  char- 
acterized by  local  symptoms  about  the  mouth,  which  include  ulceration. 
There  are  swelling  and  bleeding  of  the  gums,  which  rise  up  around  the 
teeth.  The  latter  become  loosened  and  ulceration  may  extend  even  to  the 
lips  and  cheeks.  The  tongue  and  fauces  are  not  invaded  by  ulcers,  but  are 
subject  to  ecchymoses.  Salivation  and  fetor  of  the  brealh  are  also  symp- 
toms, though  less  decided  than  in  severe  ulcerative  stomatitis.  On  the  other 
hand,  in  extreme  cases  deep-seated  gangrenous  processes  are  met.  Along 
with  these  are,  however,  the  general  symptoms  of  scurvy^  by  which  it 
is  commonly  easily  recognized. 

Treatment  of  Different  Forms  of  Stomatitis. — Prophylaxis  is  exceed- 
ingly important  in  averting  these  various  mouth  affections.  In  the  case 
of  infants  the  mouth  should  be  washed  out  with  antiseptics  after  each  nurs- 
ing. Nothing  is  better  than  a  saturated  solution  of  chlorate  of  potash,  boric 
acid,  or  bicarbonate  of  sodium,  15  grains  to  the  ounce  (i  gm.  to  30  c.c.)  of 
water.  So,  too,  the  adult  should  cleanse  the  teeth  after  each  meal.  Liquor 
Antisepticus,  U.  S.  P.,  diluted  with  twice  as  much  water,  is  an  elegant  and 
efficient  wash. 

Any  of  these  'substances  may  be  used  on  the  tooth-brush  as  a  simple 
mouth-wash.  The  tinctiu-e  of  myrrh,  a  teaspoonful  to  4  ounces  of  water, 
should  not  be  forgotten,  and,  though  less  agreeable,  carbolic  acid  may  be 
used  in  the  same  proportion.  Permanganate  of  potassium  in  the  shape  of 
Condy's  fluid,  a  teaspoonful  to  a  tumbler  of  water,  is  an  excellent  wash. 

If  stomatitis  is  established,  cleanliness  is  no  less  important  and  may 
be  secured  by  the  same  antiseptic  measures.  In  addition,  the  mouths  of 
children  may  be  treated  with  glycerin  and  borax.  Alum  itself  is  an  admir- 
able astringent,  too  much  overlooked  of  late.  A  moderately  strong  solution 
may  be  made,  30  grains  (2  gm.)  to  the  oimce  (30  c.c),  or  the  powdered  alum 
itself  may  be  applied  to  the  aphthous  sore  mouth. 

For  the  painful  aphthous  ulcers  of  adults  and  children  there  is  really 
nothing  so  efficient  as  touching  with  a  pointed  piece  of  nitrate  of  silver. 
A  single  application  will  often  suffice,  but  when  healing  does  not  foUow,  it 
may  be  made  daily.  A  very  good  application  also  is  a  solution  of  equal 
parts  of  tincture  of  the  chlorid  of  iron  and  glycerin,  applied  to  the  ulcers 
with  a  brush.     Chlorate  of  potassium  in  saturated  solution  is  also  a  very 


NOMA  329 

good  mouth-wash,  to  8  ounces  (240  c.c.)  of  which  1/2  a  fluidram  to  i  dram 
(2  c.c.  to  4  c.c.)  of  tincture  of  the  chlorid  of  iron  may  be  added. 

In  the  ulcerative  stomatitis  chlorate  of  potassium  internally  in  3 -grain 
doses  acts  almost  as  a  specific. 

Many  such  cases  have  an  acute  or  chronic  gastritis,  as  manifested  by 
the  symptoms  peculiar  to  that  condition,  therefore  the  diet  should  be  care- 
fully regulated.  The  bowels  must  be  moved  each  day.  Bismuth  is,  as  a 
rule,  an  excellent  routine  remedy.     Calomel  in  divided  doses  may  be  used. 

General  treatment  should  not  be  overlooked.  Many  persons  who 
have  stomatitis  are  much  run  down,  and  require  iron,  quinin,  and  strych- 
nin, with  nutritious  food,  to  buUd  them  up.  Attention  should  also  be  paid 
to  the  bowels. 

In  mercurial  stomatitis  the  use  of  mercury  must  at  once  be  stopped. 
Astringents  and  disinfectants  are  especially  indicated. 

Noma. 

Synonyms. — Gangrenous  Stomatitis;  Water  Cancer;  Cancrum  Oris. 

Definition. — A  rare  form  of  stomatitis,  characterized  by  hard  infiltration 
of  the  cheek  near  the  angle  of  the  mouth,  succeeded  by  rapid  gangrene  pro- 
ceeding outward  and  inward  from  the  central  focus  until  the  cheek  is 
perforated,  and  the  gangrenous  mass  separates.  It  may  start  in  the  gums 
and  produce  necrosis  of  the  jaws.     It  is  confined  to  one  side  of  the  face. 

Etiology. — A  parasitic  origin  seems  likely,  but  the  specific  organism  has 
not  been  discovered.  It  occurs  in  children  from  two  to  five  j^ears  old, 
affecting  more  of  the  former  than  of  the  latter.  Rarely  it  affects  adults. 
It  is  usually  confined  to  those  badly  fed  and  surrounded  by  unsanitary 
conditions,  especially  when  convalescent  from  infectious  fevers,  one-half 
of  all  cases  having  arisen  during  convalescence  from  measles,  scarlet  and 
typhoid  fevers.     It  may,  however,  be  primary. 

Symptoms. — Its  approach  is  insidious,  and  it  is  generally  weU  ad- 
vanced when  discovered.  It  begins  with  an  ulceration  of  the  mucous  mem- 
brane of  the  cheek,  rapidly  infiltrating  the  underlying  tissues,  and  in  a  few 
hours  or  days  causing  gangrene.  In  its  extreme  severity  it  may  involve  the 
bones  of  both  jaws,  the  eyelids,  and  ears;  but  in  its  mildest  form  its  results 
are  limited  to  perforation  of  the  cheek.  The  dead  tissue  comes  away  in 
dark,  offensive  shreds. 

The  constitutional  disturbance  corresponds  to  the  degree  of  local 
involvement,  there  being  )Agh.  fever,  reaching  often  104°  F.  (40°  C),  with 
frequent  pulse  and  rapid  exhaustion.  The  adjacent  lymphatics  are  swollen. 
Inhalation-pneumonia  of  corresponding  virulence  often  succeeds,  while 
intense  irritation  of  the  stomach  and  bowels  follows  the  swallowing  of  the 
ichorous  discharge. 

Diagnosis. — Noma  is  rarely  mistaken  for  anything  else.  Malignant 
pustule  is  less  local  in  its  invasion,  furnishes  the  history  of  contagion,  is  even 
more  severe  in  its  constitutional  effects,  and  exhibits  the  appropriate 
badllus.  Very  bad  cases  of  ulcerative  stomatitis  sometimes  suggest  cancrum 
oris,  but  the  devastation  is  not  so  rapid,  nor  is  there  such  a  tendency  to 
invasion  of  the  external  integument. 


330  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Prognosis. — The  cases  frequently  end  fatally  at  the  end  of  three  or  four 
days,  only  the  promptest  and  most  energetic  treatment  saving  life. 

Treatment. — This  consists  in  the  prompt  use  of  surgical  means.  Time 
should  not  be  wasted  with  cauterizing  agents.  Excision  offers  the  best 
chance  for  cure  of  the  patient  and  limitation  of  the  deformity.  The  general 
condition  of  the  patient  must  be  attended  to.  Every  case  of  measles  of 
severity  or  in  weak  ill-nourished  individuals  should  have  the  cheeks  regu- 
larly examined,  in  order  to  forestall  serious  results. 

Glossitis. 

Parenchymatous  glossitis,  or  inflammation  of  the  substance  of  the 
tongue  is  a  rare  disease,  but  it  occurs  as  the  result  of  violent  injury  to  the 
organ,  as  by  accidental  biting  or  poisonous  stings.  Apparentlj^  idiopathic 
inflammations  are  probably  the  result  of  concealed  causes  of  the  kind 
described. 

Symptoms. — The  tongue  is  enormously  swollen  and  painftd,  and  some- 
times extruded  from  the  mouth.  There  is  great  difficulty  in  speech,  masti- 
cation and  deglutition,  and  in  extreme  degrees  these  are  scarcely  possible. 
The  discomfort  is  almost  indescribable,  and  there  may  even  be  obstruction 
to  breathing.  If  exposed,  the  tongue  becomes  dry  and  fissured.  There 
may  be"  suppuration.  There  is  fever  corresponding  to  the  amount  of  local 
disturbance. 

Treatment. — This  consists  in  the  constant  application  of  ice,  of  frequent 
antiseptic  cleansing  of  the  mouth,  and  sometimes  of  scarification.  Evidence 
of  the  presence  of  pus  must  be  followed  by  the  prompt  use  of  the  lancet. 

Glossitis  desiccans  is  a  more  chronic  affection  of  the  tongue,  characterized 
by  deep  fissures  and  indentations,  giving  it  an  uneven,  ragged  appearance. 
Associated  therewith  are  excoriations  and  occasionally  superficial  ulcers. 
Severe  pain  is  caused  by  contact  of  acids  and  even  the  usual  food.  Its 
etiology  is  not  known,  but  it  is  sometimes  associated  with  gastrointestinal 
derangements. 

Treatment. — This  should  be  directed  to  the  cause,  if  it  can  be  dis- 
covered. Washes  of  chlorate  of  potash  should  be  employed,  and  if  there 
are  ulcers,  they  should  be  touched  with  solid  silver  nitrate. 

Epithelial  Desquamation;  Geographical  Tongue. 
Synonyms. — Eczema  of  the  Tongue. 

Definitions  and  Symptoms. — A  localized  superficial  hyperplasia  and 
desquamation  of  the  epithelium  of  the  tongue,  sometimes  associated  with 
similar  spots  on  the  cheeks  and  lips.  The  central  parts  tend  to  heal,  while 
the  periphery  spreads,  producing  circinate  patches.  The  patches  fuse  and 
extensive  areas  are  formed,  bounded  with  sinuous  outlines.  The  appear- 
ance has  been  compared  to  that  of  a  map — lingua  geographica.  The 
condition  is  chronic,  sometimes  lasts  years,  but  does  not  usually  cause 
inconvenience  save  by  the  itching  and  burning  it  occasions  and  the  appre- 
hension of  more  serious  disease.  It  is  occasionally  mistaken  for  syphilitic 
disease. 


LEUKOPLAKIA  331 

Treatment. — It  is  best  treated  by  solutions  of  nitrate  of  silver,  which  re- 
lieves the  itching.    Weak  solutions  of  iodin  may  be  used,  applied  with  a  brush. 

Leukoplakia  Buccalis. 

Synonyms. — Ichthyosis  Ungualis;  Buccal  Psoriasis;  Keratosis  mucoscBoris; 
Smoker's  Patches. 

Definition. — A  condition  in  which  there  are  intense  white  spots  on  the  mu- 
cous membrane  of  the  mouth  and  tongue,  consisting  of  thickened  epidermis. 

Etiology. — Some  cases  of  leukoplakia  are  syphilitic  in  origin.  Some 
are  the  result  of  excessive  smoking.  Others  appear  to  be  the  result  of 
irritation  of  a  badlj^  fitting  dental  plate. 

Symptoms. — The  patient  is  first  made  aware  of  the  condition  which 
appears  as  white  shiny  spots  on  various  parts  of  the  mucous  membrane  of 
the  cheeks  and  tongue,  they  may  be  few  or  many.  Occasionally  the 
whole  mucous  membrane  may  be  involved. 

The  spots  on  the  sides  of  the  tongue  are  often  notched,  giving  them 
a  scar-like  appearance,  Those  on  the  inner  surface  of  the  check  are 
simply  fiat  tabular  swellings.  They  disappear,  to  be  replaced  by  others; 
they  rarely  give  rise  to  inconvenience.  Sometimes  those  on  the  sides  of 
the  tongue  become  ulcerated,  when  they  are  painful  if  brought  into 
contact  with  irritants.  They  occur  in  adults  of  both  sexes.  They  some- 
times become  papillomatous,  and  are  said  to  have  been  the  starting-point 
of  true  epithelioma,  as  often  as  once  in  every  three  cases. 

Treatment. — Before  treatment  is  begun  or  it  is  decided  to  give  no 
treatment  a  Wasseimann  reaction  should  be  made  to  discover  if  syphilis 
is  the  underlying  cause.  If  the  patient  is  the  subject  of  syphilis  he  should 
be  put  upon  proper  treatment.  If  syphilis  is  not  present,  all  sources  of 
irritations  such  as  smoking,  ill  fitting  dental  plates,  etc.,  should  be  corrected. 
This  being  done  no  further  interference  is  necessary  unless  the  spots  begin 
to  undergo  degeneration.     If  this  occurs  they  must  be  at  once  excised. 

Mucous  Patches. 

The  true  mucous  patches  or  flat  condylomata  of  syphilis  are  opaque, 
white,  flat,  tabular  swellings  on  the  lips,  tonsils,  tongue,  and  arches  of  the 
palate,  and  especially  at  the  border-line  between  skin  and  mucous  membrane. 
They  consist  of  an  irregular  imbricated  thickening  of  the  superficial  layers 
of  the  skin;  the  cells  are  swollen  and  the  papillae  of  the  mucous  corium 
hypertrophied. 

Treatment. — The  treatment  of  the  mucous  patches  of  syphilis  is  that 
of  syphilis  constitutionally,  and  locally  by  applications  of  nitrate  of  silver. 

DISEASES  OF  THE  SALIVARY  GLANDS. 

FUNCTIONAL  DERANGEMENTS. 

Ptyalism,  or  excessive  secretion  of  saliva,  is  a  symptom  of  mercurial 
poisoning,  also  of  poisoning  by  gold,  copper,  and  iodin.  Some  persons 
are  very  susceptible  to  iodin,  so  that  a  few  grains  of  iodid  of  potassium 
will  cause  intense  salivation,  with  pain  in  the  salivary  glands.  Vegetable 
substances  producing  the  same  effect  are  jaborandi,   muscarin,   tobacco. 


332  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Indeed,  almost  anything  which  admits  of  constant  chewing  without  solution 
or  destruction  produces  salivation.  This  is  the  mechanism  of  the  various 
agents  used  in  the  disgusting  practice  of  chewing  gum. 

Xerostomia,  or  dry  mouth,  is  the  opposite  condition  of  arrest  of  sali- 
vary and  buccal  secretion,  not  due  to  fever — a  rather  common  condition, 
first  described  by  Jonathan  Hutchinson.  As  a  consequence  the  tongue  and 
mucous  membrane  are  red,  dry,  and  shining.  It  is  more  common  in  women, 
in  whom  it  follows  intense  emotion,  such  as  fright,  or  is  associated  with 
hysteria  and  hypochondriasis.  It  is  probably  a  neurosis,  the  result  of  some 
cause  operating  on  the  center  which  controls  the  secretion  of  salivary  and 
that  of  other  buccal  glands. 

Treatment. — The  treatment  of  ptyalism  and  xerostomia  is  that  of  the 
conditions  producing  them.  Xerostomia  may  be  sometimes  relieved  by  the 
use  of  pilocarpin. 

INFLAMMATION  OF  THE  SALIVARY  GLANDS. 

Acute  Parotitis,  or  Parotid  Bubo. — Apart  from  mumps,  or  specific 
parotitis,  considered  under  infectious  diseases,  in  which  any  or  all  of  the 
salivary  glands  may  be  involved,  the  parotid  is  subject  to  inflammation  from 
the  following  causes : 

1.  In  the  course  of  infectious  diseases,  especially  typhoid  fever,  but 
also  scarlet  fever,  typhus  fever,  pneumonia,  pyemia,  and  secondary  syphilis 
and  dysentery. 

2.  In  connection  with  diseases  or  injury  of  organs  in  the  abdomen  or 
pelvis,  including  the  alimentary  canal,  urinary  tract,  abdominal  wall,  perito- 
neum, pelvic  cellular  tissue,  or  genital  organs — a  very  interesting  group  of 
cases,  which  have  been  especially  studied  by  Stephen  Paget.  Sometimes 
simple  transient  irritation,  such  as  a  blow  on  the  testis  or  the  introduction 
of  a  pessary,  may  produce  it. 

3.  In  association  with  facial  neuritis.  A  fatal  case,  apparently  of  such 
origin,  has  been  reported  by  Gowers. 

In  (i)  and  (2)  septic  infection  is  doubtless  the  cause  of  the  inflam- 
mation, which  is  often  intense,  going  on  to  suppuration  in  more  than  one- 
half  of  the  cases.  Its  possible  origin  through  the  duct  of  Steno  was  con- 
sidered in  treating  typhoid  fever.  In  (3)  there  is  probably  some  vasomotor 
disturbance  which  is  responsible. 

Treatment. — This  should  consist,  at  first,  in  attempts  to  allay  the 
inflammation  by  leeches  and  the  application  of  cold,  especially  ice.  Failing 
in  this,  fomentations  should  be  applied,  while  the  lancet  should  be  used 
at  the  first  indication  of  suppuration. 

Chronic  Parotitis  sometimes  succeeds  on  acute  inflammation,  as  that 
of  mumps;  also  on  mercurialization  or  lead  poisoning,  syphilis,  and  Bright's 
disease.  Sometimes  no  cause  is  discoverable.  It  may  be  painful  or  tender 
or  painless.  It  may  be  treated  by  ointments  reputed  to  promote  absorption 
— ointments  of  iodin  and  mercury. 

Mikulicz's  Disease. — A  chronic  enlargement  of  the  salivary,  lacrymal 
and  buccal  glands  without  discoverable  cause.  It  was  first  described  in  1892 
by  Mikulicz.  It  may  last  many  years,  but  has  been  known  to  disappear  at 
least  in  part. 


TONSILLITIS  333 

LUDWIG'vS  ANGINA. 

Synonyms. — Angina  Ludovici;  Cellulitis  oj  ike  Neck;  Cynanche 
Gangrcsnosa. 

Definition  and  Symptoms. — An  infectious  inflammation,  beginning 
in  the  submaxillary  gland  as  a  secondary  inflammation  in  the  specific  fevers, 
including,  especially,  typhoid,  diphtheria,  and  scarlet  fever,  but  it  may  also 
be  primary.  It  may  succeed  on  a  carious  tooth.  It  is  probably  a  strep- 
tococcus infection.  It  spreads  rapidly  over  the  floor  of  the  mouth  and 
anterior  surface  of  the  throat,  sometimes  invading  the  glottis  by  edema, 
and  sometimes  terminating  in  sloughing  of  the  soft  parts — cynanche  gan- 
grenosa. Or  it  may  go  on  to  abscess,  pointing  externally  or  internally. 
More  rarely,  resolution  takes  place. 

Further  symptoms  are  swelling  and  extreme  pain,  first  in  the  neighbor- 
hood of  the  submaxillary  gland,  increased  by  chewing,  swallowing,  and 
talking.  The  swelling  may  produce  compression  of  the  larynx,  with 
resulting  dyspnea,  which  is  suffocative  if  the  glottis  becomes  involved. 
Constitutional  infection  may  take  place,  with  its  grave  array  of  symptoms 
and    fatal    termination.     There    may    be    remissions    and    exacerbations. 

Treatment. — This  should  consist  in  energetic  measures  calculated  to 
combat  the  inflammation,  such  as  the  use  of  ice.  If  the  condition  tends  to 
spread  immediate  dissection  of  the  inflamed  area  bj^  a  competent  surgeon 
should  be  done.     A  mere  skin  opening  is  worse  than  useless. 


DISEASES  OF  THE  TONSILS  AND  PHARYNX. 

SUPPURATIVE  TONSILLITIS. 

Synonyms. — Acute  Parenchymatous  Tonsillitis;  Phlegmonous  Tonsillitis; 
Tonsillar  Abscess;  Cynanche  Tonsillaris;  Quinsy. 

Definition. — An  acute  inflammation  of  the  substance  of  the  tonsil  and 
of  the  peritonsillar  tissue. 

Etiology. — Quinsy  is  a  disease  of  later  youth  and  adults,  being  rarely 
found  in  children  under  ten  years  of  age,  and  not  often  in  adults  over  40. 
Some  persons  are  much  disposed  to  suppiu-ative  tonsillitis,  scarcely  a  season 
passing  for  them  without  an  attack,  and  sometimes  more  than  one  attack. 
In  such,  almost  every  cold  terminates  in  quinsy.  Others,  after  a  single 
attack,  never  have  another,  and  others  stiU  are  entirely  exempt.  Sup- 
purative tonsillitis  is  always  the  result  of  infection.  Exposure  to  wet  and 
cold  certainly  often  precedes  it.  Persons  predisposed  to  tonsfllitis  are  often 
the  subject  of  chronically  enlarged  tonsils.  Over  distention  of  the  follicles 
with  inspissated  secretion  may  also  be  a  cause  of  inflammation  and 
suppuration. 

Morbid  Anatomy. — The  tonsil,  more  frequently  on  one  side,  sometimes 
on  both,  or  on  two  sides  in  succession,  becomes  rapidly  enlarged,  red,  and 
painful.  Sometimes  the  case  begins  as  one  of  follicular  tonsillitis.  It  is 
at  first  hard  and  resisting  and  very  tender  to  the  touch,  but,  if  suppuration 
takes  place,  it  gradually  softens  untU  rupture  happens  or  the  abscess  is 


334  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

opened  by  the  knife.  The  lymphoid  parenchyma  of  the  gland  becomes 
more  and  more  distended  with  leukocytes  until  the  entire  gland,  or  a  large 
part  of  it,  is  converted  into  a  pus  sac.  Very  frequently  the  peritonsillar 
tissue  is  the  part  involved  in  the  suppurative  process,  the  parenchyma  of 
the  tonsil  being  little  affected.  When  both  tonsils  are  involved,  the  throat 
is  often  almost  closed  by  the  swelling. 

Symptoms. — The  symptoms  are  pain  and  difficulty  of  deglutition,  the 
latter  causing  pain,  often  agonizing.  The  jaws  are  stiff  and  the  mouth 
cannot  be  opened  above  half  an  inch  without  extreme  suffering.  The  diffi- 
culty in  opening  the  mouth  is  increased  by  the  swelling  of  the  external 
glands  of  the  neck.  The  pain  is  not  confined  to  the  interior,  but  extends 
to  the  neighborhood  of  the  angle  of  the  jaw,  the  front  of  the  ear,  and  the 
floor  of  the  mouth.  The  voice  is  greatly  altered,  having  the  characteristic 
nasal  drawl,  and  the  diagnosis  can  sometimes  be  made  from  the  altered 
speech  alone.  There  is  increased  salivation,  and  the  saliva  dribbles  from 
the  mouth  because  of  the  pain  in  swallowing  it,  while  it  also  often  becomes 
fetid.     Respiration  may  be  seriously  interfered  with. 

There  is  h.\gh.  fever,  the  temperature  reaching  104°  and  105°  F.  (40°  to 
40.5°  C),  while  the  pulse  is  full,  bounding,  and  frequent,  no  to  130  a 
minute.  The  jace  is  anxious  and  tells  the  tale  of  suffering.  From  two  to 
six  days  are  occupied  in  the  completion  of  the  process,  at  the  end  of  which 
time  the  abscess  begins  to  point,  usually  just  above  the  last  molar  on  the 
side  affected,  when  relief  is  obtained  by  spontaneous  rupture.  But  more 
fortunate  is  the  patient  who  is  relieved  early  by  the  lancet.  Sometimes  the 
abscess  points  toward  the  pharynx.  Suffocation  has  resulted  from  the 
discharge  of  a  quinsy  passing  into  the  larynx. 

Prognosis. — Apart  from  the  rare  accident  just  referred  to,  the  prog- 
nosis is  favorable,  though  it  must  be  mentioned  also  that  death  from  suffo- 
cation has  occurred  where  the  obstruction  by  double-sided  quinsy  was  so 
great  as  to  prevent  respiration.  This  of  course  should  never  be  allowed  to 
occur. 

Treatment. — Free  scarification  is  sometimes  useful  in  shortening  an 
attack,  but  it  is  painful,  unreliable,  and  sometimes  difficult  to  do  thoroughly. 
If  deferred  until  about  the  third  day,  it  will  often  cooperate  with  the  advanc- 
ing suppuration  and  favor  an  early  rupture.  Other  applications  to  the  tonsils 
are  of  a  doubtful  efficacy,  though  some  relief  from  pain  may  be  secured  by 
painting  the  surface  with-  a  ten  per  cent,  solution  of  cocain.  Painting  with 
a  40  grain  (2.6  gm.)  solution  of  nitrate  of  silver,  after  thorough  cleansing 
with  a  cotton  swab,  is  recommended. 

Cold,  so  soothing  in  other  forms  of  sore  throat,  often  occasions  more 
discomfort  than  relief,  though  in  certain  cases  it  is  grateful.  Sucking  of 
ice  is  also  sometimes  valuable.  Then  poultices  and  fomentations  to  the 
exterior  of  the  throat  are  apt  to  be  more  soothing.  And  since  little  can  be 
done  to  prevent  suppuration,  these  measures  are  indicated  to  hasten  it.  The 
tonsil  should  be  frequently  felt  with  the  finger,  and  as  soon  as  there  is  evi- 
dence of  suppuration,  the  lancet  should  be  used.  A  curved  bistoury, 
guarded  vnth.  adhesive  plaster  almost  to  the  end,  is  the  best.  It  must  be 
inserted  into  the  area  of  pointing,  very  frequenth'  into  the  soft  palate  above 
the  last  molar.     The  incision  should  be  made  from  above  downward, 


TONSILLITIS  335 

parallel  to  the  anterior  half-arch.     If  danger  of  suffocation  is  imminent, 
the  tonsil  must  be  shaved  off. 

CHRONIC  TONSILLITIS  AND  HYPERTROPHY  OF  THE  ADENOID 
TISSUE  OF  THE  PHARYNX. 

Synonyms. — Chronic  Enlargement  of  the  Tonsils;  Chronic  Nasopharyngeal 
Obstruction;  Mouth  Breathing;  A  prose xi a. 

Definition. — A  chronic  inflammatory  enlargement  of  the  tonsils  or  of 
the  adenoid  tissue  of  the  pharynx,  of  the  lingual  tonsil,  or  of  two  or  more  of 
these  structures. 

Etiology. — The  most  frequent  cause  is  repeated  attacks  of  acute  ton- 
sillitis and  of  inflammatory  processes  associated  with  hyperemia  of  the 
tonsils  and  vicinity,  including  scarlet  fever  and  diphtheria.  It  is  more  com- 
mon in  children,  in  whom  it  is  also  sometimes  congenital,  but  it  is  found 
usually  at  the  ages  of  five  to  fifteen  years,  and  rather  more  frequently 
in  boys.  Adenoid  overgrowths  of  the  pharynx  and  lingual  tonsil  are  due  to 
the  same  causes. 

Morbid  Anatomy. — The  enlargement  of  the  tonsils  is  a  true  lymphoid 
overgrowth,  usually  symmetrical.  The  occasional  presence  of  fibrous 
stroma  produces  a  harder  and  smoother  tissue.  The  lumen  of  the  throat  is 
variously  encroached  upon,  sometimes  almost  closed.  The  pharyngeal 
adenoid  overgrowths  vary  in  extent  from  a  slight  increase  in  natural  uneven- 
ness  to  the  formation  of  actual  sessUe  and  pedunculated  tumors.  The  same 
is  true  of  the  tonsillar  structures  at  the  base  of  the  tongue,  which  may  en- 
croach upon  the  glottis. 

Symptoms. — Simple  chronic  enlargement  of  the  tonsils  may  give  rise  to 
no  symptoms  except  when  they  are  the  seat  of  further  enlargement  due  to 
acute  inflammation.  Then  obstructed  breathing  is  immediate,  while  it  is  also 
a  permanent  symptom  in  the  more  advanced  forms.  It  is  proportionally 
contributed  to  by  overgrowth  in  any  of  the  situations  named.  The  result  is 
mouth  breathing,  which  is,  perhaps,  earlier  necessitated  by  pharyngeal  than 
tonsillar  overgrowth,  while  it  may  be  due  altogether  to  the  former,  the  latter 
being  entirely  absent.  Tonsillar  obstruction  is,  however,  more  frequent. 
The  effects  are  usually  first  apparent  at  night,  when  the  child  is  found  to  be 
breathing,  more  or  less  noisily,  with  its  mouth  open  and  head  thrown  back. 
Disturbed  rest  is  an  inevitable  consequence,  the  patient  often  waking  up  with 
a  start,  again  relapsing  into  sleep,  or  continuing  permanently,  aroused 
because  of  the  dyspnea,  which  often  only  gradually  passes  away. 

As  the  conditions  persist  a  changed  expression  of  countenance  is  gradu- 
ally acquired.  The  face  becomes  apathetic,  staring,  and  vacant,  an  appear- 
ance chiefly  produced  by  the  constantly  open  mouth.  To  this  may  succeed 
actual  mental  failure  and  even  stupidity,  with  sullenness  and  general  bad 
temper.  Further  changes  in  expression  are  occasioned  by  contraction  of 
the  nostrils  and  projection  of  the  upper  jaw  and  lip.  If  the  condition  is  still 
unrelieved,  deformities  of  the  chest  make  their  appearance,  of  which  the 
most  conspicuous  is  the  well-known  chicken  breast.  In  it  the  upper  sternum 
projects,  the  manubrio-gladiolar  articulation  being  most  prominent,  while 
the  lower  part  is  depressed,  causing*a  groove  at  the  gladiolo-xiphoid  articu- 


336  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

lation.  There  is  a  cup-like  depression  of  the  lower  costal  cartilages  and  a 
horizontal  circular  depression  (Harrison's  groove)  in  the  thorax  correspond- 
ing to  the  attachment  of  the  diaphragm.  The  ribs  arc  separated  from  each 
other  anteriorly  and  closely  approximate  posteriorly,  especially  in  the  lower 
thorax.  Posteriorly  the  lower  angle  of  the  scapula  projects.  This  is  the 
result  of  the  act  of  breathing,  a  study  of  which  during  sleep  will  recognize 
the  retraction  of  the  lower  part  of  the  throax  during  inspiration,  caused  by 
the  action  of  the  diaphragm. 

Another  form  of  chest  is  the  round  or  barrel  chest,  such  as  is  commonly 
associated  with  chronic  asthma,  due  to  the  same  cause.  Still  another 
is  the  funnel,  or  Trichterbrust  of  the  Germans,  in  which  there  is  a  deep 
central  depression  at  the  epigastrium  and  of  which  the  periphery  may  extend 
upward  as  far  as  the  third  rib. 

Other  symptoms  are  an  altered  voice,  nasal  in  character,  in  which  the 
letters  m  and  n  are  especially  badly  articulated,  the  special  senses  of  smell, 
taste,  and  hearing  are  deranged,  the  breath  is  fetid  from  decaying  secretion, 
the  appetite  is  impaired,  and  with  it  the  nutrition  of  the  body.  A  gradual 
mental  as  well  as  physical  deterioration  may  take  place. 

Among  the  symptoms  ascribed  to  this  condition  are  habit  chorea  and 
stuttering.  The  former  will  be  considered  in  a  later  section.  There  is  an 
almost  constant  cough,  which  is  well  termed  "throat  cough,"  since  it  is  due 
to  irritation  of  the  respiratory  passages  by  the  throat  outgrowths  and  the 
secretion  caused  by  them.  This  secretion  is  generally  swallowed  b}^  chil- 
dren, but  is  in  part  expectorated  by  adults  by  the  aid  of  troublesome  hawk- 
ing and  coughing,  which  is  stimulated  by  a  sensation  as  of  "something  in 
the  throat"  or  larynx  which  demands  clearing.  The  absence  of  discharge 
from  the  nose  in  both  children  and  adults  is  surprisingly  frequent,  sometimes 
misleading  the  physician  as  to  the  true  cause. 

Defective  hearing  is  another  symptom  due  to  obstruction  of  the  Eusta- 
chian tube  by  encroachment  of  the  adenoid  growths,  or  by  inflammations, 
or  to  retraction  of  the  drum.  Impaired  taste  and  smell  are  due  to  involve- 
ment of  the  gustatory  papillae  and  the  terminal  distribution  of  the  olfactorj- 
nerve.  Extreme  fetor  of  the  breath  is  sometimes  present,  due  to  retention 
of  cheesy  masses  in  the  crypts  of  the  tonsils.  These  are  often  easily  visible, 
are  sometimes  expectorated,  and  can  usually  be  expressed.  The  odor  of 
these  masses  when  compressed  between  the  fingers  is  indescribably^  disagree- 
able. Sometimes  thej'  are  found  in  the  tonsils  of  persons  not  otherwise 
affected.  The  very  great  susceptibility  of  the  subjects  of  this  disease  to 
"cold"  is  constantly  adding  aggravation  to  the  sj-mptoms  described. 

Diagnosis. — This  is  not  usually  delayed  at  the  present  day,  since  the 
more  thorough  examination  of  the  throat  and  nose  has  become  common — 
thanks  to  the  throat  and  nose  specialists.  Most  important  is  it  to  remem- 
ber that  there  may  be  no  tonsillar  disease,  and  all  the  sjinptoms  may  be 
due  to  advanced  adenoid  growths  of  the  pharynx.  Digital  examination 
affords  the  most  ready  and  accurate  means  of  diagnosis.  Especially 
thorough  must  be  the  examination  behind  the  pillars  of  the  fauces.  In  chil- 
dren this  can  only  be  done  with  the  finger,  but  in  adults  the  half-arches  may 
be  drawn  forward,  while  the  laryngeal  mirror  is  availed  of. 

The  "chicken  breast"  of  mouth  breathing  in  childhood  is  different  from 


TONSILLITIS  337 

the  "violin"  shaped  chest  of  the  rickety  child.  In  the  latter  there  is  a 
prominence  of  the  whole  sternum  and  a  vertical  flattening  of  the  sides  of 
the  thorax,  leaving  a  large  curv^e  behind  the  costo-chondral  articulation  and 
a  similar  one  in  front,  in  addition  to  the  horizontal  depression  of  the  lower 
thorax  which  is  common  to  both  kinds  of  deformity. 

Prognosis. — This  depends  upon  the  early  discovery  of  the  condition, 
before  the  secondary  effects  have  established  themselves.  If  the  trouble  is 
purely  a  tonsillar  one,  it  is  comparatively  easily  removed  b}^  shaving  off  the 
organ.  If  the  overgrowth  is  pharyngeal,  little  can  be  done  until  children  are 
old  enough  to  submit  to  the  proper  treatment.  This  may  be  done  by  the  aid 
of  ether  as  early  as  the  first  year.  Hypertrophied  tonsils  begin  to  atrophy 
of  themselves  after  puberty,  and  they  have  generally  disappeared  by  30. 
The  face  and  chest  deformity  may  be  outgrown  if  the  cause  be  removed. 

Treatment. — Most  important  are  local  measures  whose  purpose  is  to 
reduce  the  overgrowth  or  to  remove  it  and  to  prevent  recurrence  of  acute 
attacks.  The  patient  should  be  discouraged  from  hawking  and  clearing  his 
throat.  If  the  tonsils  manifestly  encroach  on  the  faucial  Ivunen,  they  shoiild 
be  removed  by  carefully  dissecting  out  the  entire  tonsil.  The  same  treat- 
ment is  demanded  by  the  pharyngeal  adenoid  growths.  There  is  sometimes 
ment  is  demanded  by  the  pharyngeal  adenoid  growths.  There  is  sometimes 
copious  hemorrhage,  but  it  is  usually  easily  controlled.  It  is  certain  that 
one  or  all  of  the  symptoms  above  described  may  result  from  enlarged  tonsils 
or  adenoids.  It  is  equally  certain  that  many  enlarged  tonsils  are  uimeces- 
sarily  removed.  The  rule  to  foUow  should  be  to  remove  aU  tonsils  or  aden- 
oids which  give  symptoms  because  of  their  size  or  because  of  their  septic 
nature.  If  they  are  not  giving  symptoms  and  are  not  the  seat  of  inflam- 
matory foci  they  should  not  be  removed.  If  not  requiring  this  operative 
treatment,  they  shoiild  receive  on  alternate  days  or  every  third  day  applica- 
tions (i)  of  powdered  alum;  (2)  solution  of  iodin  of  the  strength  of  iodin 
8  grains  (0.5  gm.),  iodid  of  potassium  24  grains  (1.5  gm.),  glycerin  1/2 
oxince  (15  c.c);  (3)  of  tincture  of  the  chlorid  of  iron  and  glycerin  equal 
parts;  (4)  glycerol  of  tannin  or  (5)  silver  nitrate  i  to  20.  The  solid  stick 
of  the  latter  may  be  used  if  there  be  evident  lactmar  disease,  but  far  better 
is  electrolysis,  by  which  the  crypt  is  obliterated  and  the  gland  may  be 
gradually  destroyed.  Sprajdng  the  nose  with  antiseptic  solutions  twice 
daily  is  helpful  in  maintaining  cleanliness  and  purit}^  of  breath.  DobeU's 
solution  may  be  thus  used;  also  dilute  liquor  antisepticus.  Tablets  contain- 
ing various  proportions  of  the  ingredients  therein  named  are  made  for  solu- 
tion in  the  little  cup  of  the  spraying  apparatus.  Great  patience  and  per- 
severance are  required,  for  the  result  is  but  slowly  attained. 

"The  general  health  of  the  patient  should  be  carefully  looked  after. 
Suitable  woolen  underclothing  should  be  worn,  and  it  should  be  graduated 
to  temperature  and  exposure.  Cod-liver  oil,  iron,  quinin,  and  strychnin 
are  the  best.  It  is  most  important  that  every  effort  shovild  be  made  in 
the  direction  of  so  hardening  the  patient  that  he  may  be  able  to  resist  the 
effects  of  exposure,  a  task  not  easy  to  accomplish.  Cold  bathing  of  the 
neck  and  throat,  indeed  of  the  whole  body  is  useful,  while  nourishing  food, 
physical  exercise,  and  outdoor  life,  with  suitable  clothing,  are  means  to 
this  end. 


338  DISEASES  Of  THE  DIGESTIVE  SYSTEM 

SIMPLE  CIRCULATORY  DERANGEMENTS  OF  THE  PHARYNX. 

Hyperemia  of  the  pharynx  is  a  very  common  condition  in  smokers.  It 
is  also  almost  always  present  when  there  is  chronic  nasal  catarrh.  Under 
these  circumstances  the  mucous  membrane  is  constantly  red,  angry  looking, 
often  streaked  with  mucous,  and  is  very  easily  thrown  into  a  state  of  active 
inflammation. 

In  such  obstructions  to  the  circulation  as  are  caused  by  mitral  valvular 
disease,  cirrhosis  of  the  liver,  or  pressure  upon  the  ascending  vena  cava  by 
aneurysm  or  tumor,  there  is  venous  stasis  and  the  venules  may  often  be 
seen  distended.  According  to  most  authors  these  venules  occasionally 
burst,  producing  small  hemorrhages  which  stain  the  mucous  secretion  and 
under  certain  circumstances  the  bleeding  may  be  mistaken  for  a  pulmonary 
hemorrhage.  Unfortunately  the  opposite  is  the  rule,  pulmonary  hemorrhage 
is  constantly  diagnosed  bleeding  from  the  throat.  This  latter,  in  the  belief 
of  the  writers,  is  dangerous  teaching.  It  is  certainly  very  rarely  the  fact  that 
bleeding  from  the  mouth  should  be  thought  pharyngeal  in  origin,  never 
mthout  examination.  Almost  without  exception,  any  hemoirhage  which 
comes  from  the  mouth  other  than  that  which  comes  from  epi taxis,  bleeding 
in  purpura,  or  the  mere  shreds  of  blood  mixed  with  mucous,  or  evident 
hematemesis,  or  from  the  gums,  is  pulmonary  in  origin.  The  same  causes 
may  produce  edema  of  the  mucous  membrane  of  the  pharynx,  and  especially 
does  this  occur  in  Bright's  disease.  The  edema  may  extend  thence  to  the 
uvida,  which  becomes  greatly  swollen.  In  aortic  regurgitation  the  capillary 
pulse  may  be  seen  in  the  pharynx,  and  the  internal  carotid  may  also  be  seen 
to  throb  strongly. 

ACUTE  CATARRHAL  PHARYNGITIS. 
Synonyms. — Sore  Throat;  Simple  Angina. 

Definition. — An  acute  inflammation  of  the  mucous  membrane  covering 
the  pharynx  and  tonsils,  sometimes  extending  upon  the  palate. 

Etiology. — Acute  pharyngitis  occurs  at  all  ages;  a  trifling  cause  lights 
up  an  inflammation.  Rheumatism  and  gout  are  also  frequent  causes. 
Pharyngitis  and  tonsillitis  are  often  associated.  Most  of  the  attacks  are 
unquestionably  due  to  infection.     The  specific  organism  is  not  known. 

Symptoms. — The  first  symptom  is  usually  pain  on  swallowing,  wliich 
is  associated  at  first  with  a  dryness  and  soreness,  producing  a  desire  to  "clear 
the  throat. ' '  To  this  is  soon  added  a  full  feeling,  and  then  pain  independent 
of  swallowing.  The  inflammation  may  extend  into  the  Eustachian  tube, 
producing  partial  deafness,  or  into  the  larynx,  producing  hoarseness.  There 
is  a  varying  degree  of  constitutional  disturbance,  and  sometimes  the  fever  is 
quite  high. 

On  examining  the  throat  it  will  be  found  red  and  congested,  sometimes 
plainly  swollen,  especially  over  the  tonsils.  There  is  often  considerable 
mucous  secretion.  The  various  forms  of  ulcer  of  the  tonsils  described  under 
tonsillitis  may  be  associated  v,nth  the  pharyngitis,  increasing  the  consti- 
tutional disturbance  and  local  discomfort. 

Treatment. — Many  simple  sore  throats  pass  away  without  treatment. 


PHARYNGITIS  339 

Astringent  washes  and  gargles  are  indicated.  Even  the  mild  cases  had  better 
go  to  bed.  Twenty-four  hours  in  bed  is  by  far  the  best  medicine  for  an  ordi- 
nary cold.  A  spray  or  a  gargle  of  liquor  antisepticus  or  normal  salt  solution. 
Solution  of  nitrate  of  silver,  20  grains  (1.3  gm.)  to  the  ounce  (30  c.c),  may 
be  similarly  applied,  also  the  glycerol  of  tannin. 

In  severe  cases  cold  cloths  wrung  out  in  ice  water  and  applied  to  the  out- 
side of  the  throat,  the  clothing  being  protected  by  the  interposition  of  a  dry 
towel,  make  an  excellent  measure;  or  the  little  ice  bags  referred  to  in  the 
treatment  of  acute  tonsillitis  may  be  applied  to  the  throat,  with  a  dry  towel 
outside  of  them.  Occasionally  counterirritation  by  mustard  is  more  satis- 
factory, as  every  throat  does  not  bear  cold  equally  well. 

The  fever  should  be  met  in  the  usual  way  by  aconite,  sweet  spirit  of 
niter,  citrate  of  potash,  phenacetin  or  acetanilid  while  chlorate  of  potash  and 
chlorid  of  iron  should  also  be  administered  internally.  The  bichlorid  of 
mercury  may  be  added  under  the  same  circumstances  as  in  tonsillitis. 
There  is  no  advantage  in  giving  large  doses  of  iron.  The}'  are  not  absorbed 
and  the  excess  remaining  in  the  alimentary  canal,  locks  up  the  secretions 
and  causes  irritation.  From  2  to  10  minims  (0.12  to  0.6  gm.)  every  two 
hours  are  quite  sufficient.  The  bowels  should  be  kept  open,  and  the  treat- 
ment may  be  advantageously  commenced  with  a  saline  aperient,  such  as 
calcined  magnesia,  the  solution  of  the  citrate  of  magnesium,  Hunyadi  or  any 
natural  aperient  water. 

Where  the  disease  is  traceable  to  rheumatism  or  gout,  suitable  treat- 
ment for  these  diseases  should  be  instituted.  The  salicylates  are  the  best 
remedies  for  both,  but  guaiacum  has  some  reputation,  the  tincture  or 
ammoniated  tincture  being  the  best  preparation,  given  in  doses  of  5  to  60 
drops  (0.3s  to  4  gm.). 


CHRONIC  CATARRHAL  PHARYNGITIS. 

Synonyms. — Clergyman's  Sore  Throat;  Granular  Pharyngitis;  Chronic 
Angina;  Chronic  Follicular  Pharyngitis. 

Definition. — Chronic  pharyngitis,  when  not  associated  with  tilceration, 
presents  much  the  same  appearance  as  chronic  hyperemia,  plus  the  addition 
of  a  granular  appearance  due  to  enlargement  of  lymphatic  glandules,  with 
which  the  pharynx  is  studded. 

Etiology. — The  disease  is  rather  one  of  adults  than  children.  Its  causes 
are  repeated  attacks  of  acute  pharyngitis  and  excessive  smoking  and  alcohol 
drinking.  Chronic  nasal  catarrh  with  its  irritating  discharges  trickling 
down  the  fauces  is  a  frequent  cause,  as  is  also  nasal  obstruction  and  disease 
of  the  third  or  Luschka's  tonsil.  It  also  occurs  in  those  who  use  their 
voices  largely,  as  hucksters,  public  speakers,  and  singers,  while  the  inhala- 
tion of  dust  and  irritating  gases  is  also  held  responsible. 

Treatment. — This  is  very  much  more  unsatisfactory  than  in  the  acute 
type.  It  is  most  important  to  treat  the  causes  or  remove  them.  Postnasal 
catarrh  is  responsible  for  so  many  cases  that  the  postnasal  region  should  at 
once  be  investigated  and  its  diseases  treated.  Smoking  and  the  use  of 
alcohol,  if  responsible,  should  at  once  be  discontinued.     The  same  local 


340  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

measures  useful  in  the  acute  disease  may  be  employed  in  the  chronic,  but 
they  are  less  pronusing  as  to  results.  The  little  granules,  which  are  appar- 
ently a  source  of  irritation  as  well  as  a  result,  can  be  removed  only  by  the 
galvanocauter}'  needle.  Other  measures  to  this  end  are  unsatisfactory 
and  insufficient.  The  general  health  of  the  patient  should  be  carefully  looked 
after,  and  occupations  tending  to  keep  up  the  irritation  should  be 
discontinued. 

Ulceration  of  the  Pharnyx. 

The  ordinary  form  of  chronic  pharyngitis  rarely  produces  ulceration. 
Syphilis,  tuberculosis,  diphtheria,  inflammation,  and  lowered  nutrition,  such 
as  is  found  after  the  infectious  diseases,  like  typhoid  fever  and  scarlet  fever, 
are  frequent  causes  of  sluggish  ulcers  indisposed  to  heal.  The  chief  symp- 
tom of  these  various  varieties  of  ulceration  is  pain,  increased  during  deglu- 
tition, with  more  or  less  copious  mucous  secretion,  which  often  adheres 
firmly  to  the  pharynx.  Frequently  the  small  glands  which  dot  the  pharynx 
may  be  the  seat  of  a  foUictdar  inflamanation  of  the  same  character  as  that 
in  follicular  tonsillitis. 

Diagnosis. — It  is  not  always  easy  to  distinguish  the  different  forms  of 
ulceration.  The  syphilitic  ulcer  is  least  painful,  in  fact  often  painless,  and 
is  commonly  situated  in  the  posterior  wall  of  the  pharynx.  It  occurs  both 
as  a  secondary  and  tertiary  symptom.  As  a  secondary  symptom  it  is  super- 
ficial and  associated  with  mucous  patches,  while  as  a  tertiary  it  forms  the 
cavity  left  by  a  softened,  gummy  tumor,  and  is  correspondingly  deep.  It  is 
associated  with  the  history  of  syphilis. 

The  tubercular  ulcer  is  more  painful — indeed,  the  most  painful  of  all. 
It  is  irregular,  not  very  deep,  has  a  grayish  base,  and  is  also  seated  in  the 
posterior  wall  of  the  pharynx,  considerable  areas  of  which  may  be  involved, 
producing  an  uneven,  worm-eaten  appearance.  It  is  associated  with  tuber- 
culosis elsewhere.  The  indolent  ulcers  of  lowered  nutrition  are  also  often 
insidious  and  occasion  few  active  symptoms.  After  the  separation  of  the 
membrane  in  diphtheritic  pharyngitis  there  are  sometimes  left  ulcers  more 
or  less  extensive,  which  are  slow  to  heal. 

Treatment. — This  consists  locally  in  the  application  of  stimuli  and  anti- 
septics, the  former  represented  by  nitrate  of  silver  and  the  latter  by  thymol 
and  its  class,  together  with  general  treatment  appropriate  to  the  condition, 
such  as  toitics  of  which  iron  and  qmnin  are  the  types.  Anti syphilitic  treat- 
ment and  treatment  of  the  tuberculosis  which  always  exists  elsewhere. 

Phlegmonous  Pharyngitis. 

Definition. — This  term  is  applied  to  any  suppurating  inflammation  in- 
volving the  pharjTix,  however  induced,  except  postpharyngeal  abscess, 
which  is  a  separate  condition.  It  may  be  a  part  of  the  process  which  con- 
stitutes suppurating  tonsillitis  or  quinsy,  extending  to  the  adjacent  pharyn- 
geal structtores.  It  may  include  the  acute  infectious  phlegmon  of  the  phar- 
ynx described  by  Senator,  in  which,  along  with  swelling  of  the  external 
neck,  the  pharyngeal  mucous  membrane  is  swollen  and  injected,  and  becomes 


POSTPHARYNGEAL  ABSCESS  341 

rapidly  the  seat  of  suppuration.  It  may  include  similar  conditions  in- 
duced by  injury,  the  inhalation  of  scalding  liquids,  or  the  swallowing  of  cor- 
rosive poisons.  Or  it  may  be  the  result  of  pharyngeal  erysipelas  or  of  the 
lodgment  of  foreign  bodies. 

Symptoms. — These  are  correspondingly  intense.  There  is  painful 
swelling,  interfering  not  only  with  deglutition,  but  also  with  respiration. 
There  is  high  fever  and  rapid  exhaustion.  It  may  terminate  in  gangrene  of 
the  part  or  gangrenous  pharyngitis. 

Treatment. — The  treatment  is  locally  antiphlogistic,  including  cold  by 
ice  or  otherwise,  scarification  and  liberation  of  pus  at  the  earliest  possible 
moment,  together  with  restorative  and  stimulating  internal  measures.  If 
gangrene  results,  cauterization  and  antiseptic  applications  must  be  added. 
The  aid  of  the  surgeon  should  be  early  sought. 

Postpharyngeal  Abscess. 

Definition. — A  phlegmonous  inflammation  behind  the  proper  pharyn- 
geal tissue,  subperiosteal  in  some  instances,  arising  in  suppurative  inflamma- 
tion of  the  postpharyngeal  lymphatic  glands  or  caries  of  the  cer^dcal  verte- 
brae. It  is  a  disease  of  children  and  adults,  more  frequenth^  of  the  former, 
often  a  sequel  of  one  of  the  pharyngeal  conditions  alread}^  considered,  fav- 
ored by  bad  hygiene  and  depraved  constitutional  states,  hereditary  or 
acquired. 

Symptoms. — -Its  symptoms  are  intense  pain,  swelling,  and  interference 
with  deglutition  and  respiration,  with  more  or  less  early  appearance  of  a 
tumor  in  the  posterior  wall  of  the  pharjTxs,  which  can  generally  be  recog- 
nized by  the  finger  before  it  can  be  seen — a  fact  which  emphasizes  the 
importance  of  frequent  examination  of  the  throat  by  the  finger  in  diseases  of 
these  parts.  There  is  also  stiffness  of  the  neck,  sometimes  nasal  voice  or  even 
hoarseness,  suggesting  croup  and  edema  of  the  glottis,  but  there  is  never 
absolute  loss  of  the  voice,  as  in  the  latter,  while  croup  and  edema  are  not 
associated  with  painful  deglutition. 

Treatment. — This  consists  of  incision  of  the  abscess  as  soon  as  dis- 
covered. It  should  be  made  in  the  median  line  and  the  head  should  be 
brought  forward  to  avoid  the  entrance  of  pus  into  the  larynx.  Anodynes 
are  necessary  to  overcome  the  intense  pain,  but  it  is  to  be  remembered  that 
they  may  so  mask  the  symptoms  as  to  permit  destructive  inroads  of  the 
disease  before  it  is  discovered. 

DISEASES  OF  THE  ESOPHAGUS. 

EXPLORATION  OF  THE  ESOPHAGUS. 

This  is  a  manipulation  so  frequently  necessary  that  its  description  is 
demanded  at  the  outset. 

The  esophageal  bougie  is  made  of  flexible  whalebone  or  steel,  on  the  end 
of  which  is  firmly  fixed  an  olive-shaped  piece  of  ivory  or  hard  rubber.  The 
ends  are  made  of  different  sizes.  The  ordinary  stomach-tube  may  also  be 
used  for  the  same  purpose,  and  is  the  safest  instrument  at  the  first 
exploration. 


342  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

In  introducing  the  bougie,  or  tube,  the  patient  should  sit  on  a  low  chair 
wth  his  head  thrown  back.  The  bougie,  or  tube,  is  then  passed  to  the 
posterior  wall  of  the  pharynx  and  then  down  into  the  gullet.  Usually  a 
slight  resistance  is  encomttered  at  the  level  of  the  cricoid  cartilage,  but  it  is 
easily  overcome,  and  after  this  the  descent  is  easy.  Caution  should,  how- 
ever, always  be  exercised,  as  the  bougie  has  a  few  times  been  pushed  through 
an  ulcer  of  the  esophagus  into  the  pleural  cavity  or  lung,  while  ulceration 
has  been  produced  by  its  repeated  use  in  simple  nervous  spasmodic  obstruc- 
tion. The  patient  should  be  instructed  to  breathe  rapidly  and  to  swallow 
at  stated  interv^als.  It  is  rarely  necessary  to  pass  the  finger  of  the  operator 
into  the  mouth. 

ESOPHAGITIS. 

Acute  Esophagitis. — An  acute  inflammation  of  the  esophagus  is  prac- 
tically limited  to  inflammation  induced  by  the  swallowing  of  very  hot, 
or  corrosive  liquids,  like  strong  acids  and  alkalies,  or  by  the  lodgment  of 
foreign  bodies.  It  is  true,  diphtheritic  inflammation  sometimes  extends 
from  the  pharynx  downward,  and  the  esophagus  has  also  been  invaded 
by  a  vesicle  of  smallpox,  but  these  conditions  are  not  likely  to  be  differen- 
tiated from  the  primary  disease.  Mycotic  esophagitis,  producing  stenosis  of 
the  esophagus  in  sucklings,  has  been  alluded  to  as  a  possibility  on  page  326. 

Morbid  Anatomy. — Appearances  vary  with  the  cause.  In  addition 
to  the  usual  redness,  sloughing  and  disintegration  of  the  tissue  may  result. 
Milder  degrees  of  inflammation  produce  less  conspicuous  alteration.  A 
granular  appearance  may  succeed  desquamation  of  the  epithelium. 
Diphtheritic  false  membrane  presents  the  same  characters  here  as 
elsewhere. 

Symptoms. — These  are  chiefly  pain  beneath  the  sternum,  increased  by 
swallowing,  which  in  extreme  degrees  of  inflammation  becomes  agonizing 
and,  indeed,  renders  swallowing  impossible.  Copious  mucous  secretion  is 
sometimes  present,  which  may  be  raised  or  regurgitated  to  the  fauces  and 
expectorated  or  passed  into  the  stomach.  Milder  grades  of  inflammation 
may  be  without  symptoms,  intermediate  grades  present  corresponding  symp- 
toms. If  healing  results  after  destructive  inflammation,  the  cicatricial 
tissue  behaves  as  it  does  elsewhere  contracting  and  distorting  the  parts, 
oftentimes  with  resulting  stenosis. 

Treatment. — ^Little  can  be  done  to  aid  healing.  For  the  most  part, 
therefore,  it  must  be  given  over  to  nature.  If  deglutition  is  possible,  demul- 
cents may  be  used,  while  the  swallowing  of  pieces  of  ice  sometimes  gives 
comfort.  When  deglutition  is  impossible,  the  patient  must  be  fed  with 
nutritious  enemata.  The  treatment  of  resulting  stenosis  is  that  of  stricture 
of  the  esophagus,  which  see. 

Chronic  Catarrhal  Esophagitis.^ — This  affection  is  sometimes  fa- 
vored by  vahnilar  heart  diseases,  cirrhosis  of  the  liver,  or  other  cause  of 
venous  obstruction.  The  resulting  affection  is  a  catarrhal  inflammation 
associated  with  mucous  secretion.  A  hemorrhoidal  state  of  the  veins  may  be 
thus  caused,  which  may  proceed  to  rupture,  and  an  hematemesis  which 
closely  resembles  the  bleeding  from  a  gastric  or  duodenal  ulcer. 


ULCER  OF  ESOPHAGUS  343 

PEPTIC  ULCER  OF  THE  ESOPHAGUS. 

Definition. — An  ulceration  usually  in  the  lower  part  of  the  esophagus,  due 
to  the  direct  solvent  action  of  the  gastric  juice,  favored  by  certain  predispos- 
ing causes.     The  subject  has  been  carefully  studied  by  Tileston  and  others. 

Etiology. — It  may  occur  at  any  time  of  life  between  infancy  and  old 
age,  but  is  most  frequent  in  middle  life  and  in  men,  it  having  been  found 
in  this  sex  in  28  out  of  30  cases.  It  was  found  alone  and  complicating 
other  conditions  as  ulcer  of  the  stomach  and  duodenum.  Directly  caused 
by  the  solvent  action  of  the  gastric  juice,  it  is  favored  by  some,  associated 
condition  always  present  though  not  always  ascertainable.  One  of  these  is 
insufficiency  of  the  cardiac  orifice  of  the  stomach  permitting  regurgitation. 
Other  associated  conditions  are  repeated  vomiting  and  disease  of  the  various 
abdominal  organs,  including  peritonitis,  nephritis,  chronic  gastritis,  but 
especially  ulcer  of  the  stomach  and  duodenum;  also  dilation  of  the  stomach, 
which  is  often  responsible  for  insufficiency  of  the  cardiac  orifice. 

Morbid  Anatomy. — The  ulcer  varies  in  size  from  a  pin-head  to  a  pea  and 
may  be  single  or  multiple.  Frequently  in  the  lower  part  of  the  esophagus,  it 
is  found  most  frequently  in  the  posterolateral  portion.  Perforation  has 
taken  place  into  the  pleural  cavity,  the  pericardium  and  the  omental  cavity. 
Scars  have  been  found  representing  healed  ulcers. 

Symptoms. — The  lesion  is  sometimes  found  at  autopsy  when  pre- 
viously unsuspected,  and  again  the  symptoms  of  perforation  have  been  the 
first  indication  of  it,  but  pain,  tenderness,  dysphagia,  vomiting  and  hema- 
temesis  are  natural  consequences.  The  pain  is  usually  at  the  xyphoid 
cartilage  with  tenderness  in  the  adjoining  epigastrium.  There  is  no  ten- 
derness in  the  back  corresponding  to  that  of  ulcer  of  the  stomach.  The 
dysphagia  is  characterized  by  pain  and  difficulty  at  the  end  of  the  act  of 
swallowing.  It  may  be  intermittent.  Hematemesis  is  usually  the  result 
of  erosion  of  an  artery.  It  is  characterized  further  by  the  absence  of  nausea 
as  contrasted  with  the  vomiting  of  blood  due  to  ulcer.  Perforation  is  not 
an  infrequent  result  having  been  found  in  six  out  of  14  cares.  More  rarely 
it  is  associated  with  evidence  of  stenosis  of  the  pylorus  with  consequent 
dilatation  of  the  stomach,  itself  the  cause  of  the  insufficiency  referred  to  as 
favoring  peptic  ulcer. 

Diagnosis. — The  diagnosis  in  general  is  covered  by  the  symptomatology 
above  narrated.  Differentially  peptic  ulcer  of  the  esophagus  is  distinguished 
from  gastric  ulcer  by  the  presence  of  dysphagia,  while  the  pain  follows 
more  closely  the  act  of  deglutition  than  in  ulcer  of  the  stomach,  and  the 
pain  and  tenderness  due  to  the  latter  are  generally  lower  down.  In  ulcer 
of  the  esophagus  the  tenderness  is  substernal.  Gastric  ulcer  at  the  cardiac 
orifice  has  symptoms  more  like  those  of  ulcer  of  the  esophagus. 

It  is  well  known  that  some  of  the  most  serious  hemorrhages  in  cirrho- 
sis of  the  liver  arise  from  varicose  ulcers  of  the  esophagus.  Such  varicosities 
are  characterized  by  the  absence  of  previous  pain  and  dysphagia,  while  they 
are  also  associated  with  cirrhosis  of  the  liver  with  which  peptic  ulcer  is  not, 
as  a  rule. 

Stenosis  of  the  esophagus  may  succeed  upon  ulcer  and  must  be  distin- 
guished from  stenoses  due  to  presstu-e  from  without,  such  as  that  by  medi- 


344  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

astinal  tumors,  abscesses,  and  aortic  aneurysm,  when  the  presence  of  the 
symptoms  of  these  diseases  must  come  to  our  rescue.  Intermittent  dys- 
phagia is  a  rare  characteristic  of  aneurysm  and  of  the  other  causes  of 
stenosis;  carcinoma  is  more  insidious  and  is  associated  with  cachexia,  but 
its  duration  is  shorter.  The  blood  in  hemorrhage  from  cancer  is  scanty 
and  mixed  with  particles  of  food  and  mucus  while  the  painis  more  constant. 
The  fav-orite  seat  of  cancer  is  opposite  the  bifurcation  of  the  trachea,  while 
ulcer  is  rarely  so  high.     Enlarged  adjacent  glands  are  also  present  in  cancer. 

Stenosis  bj^  corrosive  poisons  is  readily  determined  by  the  histon,-. 
Tuberculous  and  syphilitic  ulcers  are  characterized  by  their  indolence  and 
comparatively  painless  character.  The  various  diverticula  due  to  obstruc- 
tion by  these  causes  may  generally  be  determined  by  the  sound. 

Prognosis. — The  prognosis  of  peptic  ulcer  is  unfavorable  as  far  as  cure 
is  concerned,  while  the  difficulty  in  diagnosis  increases  the  uncertainty. 

Treatment. — Treatment  is  the  same  as  that  of  gastric  talcer,  liquid, 
cool  and  demtilcent  foods  being  indicated.  In  extreme  cases  rectal  feeding 
must  substitute  all  other  forms  of  nourishment.  As  to  drugs,  silver  and 
bismuth  are  given  as  for  tilcer  of  the  stomach.  Direct  applications  may  in 
the  futiu-e  be  possible  with  the  esophagoscope.  Stenosis  must  be  treated 
in  the  usual  way. 

CANCER  OF  THE  ESOPHAGUS. 

Description. — This  is  usually  a  hard  epitheUal  tumor,  most  frequent  in 
the  middle  third  of  the  esophagus,  though  it  may  involve  the  cardiac  orifice 
of  the  stomach,  and  more  rarely  other  portions.  E.  Rindfleish,  especially, 
describes  a  softer  and  more  superficial  form,  which  invades  larger  areas 
in  a  diffuse  way.  It  is  rather  more  frequent  in  men,  and  appears  first 
as  zonular  infiltration  of  the  mucous  membrance,  which  ulcerates.  The 
resulting  ulcer  may  also  extend  around  the  tube,  acquiring  a  wddth  of 
two  or  three  inches  (5  to  6  cm.).  The  primary  and  usually  permanent 
result,  unless  ulceration  does  away  with  it,  is  a  stenosis  of  the  esophagus, 
followed  by  dilatation  of  the  tube,  with  hypertrophy  of  the  walls  above  the 
stenosis. 

Symptoms. — Difficult  and  painful  deglutition  is  usually  the  first  symp- 
tom of  stenosis,  though  pain,  independent  of  deglutition,  may  precede. 
Swallowing  becomes  more  and  more  difficult,  and  ultimately,  even  liquids 
may  be  regurgitated.  Regurgitation  of  food  may  not  be  immediate,  and  the 
date  of  its  appearance  is  usually  dependent  on  the  seat  of  the  obstruction 
and  extent  of  dilatation  above  it.  A  discharge  of  blood  and  mucus  may 
attend  an  effort  to  introduce  the  bougie.  Death  commonly  takes  place  from 
exhaustion  or  actual  starvation.  But  before  this  happens  there  may  be  a 
rupture  into  the  larynx  or  a  bronchus,  producing  death  by  suffocation,  bj' 
gangrene,  or  by  an  inhalation  pneumonia.  There  may  be  ulceration  into 
the  aorta  or  one  of  its  large  branches,  causing  fatal  hemorrhage;  into  the 
pericardium,  producing  fatal  pericarditis.  Ulceration  into  the  mediastinum 
or  erosion  of  the  cervical  vertebras  sometimes  occurs,  with  more  delayed  fatal 
ending.  Emphysema  is  a  sign  of  rupture  into  the  lung.  The  adjacent 
lymphatic  glands  of  the  neck  are  sometimes  invaded.  Rarely  the  disease 
is  latent  throughout  its  entire  course. 


STRICTURE  OF  ESOPHAGUS  345 

Diagnosis. — This  may  have  to  be  delayed  a  short  time,  but  is  soon 
clear.  The  continued  obstruction,  the  emaciation,  and  the  weakness  soon 
distinguish  the  case  from  one  of  spasmodic  stenosis.  Compression  by 
adjacent  growths  should  be  remembered  as  a  source  of  obstruction,  aneu- 
rysm being  perhaps  the  most  frequent  cause  of  this  kind;  but  aneurysm  may 
generally  be  recognized  by  its  other  signs.  Examination  by  the  esophago- 
scope  with  removal  of  a  portion  of  the  growth  for  microscopic  examination 
is  necessary. 

Prognosis. — This  is  always  ultimately  fatal. 

Treatment. — Treatment  can  only  be  made  to  prolong  life.  The  bougie 
should  not  be  used  after  the  diagnosis  of  cancer  is  established,  because 
of  the  danger  of  causing  perforation.  So  long  as  liquid  food  can  pass  the 
obstruction  it  should  be  used;  after  this,  nutritious  enemas  in  the  manner 
recommended  under  cancer  of  the  stomach.  Esophagostomy  or  gastros- 
tomy may  be  presented  for  the  patient's  consideration.  The  former 
promises  nothing,  but  life  may  be  prolonged  by  the  latter  with  much  com- 
fort to  the  patient. 


SPASM  OF  THE  ESOPHAGUS. 

Synonym  . — Esophagismus. 

This  is  not  an  unusual  affection  in  hysterical  women,  and  even  in  male 
hypochondriacs.  These  are  generally  past  middle  life.  It  also  occurs  in 
hydrophobia,  chorea,  and  epilepsy.  The  spasm  is  commonlj^  excited  by  an 
effort  to  swallow  solid  food,  and  rarely  even  liquids  act  similarly.  A 
possible  result  of  spasm  is  a  dilatation,  as  shown  in  a  case  of  my  own,  to  be 
again  referred  to. 

Diagnosis. — The  diagnosis  is  readily  made  by  the  bougie,  which,  though 
it  may  be  stayed  for  a  minute  at  the  seat  of  spasm,  ultimately  passes  it 
without  the  application  of  force.  It  is  also  associated  with  other  symptoms 
of  hypochondriasis,  while  extreme  pain,  the  gradual  emaciation,  weakness, 
and  ultimate  cachexia  of  cancer  are  absent.  Errors  of  diagnosis  have, 
however,  been  made,  and  death  has  even  occurred  when  autopsy  disclosed 
no  lesion  to  explain  it. 

Treatment. — This  is  that  of  the  hypochondriacal  state  and  the  frequent 
use  of  the  bougie,  of  which  the  moral  effect  is  also  good.  One  introduction 
has  sometimes  been  sufficient.  On  the  other  hand,  repeated  passage  of  a 
bougie  has  produced  ulceration,  whence  the  caution  already  enjoined  in  the 
use  of  the  instrument. 


STRICTURE  OP  THE  ESOPHAGUS. 

Etiology. — Stricture  may  be  produced  by  any  of  the  conditions  just 
considered,  carcinoma,  contraction  of  scar  tissue  after  esophagitis,  whether 
traumatic  or  syphilitic,  or  by  spasm.  Other  causes  are  pressure  by  external 
tumors,  such  as  aneurysm,  enlarged  lymphatic  glands  or  mediastinal 
tumors.     Then  there  is  congenital  narrowing,  and  finally  polypoid  tumors 


346  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

projecting  from  the  mucous  membrane.  If  the  stenosis  be  cicatricial,  the 
precise  cause  is  to  be  determined  by  the  history  of  the  case  and  its  situation 
by  the  esophageal  bougie. 

Symptoms. — These  are  those  of  obstruction,  described  under  cancer 
and  spasm,  with  or  without  the  painful  element;  to  which  may  be  added 
those  of  dilatation  of  the  esophagus,  to  be  next  considered. 

Treatment. — This  is  altogether  by  the  careful  use  of  the  bougie.  Dilata- 
tion of  the  cicatricial  stenosis  is  often  quite  successful.  The  largest  bougie 
should  be  first  introduced  very  gentl}^  without  force,  really  as  a  sound, 
as  far  as  the  obstruction  only.  Then  smaller  sizes  should  be  tried  until 
one  is  found  which  will  pass,  and  from  this  point,  again,  larger  sizes  should 
be  successively  employed.  At  each  sitting  the  bougie  originally'  passed 
with  ease  should  be  started  with  and  followed  more  rapidly  by  the  larger 
sizes,  as  the  physician  becomes  familiar  with  his  patient's  case. 

In  congenital  cases  less  is  to  be  expected,  while  obstruction  by  external 
growths,  unless  they  be  removable,  is  practically  irremediable,  and  grows 
gradually  worse.  Even  cicatricial  stenosis  may  be  such  that  the  smallest 
bougie  cannot  pass,  in  which  event  nourishment  by  the  rectum  may  be 
used.     Gastrostomy,  however,  should  be  at  once  performed. 

DILATATION  OF  THE  ESOPHAGUS. 

Dilatation  of  the  esophagus  ma}-  involve  the  whole  circumference  of 
tube,  when  it  is  known  as  diffuse  or  total;  or  it  may  affect  only  one  spot, 
when  it  is  circumscribed,  or  constitutes  a  diverticulum. 

Diffuse  Dilatation. — In  every  case  of  organic  stenosis  of  the  esophagus, 
from  whatever  cause,  there  is  sooner  or  later  dilatation  above  it,  delayed  at 
first  by  hypertrophy  of  the  muscular  coat,  which  is  thus  enabled  to  force 
the  food  through  the  narrowing.  Sooner  or  later  this  coat  becomes  para- 
lyzed, the  wall  yields  to  the  pressure  of  accumulated  food,  and  dilatation 
follows.  The  resulting  sac  is  usually  spindle-shaped,  but  may  be  cylindrical, 
and  is  naturally  larger  the  lower  the  seat  of  obstruction. 

But  dilatation  occurs  without  pre\'ious  organic  stenosis.  Repeated 
spasm  is  a  cause,  and  dilatation  from  cardio-spasm  has  come  to  be  a  well- 
recognized  condition.  It  may  be  that  it  is  preceded  at  times  by  some 
traumatic  cause  which  weakens  the  waU  of  the  tube. 

Diverticula. — Diverticula  or  circtunscribcd  pouches  in  the  walls  of  the 
esophagus  are  of  two  varieties.  They  have  been  especially  studied  b}' 
Zenker,  who  has  divided  them  into  pressure  or  propulsion  diverticula  and 
traction  diverticula  according  to  their  mode  of  origin. 

Traction  diverticula  are  the  more  frequent,  yet  clinically  are  of  less 
interest  because  often  not  recognized  until  their  subjects  are  on  the  necropsy 
table.  They  are  small,  scarcely  ever  exceeding  a  centimeter  (0.4  in.)  in 
diameter,  and  relatively  frequent  in  children.  They  are  ascribed  to  some 
traction  effect  exerted  on  the  wall  of  the  esophagus.  This  may  be,  as 
Rokitansky  and  Zenker  suggested,  due  to  the  contraction  of  a  tissue  which 
has  formed  adhesions  to  the  esophagus.  Such  a  tissue  is  afforded  by  the 
bronchial  glands,  which  become  inflamed,  caseate,  and  contract,  and  as  they 
are  situated  at  the  bifurcation  of  the  trachea,  the  more  frequent  occurrence 


DIVERTICULUM  OF  ESOPHAGUS  347 

of  traction  diverticula  at  this  situation  in  the  anterior  wall  of  the  gullet  is 
thus  explained.     Such  diverticula  may  be  multiple. 

Pressure  diverticula  are  much  rarer.  They  occur  almost  always  in  men 
rarely  in  children.  They  are  found  most  frequently  at  the  junction  of  the 
pharynx  and  esophagus,  on  a  level  with  the  cricoid  cartilage,  where  the 
muscular  wall,  formed  chiefly  by  the  inferior  constrictor  of  the  pharynx, 
is  weakest,  and  are  caused  by  pressure  from  within.  This  may  be  exerted  by 
the  bolus  of  food  itself,  especially  if  it  be  habitually  large,  as  in  rapid  eaters, 
while  its  operation  may  be  further  facilitated  by  some  traumatic  injury 
to  this  part  of  the  throat,  such  as  may  be  caused  by  the  lodgment  of  a 
bone. 

The  sac  is  found  to  be  bounded  by  mucous  membrane  and  thickened 
submucous  coat,  the  muscular  coat  giving  way  to  let  the  mucous  coat  pass 
through  it,  as  in  a  hernia.  It  is  found  invariably  in  the  posterior  wall,  and 
hangs  in  front  of  the  spinal  column.  One  such,  reported  by  Joseph  McFar- 
land  and  John  M.  Swan  was  5  centimeters  long  and  3  wide.^ 

' '  Their  causation  is  doubtless  due  to  the  fact  that  the  effect  of  pressure 
of  the  wall  between  a  firm  bolus  of  food  and  a  hard  organ  externally  (such  as 
tracheal  calcification,  a  calcified  thyroid,  or  even,  it  is  said,  a  calcareous 
artery)  is  to  injure  the  tissues;  they  are  deprived  of  physiological  rest  by 
constant  movements  entailed  in  eating  and  drinking.  When  the  esophageal 
wall  is  thus  weakened,  the  muscular  and  supportive  tissues  become  insvif- 
ficient  and  stretch  easily;  after  each  considerable  distention  the  wall  fails 
to  contract  to  its  proper  degree,  and  the  lumen  of  the  tube  remains  a  little 
wider  at  this  point  than  normal,  and  each  successive  dilatation  increases  the 
size  of  the  pouch.  When  the  wall  is  weakened,  a  diverticulum  is  caused  by  a 
stretching  of  the  muscle  fibers  and  a  separation  of  one  from  another;  when 
an  individual  group  of  fibers  break,  or  when  this  separation  occurs,  a  hernial 
protrusion  of  the  mucosa  and  submucosa  through  the  gap  follows;  rarel}^ 
these  protrusions  are  still  covered  by  an  incomplete  muscle  layer,  but  even 
when  this  is  not  the  case  the  thickened  submucosa  forms  a  wall  that  is  at 
times  as  thick  as  the  normal  esophagus.  When  they  result  from  such  a 
hernial  protrusion  they  often  have  a  narrow  slit-like  opening ;  notwithstand- 
ing this,  they  may  attain  a  large  size  when  their  liability  to  rupture  consti- 
tutes a  real  menace  to  the  safety  of  the  individual.  The  increase  of  intra- 
esophageal  pressure  by  the  passage  of  food  distends  yet  more  the  beginning 
sac,  and  because  of  their  production  thus  by  pressure  from  within,  these  are 
called  '  'pressure  or  pulsion  diverticula."  They  occur  most  frequently  in  the 
male  sex  and  in  middle  or  advanced  life ;  it  is  supposed  by  some  good  authori- 
ties that  pressure  diverticula  occurring  in  the  continuity  of  the  tube  are 
really  the  result  finally  of  traction  diverticula;  if  this  be  true,  these  woiild  be 
properly  called  "pressure  traction  diverticula"  a  class  described  by  some 
authors,  which  is  for  our  purposes  a  needless  refinement."  (McCrae  in  Osier's 
System) . 

Symptoms. — In  cases  of  diffuse  dilatation  originating  in  stenosis, 
apart  from  the  inference  that  where  there  is  stenosis  there  must  ultimately 
be  dilatation,  the  first  symptom  to  attract  attention  is  the  feeling  on  the  part 
of  the  patient  that  his  food  does  not  enter  the  stomach,  but  lodges  higher  up, 

*  Reprinted  from  "Medicine,"  May,  1903. 


348  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

though  the  quantity  swallowed  is  evidently  more  than  would  be  held  by  an 
esophagus  of  ordinary  caliber;  usually,  sooner  or  later,  follows  the  regur- 
gitation, or  gulping  up  of  this  accumulation.  The  same  symptoms  are  said 
to  attend  dilatation  without  stenosis.  The  latter  event  can  onl}'  be  ex- 
plained on  the  supposition  that,  in  consequence  of  the  paralyzed  state  of  the 
muscular  wall  of  the  esophagus,  there  is  no  force  to  push  the  food  down, 
while  the  gradual  widening  of  the  tube  affords  support  for  its  lodgment, 
which  is  further  favored  if  the  enlargement  takes  the  shape  of  sacculations 
or  a  pocket. 

Traction  diverticulttm  rarely  causes  symptoms.  Those  arising  from 
pressure  diverticulum  are  first  those  of  dysphagia,  as  the  diverticulum  grows 
larger,  and  the  food  lodges  more  and  more;  regurgitation,  though  the  sac 
is  rarely  thoroughly  emptied,  and  the  retained  food  sometimes  undergoes 
decomposition,  giving  rise  to  fetid  breath.  "The  inflammation  so  set  up  may 
spread  to  the  esophagus  itself,  or  may  even  proceed  to  ulceration  and  rup- 
ture, with  the  formation  of  peri-esophageal  abscess ;  or  the  break  may  occur 
into  the  thoracic  cavity,  setting  up  gangrene  of  the  lung  or  empyema;  a 
diverticulum  has  been  known  to  burst  into  a  tuberculous  cavity  of  the  limg 
(Schmidt) .  When  the  diverticulum  is  small  the  tube  will  readily  pass  it,  but 
as  it  becomes  larger  the  tube  is  often  directed  into  the  sac  itself,  where  the 
mobility  of  its  lower  end  and  the  impossibility  of  passing  it  farther  may  assist 
the  diagnosis  (McCrae  in  Osier's  System).  The  difficulties  increase  until 
after  a  while  it  is  almost  impossible  to  get  food  into  the  stomach,  though 
extraordinary  efforts  are  made  by  the  patient  to  do  so,  with  greater  or  less 
success.  Complete  closure  results  when  the  diverticulum  becomes  so 
large  as  to  flex  upon  the  gullet  and  compress  it. 

Diagnosis. — This  is  suggested  by  an  inability  on  the  part  of  the  patient 
to  swallow  well,  and  regiu-gitation  of  food.  This  is  further  confirmed  when 
the  condition  is  a  diverticulum  due  to  spasm  by  the  inability  to  pass  a  soft 
tube  into  the  esophagus  while  a  soUd  bougie  can  be  passed  with  little  diffi- 
culty. If  on  the  other  hand  a  diverticulum  is  present,  the  tip  of  a  soUd 
bougie  is  likely  to  catch  in  the  pouch  and  effectually  prevent  its  passage 
downward.  The  best  method  of  diagnosis,  however,  is  the  one  of  X-ray 
with  the  administration  of  bismuth.  When  the  case  is  thus  studied  the 
diagnosis  of  stricture,  dilatation  or  diverticulum  can  be  certainly  made.  No 
excuse  now  exists  for  a  long  delayed  diagnosis. 

With  the  prolongation  of  the  condition  the  proper  nourishment  of  the 
patient  becomes  more  and  more  difficult;  he  emaciates,  grows  weaker, 
and  ultimately  perishes  from  exhaustion  unless  carried  off  by  some  other 
disease. 

Treatment. — The  treatment  of  diffuse  dilatation  and  diverticula  is 
essentially  the  same.  It  consists,  first,  in  measures  to  maintain  the  nutrition 
of  the  patient.  Generally  he  is  able  to  ingest  a  certain  amount  of  food  by 
his  own  efforts,  of  which  those  detailed  in  the  case  of  my  own  patient  are  an 
illustration.  After  this  the  stomach-tube  becomes  the  most  ready  way. 
This,  too,  he  should  be  taught  to  use  himself.  Rectal  alimentation  may 
help  somewhat,  but  is  alone  inadequate  for  any  length  of  time,  while  the  in- 
convenience of  any  and  all  of  these  procedures  renders  the  patient  anxious 
for  more  complete  relief.     The  treatment  of  dilatation  due  to  cardio-spasm 


ACUTE  GASTRITIS  349 

will  be  detailed  later  and  must  of  course  be  the  treatment  of  the  cardio- 
spasm. 

Complete  relief  may  be  accomplished  by  operation,  by  which  diverticula 
have  been  successfully  removed.  The  difficulties  in  the  way  of  operation 
are,  however,  great.  The  operative  treatment  of  dilatations  due  to  stenoses 
resolves  itself  into  that  of  the  stenoses  themselves.  In  both  forms  gas- 
trostomy may  be  the  ultimate  measure  that   promises  relief  for  a  time. 

DISEASES  OF  THE  STOMACH  AND  INTESTINES. 

ACUTE  GASTRITIS. 

Synonyms. — Acute  Gastric  Catarrh;  Acute  Dyspepsia. 

Definition. — Acute  inflammation  of  the  stomach,  of  moderate  intensity, 
due  to  simple  nonspecific  irritation  or  to  irritation  from  the  products  of 
decomposing  and  fermenting  foods. 

Etiology. — This  form  of  infiammation  occurs  at  aU  ages,  and  is  often 
due  to  the  irritant  effect  of  indigestible  food  or  food  in  a  state  of  incipient 
decay  and  fermentation.  Simply  overloading  the  stomach,  even  though  the 
food  be  wholesome,  may  be  a  sufficient  cause.  The  introduction  of  large 
quantities  of  strong  alcoholic  drinks,  as  often  happens  in  a  debauch,  is  one 
of  the  most  common  causes  of  acute  gastritis  of  the  simple  variety.  The 
susceptibility  of  different  individuals  and  of  different  families  to  the  fore- 
going causes  of  irritation  varies  greatly. 

Morbid  Anatomy. — A  more  or  less  uniform  coating  of  the  stomach 
with  mucus  is  the  most  constant  feature  of  simple  acute  gastritis,  and  justi- 
fies for  it  the  name,  gastric  catarrh.  The  removal  of  this  mucous  coating 
reveals  a  hyperemic  redness,  which  in  the  highest  degrees  may  be  associated 
with  punctiform  hemorrhages  and  hemorrhagic  erosions.  The  mucous 
membrane  is  swollen  and  edematous,  and  minute  examination  recognizes 
ntmierous  mucous-laden  cylinder  cells,  which  have  been  extruded  from  the 
mucus-glands  everywhere  present,  whUe  even  the  peptic  gland  cells  are 
cloudy  and  granular. 

Symptoms. — These  are  a  natural  sequence  of  the  morbid  state.  A 
want  of  appetite  and  loathing  of  food,  nausea,  more  rarely  pain — these  are 
the  more  constant  subjective  symptoms.  To  them  may  be  added  an 
unpleasant  taste  in  the  mouth,  sometimes  bitter,  sometimes  metallic,  a  pasty 
sensation  of  dryness,  and  even  thirst,  a  sense  of  ftdlness  in  the  head  rather 
than  headache,  and  dizziness,  and  often  extreme  mental  depression. 

Objective  symptoms  are  epigastric  distention,  more  rarely  tenderness, 
a  coated  tongue,  dryness  of  the  lips,  rarely  herpes,  a  heavy  breath,  acid  or 
bitter  eructations,  sometimes  a  scanty  secretion,  at  others  an  excess  of  saliva, 
finally  retching  and  vomiting  with  greater  or  less  relief.  The  bowels  are 
constipated,  though  sometimes  there  is  diarrhea.  Jaundice  is  occasionally 
present,  and  indicates  that  the  inflammation  extends  into  the  duodenum  and 
produces  obstruction  of  the  common,  bile-duct.  There  may  be  slight  fever, 
sometimes  decided,  with  a  temperature  of  ioi°  F.  (38.3°  C),  or  slightly 
more,  and  a  corresponding  pulse.  On  the  other  hand,  the  pulse  is  not  infre- 
quently slowed  below  the  normal,  being  inhibited  by  the  gastric  irritation. 


350  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

The  urine  is  "feverish,"  scanty,  and  hi^h  colored,  -svith  a  corri^sponding  spe- 
cific gravity  and  a  tendency  to  deposit  urates.  Most  cases  are  without 
febrile  symptoms.  Indeed,  v.  Leube  says  that  in  a  few  instances  only  is 
fever  the  result  of  acute  gastric  catarrh,  and  that  when  the  two  are  asso- 
ciated, the  gastric  catarrh  is  rather  the  result  of  some  acute  febrile  process, 
as,  for  example,  one  of  the  infectious  fevers.  It  has  occasionally  happened 
that  gastritis  has  been  ushered  in  with  a  chill. 

Gastric  Contents. — The  vomited  matter  and  gastric  contents  removed 
after  a  test-meal  are  deficient  in  hydrochloric  acid,  but  contain  an  excess 
of  mucus,  lactic  and  fatty  acids,  and  more  than  the  normal  residue  of  undi- 
gested food.  Digestion  is  prolonged,  the  stomach- washings  exhibiting  a 
considerable  amount  of  undigested  food  seven  hours  after  the  ingestion  of 
a  test-meal.  Indeed,  it  often  happens  that  in  from  12  to  24  hours  after  the 
beginning  of  such  an  attack  large  quantities  of  undigested  food  are  vomited 
in  much  the  same  condition  in  which  they  are  swallowed. 

Diagnosis. — This  is  not  usually  difficult,  except  in  the  case  of  the 
febrile  form.  In  this  form,  especially  when  the  disease  has  been  ushered  in 
with  a  chill,  it  is  sometimes  difficult  to  decide  between  it  and  some  one  of  the 
infectious  fevers,  but  a  few  days'  waiting  will  soon  remove  the  doubt  by  the 
appearance  in  the  latter  of  eruptions  or  other  distinctive  symptoms.  The 
presence  of  a  cause  sufficient  to  excite  gastric  inflammation  will  add  to  the 
probability  of  the  presence  of  acute  catarrhal  gastritis. 

Prognosis. — This  is  invariably  favorable  in  cases  of  true  simple  gastritis. 

Treatment. — Many  mild  cases  recover  spontaneously,  if  let  alone  and  if 
all  food  is  withdrawn  for  24  hours.  The  symptoms  gradually  subside  and 
the  patient  recovers.  In  a  few  cases  where  there  is  evidently  retained 
food,  a  lavage  will  give  relief;  in  all,  a  brisk  saline  purge  is  helpful.  A 
bottle  of  cold  solution  of  citrate  of  magnesium  in  divided  doses,  a  fourth 
every  half  hour,  is  one  of  the  most  agreeable  and  efficient  aperients  to  relieve 
the  congestion  and  the  symptoms.  Or  some  one  of  the  natural  aperient 
waters,  such  as  Hunyadi  Janos  or  Friedrichshalle,  Apenta,  Rubainat, 
Veronica,  or  Carlsbad,  may  be  substituted.  If  there  be  great  sensitive- 
ness of  the  stomach,  small  doses  of  calomel,  frequently  repeated,  1/6  to 
1/4  grain  (o.oii  to  0.016  gm.)  every  hour,  may  be  substituted,  or  7  1/2  to 
10  grains  (0.5  to  0.666  gm.)  may  be  given  in  one  dose.  In  either  event 
a  saline  should  be  given  sooner  or  later,  as  in  this  way  is  secured  copious 
depletion  of  the  upper  alimentarj^  canal.  The  alkaline  mineral  waters, 
represented  by  Vichy  and  Vals  in  PVance,  by  Carlsbad  and  Marienbad  in 
Bohemia,  are  admirable  adjuvants,  since  they  aid  in  clearing  the  stomach 
of  mucous  secretion  and  in  producing  osmosis.  The  saline  mineral  waters 
represented  by  the  well-known  Saratoga  waters  of  this  country  are  also 
efficient,  more  especially  by  their  aperient  qualities. 

CHRONIC  GASTRITIS. 
Synonyms. — Chronic  Gastric  Catarrh;  Chronic  Catarrhal  Dyspepsia. 
Definition. — A  condition  of  chronic  hyperemia,  associated  with  excessive 
mucous  secretion  and  deranged  gastric  juice  formation  and  lack  of  motor 
power,  with  ultimate  structural  changes  in  the  mucosa. 


CHRONIC  GASTRITIS  351 

Etiology. — Any  cause  which  will  produce  continuous  moderate  irritation 
of  the  mucous  membrane  of  the  stomach  is  capable  of  producing  chronic 
gastritis.  The  immoderate  use  of  alcohol,  constant  overeating,  rapid 
eating,  eating  of  improper  food,  are  all  common  causes  of  this  condition. 

Very  frequently,  too,  chronic  gastritis  is  secondary  to  primary  disease 
elsewhere,  and  especially  mitral  disease  of  the  heart  and  interstitial  hepatitis 
and  nephritis.  Both  of  these  affections  cause  a  passive  congestion  of  the 
stomach,  which  ultimately  produces  the  lesions  characteristic  of  chronic 
gastritis.  Thrombosis  of  the  portal  vein  acts  similarly.  Chronic  pul- 
monary disease,  and  even  diseases  of  the  pleura  impeding  the  circulation  in 
the  lungs,  produce  similar  effects  through  stasis.  A  predisposition  exists 
in  certain  families  to  chronic  gastric  catarrh.  All  cases  of  carcinoma  and 
many  cases  of  ulcer  and  dilatation  are  causes.  General  diseases  such  as 
anemia,  tuberculosis,  gout  and  diabetes  are  found  among  the  causative 
factors. 

Morbid  Anatomy .^The  fundamental  condition  is  a  hyperemic  swelling 
of  the  gastric  mucosa.  This  is  favored  by  the  superficial  situation  of  the 
venus  plexus  about  the  mouths  of  the  gastric  glands  as  contrased  with  the 
deep-seated  position  of  the  arterial  network  around  their  bases,  by  the  thin- 
ness and  compressibility  of  the  venous  walls,  and  by  the  sluggishness  of 
circulation  necessitated  by  the  peculiar  secretory  function  of  the  stomach. 
The  hyperemic  surface  is,  however,  more  or  less  obscured  by  a  tough  yellow- 
ish-white covering,  made  up  of  mucus  and  emigrant  pus-cells. 

These  may  constitute  the  sum  of  changes,  but  in  more  chronic  cases 
minute  examination  reveals  a  varying  degree  of  hyperplasia  of  the  connective 
tissue,  and  even  of  the  mucous  glands,  which  exhibit  in  places  an  atypical 
branching,  like  the  fingers  of  a  glove.  The  tubules  are  distended  by  secre- 
tion in  some  places,  and  in  others  stenosed  by  the  contraction  of  the  over- 
grown connective  tissue  surrounding  them.  The  hyperplastic  process  may 
result  in  plication  of  the  mucous  membrane,  such  as  is  natural  at  the  pyloric 
end,  and  lead  finallj^  to  the  mammillated  stomach  by  atrophy  and  contraction 
of  certain  portions,  and  to  more  pronounced  swelling  of  the  remaining  parts. 
An  ultimate  result  is  sometimes  the  rare  condition  known  as  polyposis 
ventriculi.  Atrophy  of  the  mucous  membrane  may  be  extensive,  and  even 
almost  total,  such  as  are  being  reported  by  Henry  and  Osier. 

Symptoms. — These  naturally  result  from  the  morbid  state.  The 
mucous  membrane  is  bathed  with  mucus.  The  gastric  juice  is  imperfect  in 
quality  and  quantity.  Especially  is  the  hydrochloric  acid  deficient.  Diges- 
tion is  therefore  imperfect,  the  residue  of  ingested  food  undergoes  fermen- 
tation and  decomposition,  generating  lactic,  acetic,  butyric  acids  and 
alcohol.  Peristalsis  is  delayed  because  of  the  absence  of  its  natural  stimulus 
and  thence  follows  a  further  retention  of  food  in  the  stomach  with  eructation 
of  gas  and  fermented  food  materials.  The  natural  consequence  of  such 
morbid  changes  is  loss  of  appetite  and  even  disgust  for  food,  an  unpleasant 
taste,  a  pasty  sensation  in  the  mouth,  a  coated  tongue,  and  discomfort  after 
taking  food,  including  nausea,  often  vomiting,  sometimes  immediately, 
sometimes  an  hour  or  two  after  taking  food.  The  vomitus  consists  of 
undigested  food,  usually  mixed  with  a  large  amount  of  mucus.  Its  reaction 
may  be  neutral  or  acid,  sometimes  even  acridly  so,  but  the  acidity  is  not 


352  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

due  to  hydrochloric  acid,  which  is  diminished,  but  to  the  organic  acids 
generated  in  fermentation. 

To  these  symptoms  may  be  added  headache,  or  a  dull,  unpleasant  feeling 
in  the  head,  vertigo,  disturbed  sleep,  depression  of  spirits,  a  sense  of  weariness, 
disgust  with  life  and  nausea.  Very  disagreeable  is  the  distention  and  sense 
of  fullness  in  the  epigastrium,  causing  even  pain,  which  adds  further  to 
existing  discomforts.  There  may  be  tenderness,  but  it  is  diffuse,  and  not 
circumscribed.  There  is  usually  constipation,  while  the  urine  may  be  scanty. 
Reflected  symptoms  are  palpitation;  frequent,  slow,  or  irregular  pulse; 
shortness  of  breath.  There  is  no  fever.  Cough — the  so-called  "stomach 
cough" — is  sometimes  present,  but  more  frequently  what  is  called  by  the 
patient  stomach  cough  is  the  cough  of  tuberculosis,  which  the  sanguine 
patient  easily  convinces  himself  is  due  to  stomach  derangement. 

Gastric  Contents. — Analysis  of  the  gastric  contents,  withdrawn  after  a 
test-meal,  shows  a  deficiency  of  pepsin  as  well  as  of  hydrochloric  acid, 
while  other  tests  show  retarded  peristalsis  and  delayed  absorption.  Fre- 
quently fungi,  especially  yeast-spores  and  sarcinae  ventriculi  are  foimd. 

Should  the  disease  progress  to  total  atrophy,  the  gastric  contents,  after 
a  test-meal,  may  even  be  devoid  of  mucus  as  well  as  of  free  and  combined 
hydrochloric  acid,  of  pepsin,  and  epithelium,  and  may  be  made  up  mainly 
of  undigested  food,  with  bacteria  and  a  few  round  cells.  Repeated  examina- 
tions of  stomach  contents,  after  a  test-meal,  may  be  necessary  before  a 
sufficient  knowledge  of  its  features  can  be  arrived  at.  These  cases  are 
often  accompanied  by  a  severe  anemia,  the  gastric  disorders,  and  loss  of 
weight  causing  the  cases  to  closely  resemble  gastric  carcinoma. 

Diagnosis. — With  the  symptoms  detailed,  and  the  altered  state  of  the 
secretory,  absorptive,  and  motor  functions  of  the  stomach  ascertained, 
there  is  usually  no  difficulty  in  diagnosing  chronic  gastric  catarrh.  It  is 
to  be  remembered,  however,  that  chronic  gastric  catarrh  may  accompany 
ulcer  and  carcinoma  of  the  stomach,  in  which  the  otherwise  distinctive  symp- 
toms of  the  former  are  obscured,  while  with  the  exception  of  tumor  and 
occasional  coffee-grounds  vom.it  the  symptoms  of  carcinoma  may  not  differ 
from  those  of  chronic  gastric  catarrh,  hydrochloric  acid  and  pepsin  being 
deficient  in  both.  Dilatation  of  the  stomach  is  also  accompanied  with 
symptoms  of  gastric  catarrh,  including  even  the  clinical  characters  of  the 
gastric  juice,  and  careful  examination  must  always  be  made  for  the  physical 
signs  of  dilatation.  The  use  of  bismuth  meal  and  examination  b}-  X-ray 
is  advisable.  Constantly  imperfect  peristalsis,  a  puckering  of 'the  wall  of 
the  stomach  or  retention  will  be  indicative  of  either  carcinoma  ulcer,  or 
perigastric  adhesions  which  woiild  not  otherwise  be  considered. 

Gall-stones  and  cholecystitis  from  other  sources  must  always  be  con- 
sidered. Chronic  appendicitis  must  also  be  kept  in  mind,  for  it  must  be 
remembered  that  many  cases  of  "indigestion,"  supposed  to  be  due  to  a 
simple  chronic  gastritis  are  really  symptomatic  of  cancer,  ulcer,  gall-stone, 
appendicitis  of  pancreatitis. 

Prognosis. — The  prognosis  and  treatment  will  depend  upon  the  etiology. 
If  the  chronic  gastric  catarrh  is  a  result  of  chronic  cardiac  or  hepatic  disease, 
it  is  curable  only  so  far  as  these  affections  are  curable,  and  is  reUeved  as 
these  are  relieved.    If  it  is  the  resvdt  of  carcinoma,  ulcer,  gall-stones  or  appen- 


CHRONIC  GASTRITIS  353 

dicitis  the  prognosis  must  depend  entirely  upon  the  ability  to  remove  these 
conditions.  Careful  physical  examination  is  always  necessary  in  each  case, 
that  obscure  cases  may  be  recognized. 

Chronic  gastric  catarrh  not  the  result  of  any  organic  disease,  and  which 
has  not  already  resulted  in  atrophy  of  the  mucous  membrane,  may  be 
cured  by  careful  and  persevering  treatment.  If  there  be  extensive  atrophy 
of  the  gastric  mucous  membrane,  a  proper  assimilation  of  food  becomes 
impossible,  and  the  symptoms  of  anemia  are  ultimately  added.  Their 
close  resemblance  to  those  of  pernicious  anemia  has  been  pointed  out,  while 
an  essential  cause  of  pernicious  anemia  has  been  held  to  be  gastric  atrophy, 
in  evidence  of  which  a  case  of  William  Osier  and  Frederick  P.  Henry  is  often 
quoted. 

Treatment. — The  treatment  of  chronic  gastritis  caused  by  any  organic 
disease  resolves  itself  into  the  treatment  of  that  disease.  If  the  causative 
disease  is  irremediable  then  symptomatic  treatment  of  the  gastritis  will 
frequently  give  relief.  Chronic  appendicitis  and  gall-stones  must  be 
removed.  Gastric  ulcers  and  carcinomata  must  be  subjected  to  operation 
by  a  skilled  surgeon. 

A  successful  treatment  of  catarrhal  dyspepsia  requires  considerable 
patience,  but  if  the  diagnosis  be  correctly  made  and  the  cause  removed,  the 
patient  may  be  promised  a  cure  in  time.  Of  primary  importance  is  the  elimi- 
nation oj  the  cause,  whether  it  be  alcohol,  injudicious  eating,  or  lack  of  proper 
exercise  and  fresh  air.  Alcohol  must  be  abstained  from.  Regulated  exer- 
cise in  the  open  air  must  be  taken,  the  diet  must  be  regulated.  Simple, 
wholesome,  and  properly  cooked  food,  thoroughly  masticated  and  slowly 
taken,  should  be  the  rule  of  every  life,  and  the  simple  forms  of  the  disease 
may  sometimes  be  cured  by  the  return  to  such  a  habit,  especially  if  a  proper 
action  of  the  bowels  is  also  habitually  secured. 

Diet. — Each  case  must  be  studied  separately.  No  routine  diet  can  be 
selected.  After  careful  study  and  inquiry  the  patient  should  be  given  a 
printed  or  written  list  containing  the  foods  he  may  take.  A  convenient  list 
is  one  which  contains  the  printed  names  of  all  ordinary  foods  and  drinks. 
The  foods  not  allowed  to  the  patient  under  treatment  may  be  stricken 
from  the  list  (pp.  354,  355). 

Of  course  all  fat  foods,  fried  foods,  pastry  and  confections  must  be  de- 
barred. 

No  less  important  than  the  kind  of  food  taken  in  the  method  of  eating. 
Food  should  be  well  chewed,  eaten  slowly,  taken  in  moderate  quantity  at 
regular  intervals.  Neither  just  before  nor  just  after  violent  physical  or 
mental  exertion. 

The  measures  by  which  the  regular  habit  of  bowel  movement  is  brought 
about  must  vary  with  circumstances.  Perhaps  the  most  important  factor  in 
obtaining  a  daily  bowel  movement  is  regulation  of  the  time  at  which  a  stool 
is  attempted.  Too  often  a  stool  is  only  had  at  a  convenient  time.  If  the 
patient  is  directed  to  attempt  a  stool  at  a  certain  time  each  day  this  regula- 
tion of  habit  will  in  itself  frequently  cause  a  stool.  It  is  important  that  this 
regularity  be  insisted  upon  in  early  life.  Foods  rich  in  refuse  matter  such  as 
fruits,  stewed  or  raw,  cereals,  etc.,  are  efficacious.  Pernicious  drugging  is 
harmful.     The  millions  of  laxative  pills  yearly  used  without  reason  cause  an 


354 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


DIET 


SOUPS 

DAILY 

O         MEATS 
'-^Boiled 

DAILY 

VEGETABLES 

DAILY 

AMOUNT 

AMOUNT 

O  Starchy 

AMOUNT 

O  Broths 
^      Beef 

Stewed 

Roasted 

Rice 

Veal 

Broiled 

Corn 

Mutton 

Hashed 

Peas 

Chicken 

Beef 

Beans 

Bouillon 

Mutton 

Lima  Beans 

Consommd 

Mutton  Chops 

Lentils 

Ox-tail 

Lamb 

Lamb  Chops 

Veal 

Sweetbreads 

Brains 

Liver 

Potatoes 

Baked 

Boiled 

Mashed 

cupped 
Sweet  Potatoes 

O  Purses  &  Creams 

Kidneys 

Beets 

Barley 

Pork 

Parsnips 

Rice 

Bacon 

Turnips 

Pea 

Ham 

Carrots 

Bean 

Dried  Beef 

Kohl  Rabi 

Potato 

Corned  Beef 

Artichokes 

Tomato 

Sausages 

Salsify 

Asparagus 

Pigs'  Feet 

Radishes 

Onion 

Tongue 

Celery 

Tripe 

O      POULTRY 

Chicken 

While  Meal 

O  Green  Vegetables 

Tomatoes 

O  Thick  Soups 

Ra-w 

Vegetable 

Squab 

Stewed 

Noodle 
Julienne 

Turkey 
Duck 

Baked     ■ 
Egg  Plant 

Vermicelli 

Baked 

Calf's  Head 

Guinea  Fowl 

Onions 

Mock  Turtle 

Boiled 

MuUigatawney 

Baked 

Clam  Chowder 

Leeks 

Fish  Soups 

O        GAME 

Venison 
Rabbit 
Wild  Duck 
Birds 

Cabbage 

Sauer  Kraut 

Cole  Slaw 
Cauliflower 
Brussels  Sprouts 
Sea  Kale 

O        FISH 

String  Beans 

Boiled 

Asparagus 

Broiled 

O       EGGS 

Pumpkins 

Baked 

Squashes 

Salted 

Soft  Boiled 

Celery 

Sardines  in  Oil 

Poached 

Raw 

Scrambled 

Stewed 

Omelet 

Rhubarb 

Veg'fle  Marrow 

Spinach 

Lettuce 

O          OYSTERS 
Raw 
Panned 
Broiled 

O        MILK 

Unskimmed 

Skimmed 

Buttermilk 

Water  Cress 

Beet  Tops 

Okra 

Capers 

Cucumbers 

Endives 

Chiccory 

Sorrel 

Stewed 

Cream 

Scalloped 

Boiled  Milk 
Pasteurized 

O  Clams 

O         BUTTER 

Crabb 

Lobsters 

Shrimps 

O        CHEESES 

Terrapin 

Directions: 


Individual   articles  in   any   list 


General  Instructions: 

1.  Eat  slowly  and  at  regular  hours;  masticate  thoroughly. 

2.  Take  fluids  moderately  at  meals;  drink  water  freely  at  other  times. 

3.  Avoid  an.xiety  and  business  cares  at  table;  rest  for  a  while  after  meals. 

4.  Use  laxative  foods  and  drink  an  abundance  of  water  to  prevent  constipation. 

5.  Do  not  partake  of  a  great  variety  of  dishes  at  any  one  time,  nor  eat  large  quan- 

tities of  anything  very  hot  or  cold. 


CHRONIC  GASTRITIS 


355 


LIST. 


O           BREAD 

DAILY 

O      ICE  CREAM 

DAILY 

O             NUTS 

DAttY 

Fresh  Baked 

AMODNT 

Vanilla 

AMODNT 

Cocoanuts 

AUOUNT 

Stale 

Chocolate 

Chestnuts 

Toasted 

Fruit  Flavors 

Walnuts 

Pulled 

English  Walnuts 

Zwieback 

Brazil  Nuts 

White  Flour 
Graham 

O     WATER  ICES 
Orange 
Lemon 

Hazel  Nuts 
Pecan  Nuts 

Rye 

Shellbarks 

Crackers 

Sherbets 

Salted 

Gluten 

Almonds 

Almond 

Peanuts 

Inulin 
Soya 

O          CAKE 

Plain 

O  Olives 

Aleuronat 

Fancy 

Pickles 
TruiBes 
Mushrooms 

O      HOT  CAKES 

O       JELLIES 

Lemon 

Wine 

Fruit 

BEVERAGES 
O  Non-Alcoholic 

O        CEREALS 

^^  Oat  Meal 

CoSee 
Tea 

Corn  Meal 

Cocoa 

Hominy 

Chocolate 

Arrow-root 

O       SUGARS 

Lemonade 

Tapioca 

Grape  Juice 
Ginger  Ale 

Cornstarch 

Cane  Sugar 

Farina 

Grape  Sugar 

Soda  Water 

Sago 

Honey 

Mineral  Waters 

Macaroni 

Molasses 

Label: 

Spaghetti 

Confectionery 

Saccharine 

Levulose 

O  AlcohoUc 

O         SPECIAL 
'-'  Beef  Juice 

Ale 

Porter 

Clam  Juice 

O       FRUITS 

Oranges 

Stout 

Scraped  Beef 

Cider 

Beef  Tea 

Lemons 

Sherry 

Albumen  Water 

Limes 

Port 

Milk  Toast 

Shaddocks 

Maderia 

Toast  Water 

Grapes 

Malaga 

Barley  Water 

Bananas 

Tokay 

Gruel 

Pineapples 

Rhine  Wines 

Irish  Moss 

Melons 

Label: 

Flaxseed  Tea 

Champagnes 

Milk  Punch 

Label: 

Egg  Nog 

Fresh 

Clarets 

Koumiss 

Dried 

Label: 

Wine  Whey 

Stewed 

Burgundies 

Mulled  Wine 

Preserved 

Label: 

Panada 

Apples 

Whiskies 

Caudle 

Peaches 

Label: 

Broth  with  Egg 

Pears 

Brandies 

Predigested  Food 

Plums 
Prunes 
Apricots 

Label: 

Gin 

Label: 

O         PASTRY 

Cherries 
Raisins 

Liqueurs 
O    CONDIMENTS 

Dates 

O       PUDDINGS 

Figs 

Pepper 

^  Bread 

Mustard 

Cornstarch 

Spices 

Blanc  Mange 

O         BERRIES 

Strawberries 

Herbs 

Rice 

Vinegar 

Tapioca 

Blackberries 

Olive  Oil 

Cup  Custard 

Raspberries 

Horseradish 

Junket 

Huckleberries 

Sauces 

Cottage 

Gooseberries 

Caviare 

Hasty 

Cranberries 

Patfe  de  Foie  Gras 

Suet 

Mulberries 

Fruit 

Currants 

O          SALADS 

6.  Rich  dishes,  fried   foods,  pastiies,  sweets,  stimulants,  and  strong  condiments, 

should  be  used,  if  at  all,  only  in  small  amounts. 

7.  Under-cooked  vegetables,  overdone  or  hashed  meats,  hard-boiled  eggs,  and  any 

articles  habitually  found  to  disagree,  are  to  be  avoided. 

8.  A  moderate  daily  quantity  of  food  for  adults  should  average  about — 

10  ounces  of  animal  food  (fish,  oysters,  meat,  poultry,  eggs,   etc.); 
30   ounces   of   vegetable   food    (including   bread    and    cereals);   and 
50   to   80  .  ounces   of  liquids,   including   tea,    coffee    or    cocoa,    but 
principally  water. — Thompson. 

Special  Instructions: 


3ofi  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

artificial  condition  which  demands  the  stimulation.  They  should  not  be 
used. 

Drinking  of  water  before  meals  is  useful.  A  small  simple  enema  or  a 
glycerin  suppository  may  occasionally  be  used  in  the  beginning  of  the  regu- 
lation of  the  habit  of  stooling.  Massage  of  the  abdomen  is  of  the  utmost 
value  in  causing  a  patient  to  have  a  normal  stool  without  the  aid  of  drugs. 
Drugs  of  the  vegetable  laxatives  cascara  sagrada  may  be  used  in  30-droiJ 
doses  of  the  fluid  extract  three  times  a  day  or  a  teaspoonful  at  bedtime. 
Podophyllin  aloin  and  belladonna  make  an  excellent  combination  in  pill 
form.  When  it  is  remembered  that  we  have  to  deal  with  a  congested 
mucous  membrane,  it  is  plain  why  the  salines  which  deplete  the  upper  ali- 
mentary canal  are  so  efficient.  Among  these  are  the  numerous  natural 
aperient  waters,  such  as  Friedrichshalle,  Hunyadi  Janos,  Apenta,  Carlsbad 
waters,  and  our  own  Saratoga  and  Bedford  waters,  all  of  which  deplete  the 
alimentary  canal.  The  useful  effects  of  these  waters  is  so  often  availed  of  to 
remove  the  uncomfortable  effect  of  a  debauch  in  eating  that  their  use  is 
abused.  No  remedies  are,  however,  so  useful  when  needed,  and  the  fact 
that  almost  any  of  them  can  be  taken  before  breakfast,  seciuing  an  effect 
after  that  meal,  makes  them  doubly  convenient.  A  fit  substitute  for  the 
water,  especially  when  traveling,  is  the  Carlsbad  Sprudel  Salt,  obtained  by 
evaporating  the  Carlsbad  water.  Carlsbad  salt,  of  which  the  dose  is  usually 
a  teaspoonful,  is  best  taken  in  a  glass  of  hot  water.  An  artificial  Carlsbad 
salt  may  be  made  as  follows:  Sodium  sulphate,  50  parts;  sodium  bicar- 
bonate, 6;  sodium  chlorid,  3.  The  dose  is  a  teaspoonful  dissolved  in  a  half 
a  glass  to  a  glass  of  water.  The  natural  waters  are,  however,  to  be  preferred, 
if  they  can  be  obtained. 

Cascara  sagrada  is  one  of  the  most  valuable  of  aperients.  The  best 
preparations  are  the  solid  and  fluid  extracts.  The  former  may  be  given  in  2 
to  5  grain  doses  (0.132  gm.)  in  a  pill  after  dinner  and  after  supper.  The  fluid 
extract,  in  15  or  20  minim  (i  to  1.3  gm.)  doses,  can  be  given  in  the  same 
manner,  but  the  dose  of  each  must  be  modified  to  suit  the  requirements  of 
individual  cases.  In  lieu  of  the  saline  aperients  before  breakfast,  a  glass  of 
hot  water  alone,  slowly  sipped  while  dressing,  is  often  useful  and  tends  to 
relieve  the  morning  sickness  that  sometimes  attends  chronic  gastric  catarrli. 
It  probably  liquefies  the  mucus  and  washes  it  away  into  the  duodenum. 
Phenolpthalein  in  doses  of  three  grains  either  alone  in  pill  form  or  in  combi- 
nation with  one  of  the  laxatives  mentioned  above  is  of  great  value.  It  is  of 
the  greatest  importance  that  patients  be  warned  against  indiscriminate 
drugging,  either  by  the  various  laxative  pills  or  by  pills  and  capsules  regu- 
larly prescribed. 

As  to  medicines  intended  to  aid  indigestion,  the  most  efficient  is  hydro- 
chloric acid  or  nitromuriatic  acid,  probably  best  combined  with  one  of  the 
bitter  tonics,  tinetiu"e  of  nux  vomica  or  tincture  of  gentian.  It  seems  now 
definitely  settled  that  hydrochloric  is  the  acid  to  which  the  gastric  juice  owes 
its  efficiency,  and  as  well  settled  that  it  is  diminished  in  chronic  gastric 
catarrh.  Another  important  rdle  is  assigned  to  hydrochloric  acid,  viz.,  an 
antiseptic  effect,  in  checking  the  multiplication  of  pathogenic  bacteria — 
bacteria  of  fermentation  and  decomposition — which  are  continually  intro- 
duced with  the  food  into  the  stomach.     The  latter  has,  heretofore,  been 


CHRONIC  GASTRITIS  357 

administered  in  too  small  doses.'  Not  less  than  15  minims  (i  gm.)  of  the 
dilute  acid  should  be  given,  and  from  30  to  60  minims  (2  to  4  gm.)  are  some- 
times required.  It  should  be  given,  further  diluted,  i  s  minutes  after  a  meal, 
through  a  glass  tube  carried  back  into  the  fauces,  not  merely  to  save  the 
teeth,  but  also  to  avoid  the  unpleasant  taste. 

It  is  usual  also  to  employ  the  bitter  tonics  in  the  treatment  of  this  form 
of  dyspepsia,  including  gentian,  quassia,  columbo,  angostura,  cardamom,  and 
nux  vomica.  They  are  supposed  to  stimulate  the  secretion  of  gastric  juice, 
and  should  be  taken  immediately  before  meals  or  with  food.  Common 
salt,  on  the  other  hand,  is  a  rational  adjuvant,  furnishing  chlorin  for  the 
formation  of  hydrochloric  acid. 

Nitrate  of  silver  is  also  a  useful  drug  in  cases  of  chronic  gastric  catarrh, 
in  doses  of  1/4  grain  (0.0165  gm.)  15  minutes  to  half  an  hour  before  meals, 
dissolved  in  a  quarter  of  a  glass  of  water.  Great  care  must  be  exercised 
that  the  silver  treatment  be  discontinued  after  two  or  three  weeks,  use  to 
prevent  the  appearance  of  argyria.  It  may  be  recommenced,  however,  after 
another  interval  of  two  or  three  weeks.  Where  there  is  acidity  bismuth, 
sodium  bicarbonate,  and  magnesia  may  be  used,  but  it  is  better,  if  possible, 
to  strike  at  the  root  of  the  evil  by  preventing  the  fermentations  which  pro- 
duce the  flatidence  and  acid.  Beta  naphthol  in  3  grain  (0.2  gm.)  doses  after 
meals  is  also  an  efficient  remedy  where  there  is  fermentation  and  gaseous 
distention. 

In  obstinate  cases  the  milk  treatment  may  be  resorted  to  with  advan- 
tage, and  should  be  carried  out  with  skimmed  milk  or  whole  mUk  diluted 
with  water  or  Vichy.  The  efficiencj^  of  the  milk  treatment  is  largely  due  to 
the  fact  that  the  quantity  of  food  taken  is  greatly  reduced.  Not  more  than 
2  ounces  should  be  given  at  first,  every  two  hours,  the  quantity  increased 
only  as  the  hunger  of  the  patient  demands  more.  There  will  be  at  first  a 
loss  of  weight,  but  this  is  again  recovered  with  the  increase  in  quantity. 
Having  secured  a  tolerance  for  milk,  of  which  from  3  to  5  pints  (i  1/2  to 
21/2  liters)  are  required  in  24  hotus,  the  interval  may  be  prolonged  and 
the  other  articles  of  food  cautiously  added — a  little  bread  and  butter,  an 
egg,  a  chop,  or  a  small  piece  of  steak,  broiled.  Gradual!}^  the  simpler 
vegetables,  such  as  rice  and  potatoes,  may  be  added,  then  weak  tea  and 
coffee  cautiously,  the  effect  of  each  article  being  carefuUj'  watched.  If 
flatulence  is  caused  by  the  farinacea  and  sugars,  they  shovdd  be  withdrawn. 
The  same  may  be  said  of  ice-cream  and  iced  water  with  meals,  though  a 
moderate  amount  may  be  permitted  between  meals,  especially  of  iced  water. 
'Ripe  fruits,  on  the  other  hand,  are  ver>'  desirable  foods  and  should  be  allowed 
tentatively. 

In  bad  cases  of  chronic  gastritis  with  retention  lavage  is  one  of  the  most 
useful  measures.  Not  only  does  it  wash  away  the  coating  of  mucus  which 
is  at  once  a  hindrance  to  the  secretion  of  the  gastric  juice  and  a  cause  of 
nauseous  discomfort  to  the  patient,  but  it  also  stimidates  glandular  activity. 
It  should  be  done  in  the  morning  before  breakfast,  with  the  stomach-tube 
with  funnel  attachment.  Simple  water  as  hot  as  can  be  borne  may  suffice, 
or  if  there  be  much  mucus,  a  two  per  cent,  solution  of  sodium  bicarbonate 

1  Since  4.5  liters  (9  pints)  of  0.2  per  cent,  solution  of  HCl  are  required  to  saturate  100  gm.  (about  3  oz., 
of  dry  fibrin,  and  tbis  amount  of  acid  utilized  in  combining  with  the  albumin  leaves  none  apparent  as  free 
HCl,  it  is  plain  why  the  small  doses  often  prescribed  are  insufficient. 


358  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

or  Carlsbad  salt,  or  a  six  per  cent,  solution  of  sodium  chlorid  maybe  used. 
If  antiseptic  fluids  are  indicated,  a  two  per  cen£.  solution  of  resorcin  may  be 
substituted,  or  a  one  per  cent,  solution  of  salicylic  acid.  It  is  extremely 
unwise  to  advise  the  patient  to  wash  out  his  own  stomach.  A  true  habit 
is  frequently  formed  contributing  much  to  the  neurasthenic  state  often 
present.  The  stomach  must  be  previously  cleansed  and  the  silver  also 
finally  washed  out  by  lavage,  using  salt  solution  if  a  solution  of  silver  nitrate 
is  used. 

It  is  in  these  cases,  too,  that  a  course  at  Carlsbad  is  very  efficient,  and 
remarkable  cures  are  reported.  Here,  too,  the  restricted  dietary  and 
depletion  of  the  upper  alimentary  canal  by  the  natural  mineral  waters  are 
the  beneficial  agents.  Similar  courses  are  carried  out  at  Kissengen,  Wies- 
baden, and  Ems,  but,  unfortunately,  we  have  no  such  places  in  America. 
Saratoga  fulfills  the  conditions  so  far  as  an  aperient  water  is  concerned,  but 
the  majority  of  persons  who  go  to  Saratoga  continue  eating  and  drinking  as 
at  home.  Finally,  the  habitual  use  between  meals  of  the  alkaline  mineral 
waters  alluded  to — viz.,  Vichy,  Vals,  and  Contrexville — is  undoubtedly  use- 
ful, relieving  and  averting  gastric  catarrh. 

PHLEGMONOUS  OR  SUPPURATIVE  GASTRITIS. 

Definition. — A  rare  form  of  gastritis,  in  which  there  is  diffuse  puru- 
lent infiltration  of  the  submucosa,  but  sometimes  also  circumscribed  abscess, 
causing  a  possibly  detectable  tumor  in  the  gastric  region,  a  tiunor  which  dis- 
appears if  the  abscess  ruptures. 

Etiology. — Phlegmonous  gastritis  is  a  result  of  infectious  processes, 
among  which  have  been  puerperal  fever  and  other  forms  of  pyemia.  It  has 
been  found  associated  with  peritonitis  and  trauma.  It  has  been  met  more 
frequently  in  men  than  in  women.  It  sometimes  occurs  without  discover- 
able cause  in  drunkards. 

Symptoms  and  Diagnosis. — Epigastric  pain  and  tenderness,  general 
abdominal  pain  and  tympany,  vomiting,  diarrhea,  fever,  delirium,  dry 
tongue,  small,  frequent  pulse,  coma,  collapse,  and  death — symptoms  that 
closely  resemble  those  of  peritonitis,  with  which,  as  has  been  said,  it  is  some- 
times associated — are  those  met  in  phlegmonous  gastritis.  The  vomited 
matter  very  rarely  contains  pus.  It  is  plain,  therefore,  that  these  sj'mptoms, 
associated  with  an  infectious  process,  can  only  give  rise  to  suspicion  that  the 
disease  is  present,  since  the  same  symptoms  may  be  caused  by  peritonitis. 
Even  the  vomiting  of  pus  is  not  diagnostic,  because  pus  may  arise  from  other 
sources  between  the  mouth  and  stomach.  The  presence  of  a  tumor  which 
.subsides  after  vomiting  of  ptis  furnishes  better  ground  for  suspicion,  though 
vomited  pus  may  also  come  from  an  abscess  in  the  vicinit)'  of  the  stomach 
which  has  ruptured  into  that  organ. 

Treatment. — This  can  only  be  symptomatic,  as  nothing  can  be  done  to 
avert  a  termination  which  is  invariably  fatal. 

TRAUMATIC  AND  TOXIC  GASTRITIS. 

Definition. — An  inflammation  of  the  stomach  caused  by  the  ingestion  of 
corrosive  poisons,  such  as  the  strong  mineral  or  organic  acids,  caustic  alka- 
lies, phosphorus,  arsenic,  corrosive  sublimate,  and  the  like. 


TOXIC  GASTRITIS  359 

Morbid  Anatomy. — The  appearance  differs,  according  to  the  degree  of 
irritation,  and  the  character  of  the  poison  causing  the  condition.  In 
extreme  degrees,  such  as  are  produced  by  the  strongest  acids  and  alkahes, 
the  mucous  membrane  is  disintegrated,  shreddy,  and  may  be  converted 
into  a  black  eschar,  the  borders  of  which  are  lighted  up  with  intense  inflam- 
mation. In  milder  forms,  such  as  are  produced  by  phosphorus,  arsenic, 
and  strong  alcohol,  there  are  cloudy  swelHng  and  fatty  degeneration  of  the 
gastric  gland  cells  and  vessel-waUs,  producing  ulceration  and  hemorrhagic 
extravasation. 

Symptoms. — These  also  vary  with  the  degree  of  irritation,  but  there  are 
always  intense  burning  pain,  tenderness  on  pressure,  thirst,  and  vomiting  of 
blood  and  even  of  fragments  of  mucous  membrane.  To  these  are  added, 
in  severe  cases,  small,  frequent  pulse,  cold  sweat,  and  collapse.  Peritonitis 
often  results  from  extension  of  the  inflammation.  If  the  patient  does  not 
perish  promptly,  symptoms  referable  to  the  systematic  action  of  the  drug  causing 
the  poison,  supervene.  When  recovery  takes  place  or  death  is  long  delayed, 
varying  areas  of  mucous  membrane  may  be  replaced  by  cicatricial  tissue,  and 
there  may  be  subsequent  contraction  and  distortion. 

Diagnosis. — This  is  based  on  a  knowledge  that  the  patient  has  swal- 
lowed a  corrosive  poison.  In  the  absence  of  this  knowledge  the  odor  of  the 
breath  may  suggest  the  cause,  and  evidences  of  corrosive  action  in  the  mouth 
and  pharynx  often  disclose  unfailing  signs. 

Prognosis. — This  varies  with  the  promptness  of  treatment  and  the  degree 
of  lesion.  The  gastritis  caused  by  large  doses  of  the  powerful  corrosive 
poisons  is  always  fatal.     The  lesser  degrees  may  be  followed  by  recovery. 

Treatment. — This  consists,  first,  in  the  use  of  prompt  lavage  and  imme- 
diate use  of  the  chemical  antidote  to  the  poison  swallowed.  (See  chapter 
on  Treatment  of  Poisons.)  These  should  be  followed  by  the  free  use  of 
diluents  and  demulcents,  of  which  the  various  mucilages  and  milk  are 
examples.     (See  concluding  section  of  book  on  the  Treatment  of  Poisons.) 

Membranous  Gastritis. — This  occurs  secondarily  to  typhus  or  typhoid 
fever,  small-pox,  scarlet  fever,  pneumonia,  and  sometimes  primarily  in 
weak  children.  There  is  no  way  to  recognize  such  condition  during  life. 
True  diphtheria  of  the  stomach  may  occur,  and  according  to  Adami  may 
extend  from  the  fauces  without  attacking  the  esophagus. 

Mycotic  Gastritis  .—It  is  very  doubtful  how  far  fungi  can  cause  inflam- 
mation of  the  stomach.  The  bacteria  which  flourish  in  the  mouth  are 
destroyed  by  the  acid  gastric  juice,  while  the  fungi  that  thrive  in  acid  fluids, 
such  as  the  yeast  fungus,  the  penicUium,  and  the  sarcina,  are  probably 
accidental  results  of  the  retention  of  the  gastric  contents  beyond  the  natural 
time  and  are  not  harmful.  The  possibility  of  their  producing  noxious  results 
cannot,  however,  be  denied.  Ulceration  has  even  been  ascribed  to  them. 
On  the  other  hand,  the  larvae  of  certain  insects  must  also  be  acknowledged  as 
possible  causes  of  inflammation.     True  thrush  has  been  found. 

Syphilis  of  the  stomach  is  rare,  but  has  been  described  by  Oberndorfer 
and  by  Brunner.  It  may  give  rise  to  abnormal  shapes  of  the  stomach  and  to 
perforation. 

Tuberculosis   it   almost   invariably  associated  with  tuberculosis  of  the 

'Prepared  by  precipitating  solution  of  persulphate  of  iron  by  i 


360  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

lungs  in  an  advanced  stage.     The  treatment  of  both  these  local  conditions 
resolves  itself  into  treatment  of  the  infection. 

Hair  balls  may  form  in  the  stomach  by  reason  of  the  patient  swallowing 
her  own  hair  and  that  of  any  other  individual.  The  diagnosis  must  depend 
upon  discovery  of  the  habit  and  removal  of  the  mass  by  surgical  means. 


Gastric  Neurosis. 

Synonym. — Nervous  Dyspepsia;  Gastric  Neurasthenia. 

Frequently  in  nervous  individuals  severe  gastric  symptoms  arise  which 
are  not  due  to  any  organic  condition  of  the  stomach,  but  are  due  wholly  to 
disttu-bance  of  the  nervous  tone  of  the  patient.  These  so-called  gastric 
neuroses  may  be  so  marked  in  their  gastric  aspect  that  the  underlying  nervous 
condition  of  the  patient  is  not  observed.  Or,  it  may  be  the  expression 
of  a  nervous  state  which  itself  is  the  result  of  some  physical  disturbance, 
tuberculosis,  chronic  nephritis,  locomotor  ataxia,  etc.  Therefore,  in  the  diag- 
nosis of  these  conditions  no  examination  of  the  patient  should  be  considered 
complete  which  does  not  include  every  organ  in  the  body. 


HYPERCHLORHYDRIA. 

Synonyms. — Nervous   Hypersecretion   of   Hydrochloric    Acid. 

Definition. — Hyperchlorhydria,  or  hypersecretion  of  hydrochloric  acid 
in  the  gastric  juice,  is  a  symptom  of  different  morbid  conditions  of  the 
stomach,  notably  ulcer  and  nervous  dyspepsia.  In  a  certain  number  of 
cases,  however,  being  the  chief  symptom  and  apparently  independent  of  any 
stimulus  like  the  presence  of  food,  it  may  be  studied  as  an  independent 
neurosis.  In  normal  digestion  the  total  acidity  as  represented  by  free  and 
combined  HCl  may  be  put  down  at  1.5  to  2  parts  per  1000,  requiring  4  to 
6  c.c.  decinormal  solution  for  neutralization,  while  in  hyperchlorhydria  it 
may  reach  3  and  4  parts  in  1000,  requiring  8  to  10  c.c.  decinormal  solution 
to  neutralize. 

Eliminating  the  hyperchlorhydria  of  cholelithiasis,  ulcer  of  the  stomach, 
there  remain  two  varieties : 

1.  Simple  paroxysmal  hyperchlorhydria,  lasting  for  an  hour  or  several 
days. 

2.  Continuous  chronic  hypersecretion,  which  takes  place  spontaneously 
during  fasting,  or,  even  though  excited  by  food  stimulus,  continues  after  the 
latter  has  ceased  to  act.  The  latter  variety  is  also  called  Reichmann's 
disease,  after  him  who  first  described  it. 

Etiology. — Both  forms  of  hyperchlorhydria  are  most  frequent  in  neuras- 
thenics and  emotional  persons,  but  occur  also  in  connection  with  other 
neuropathies,  such  as  migraine,  chlorosis,  and  tabes. 

Symptoms. — In  paroxysmal  hyperchlorhydria  there  are  pain  and  epi- 
gastric discomfort,  eructations,  heartburn,  thirst,  nausea,  and  even  vomiting, 
headache,  most  common  two  or  three  hours  after  eating.  Constipation 
is  the  rule.     The  attacks  may  last  for  an  hour,  or  may  extend  over  several 


E  YPERCHLORH  YDRIA  36 1 

days,  terminating  in  vomiting;  they  may  be  ended  by  remedial  measures, 
such  as  drinking  large  quantities  of  water,  which  dilutes  the  acids,  orb\' 
saturation  with  albuminous  food,  with  which  it  enters  into  combination. 
The  urine,  because  of  much  ingestion  of  albuminous  food,  is  apt  to  be  highly 
charged  with  urea. 

In  the  continuous  form  the  same  symptoms  are  present,  but  without 
intermission.  The  pain  is  even  more  severe,  and  is  epecially  prone  to  come 
on  at  night;  there  is  a  capricious  appetite,  which  is  often  excessive.  Where 
the  appetite  remains,  pain  may  occur  several  hours  after  taking  food.  The 
vomiting  is  often  copious,  gaseous,  may  contain  remnants  of  undigested 
starchy  food,  and  is  of  intensely  acid  reaction.  It  is  likely  to  take  place  sev- 
eral hours  after  a  meal,  also  at  night.  The  urine  is  scanty  ant  there  is  con- 
stipation. The  patients  gradually  emaciate  and  become  anemic,  even  though 
they  may  take  a  good  deal  of  food. 

Diagnosis. — A  positive  diagnosis  of  hyperchlorhydria  can  only  be 
made  through  analysis  of  the  gastric  contents.  This  is  done  in  the  sixth 
hour  after  a  test  dinner,  with  a  view  to  discovering  the  presence  of  an  excess 
of  hydrochloric  acid.  The  same  symptoms  may,  indeed,  be  caused  by 
organic  acids,  while  the  hydrochloric  acid  is  in  normal  amount.  If  the 
stomach  is  washed  out  in  the  evening  and  the  next  morning,  no  food  being 
ingested  in  the  meantime,  the  contents  are  expressed  and  found  to  contain 
an  excess  of  hydrochloric  acid,  the  condition  is  one  of  continuous  hyper- 
chlorhydria. Microscopic  examination  of  the  gastric  contents  may  also 
aid  in  the  diagnosis.  Such  examinations  made  one  to  one  and  a  half  hours 
after  a  test  breakfast  or  three  to  four  hours  after  a  test  dinner,  will  often 
reveal  a  large  number  of  unaltered  starch-corpuscles,  instead  of  only  a  few 
as  in  normal  digestion.  Great  care  must  be  taken  not  to  mistake  gastric 
ulcer  and  gall-stones  for  a  simple  hyperchlorhydria.  The  diagnostic  points 
will  be  considered  under  these  two  conditions. 

Prognosis. — The  prognosis  of  simple  hyperchlorhydria  is  favorable; 
that  of  the  continuous  form  is  grave,  the  disease  being  incurable  after  a 
certain  stage  has  been  reached.  It  becomes,  therefore,  important  to  treat 
the  simple  form  promptly  and  intelligently  before  it  passes  over  into  the 
continuous  form. 

Treatment,  Hygienic. — Many  individuals,  the  subject  of  hyperchlor- 
hydria, pass  their  lives  either  because  of  poverty,  wealth,  overwork  or  idle- 
ness in  an  entirely  artificial  manner.  Mill  workers  should  be  allowed  ample 
time  for  lunch,  which  could  be  economically  supplied  at  a  small  cost  in  or 
about  the  mill  building.  They  should  be  taught  not  to  bolt  their  food,  to 
rest  or  take  rational  enjoyment  in  the  evenings,  not  to  remain  until  midnight 
in  a  crowded  moving  picture  show.  To  sleep  with  an  abundance  of  air  in 
their  rooms,  winter  and  summer.  The  more  wealthy  should  be  warned 
that  dancing  until  early  hours,  wine  drinking,  excitement  of  society  are 
fertile  sources  of  this  condition.     Alcoholism  should  be  avoided. 

Medicinal  measures  have  two  particular  objects:  (i)  To  neutralize  the 
excessive  acid  sceretion,  and  (2)  to  restrain  its  formation. 

The  first  indication  is  met  in  two  ways : 

(a)   By  saturating  the  acid  by  nitrogenous  food. 

(&)  By  the  administration  of  alkalies. 


362  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

(a)  The  former  is  fulfilled  by  the  use  of  meat  and  milk  diet.  It  has, 
however,  its  limits,  because  when  the  tendency  to  acid  secretion  exists,  it  is 
often  maintained  even  after  that  present  is  combined  with  any  albuminous 
food  that  may  be  in  the  stomach.  Hence  it  is  that  the  pain  is  felt  some  hours 
after  a  meal  when  the  albumen  is  digested,  (b)  Since  there  is  a  limitation 
to  the  ingestion  of  meat  its  use  must  be  supplemented  by  antacids,  which 
further  neutralize  the  effect  of  the  acid.  The  alkali  most  frequently 
employed  for  this  purpose  is  sodium  bicarbonate,  though  calcined  mag- 
nesia is  in  some  respects  better  because  of  its  greater  saturating  power. 
The  sodium  bicarbonate  should  be  administered  some  time  after  meals, 
just  before  the  time  the  pains  are  expected.  It  should  be  dissolved  in  water 
or  milk,  or  put  in  capsiiles  or  cachets.  The  doses  should  be  sufficient  to 
counteract  the  acidity — i.  e.,  lo  to  20  grains  (0.66  to  1.3  gm.)  or  more.  The 
quantity  of  carbonic  acid  evolved  sometimes  distends  the  stomach  uncom- 
fortably. Smaller  doses  of  magnesium  oxide  suffice,  and  it  is  surprising 
that  its  use  is  not  more  general.  It  has  the  disadvantage  of  being  insol- 
uble in  water,  but  not  only  are  smaller  doses  sufficient,  but  there  is  also 
absence  of  carbonic  acid  evolution.  It  is  indicated  especially  where  there 
is  constipation. 

Other  alkalies  may  be  used,  such  as  the  potassium  salts.  A  mixture  of 
potassium  or  sodium  bromide  with  Spts.  of  aromatic  ammonia  often  is  of 
the  greatest  value,  and  the  officinal  liquor  potasses  in  5  to  10  drops  (0.2  to 
1.6  c.c.)  in  mUk  may  be  used  with  benefit.  The  benzoate  of  sodium  may  be 
prescribed  in  10  grain  (0.66  gm.)  doses  where  antisepsis  is  required  or  fer- 
mentation is  present.  Lime-water  is  also  useful,  but  large  doses  are  required, 
as  its  neutralizing  power  is  small.  One-half  ounce  to  an  ounce  (15  to  30  c.c.) 
or  more  should  be  given.  Lime  dissolves  more  largely  in  saccharine  solution 
than  in  pure  water,  and  larger  doses  may  thus  be  given  in  smaller  bulk. 
Dilute  alkahne  mineral  waters,  such  as  Vichy,  Vals  or  ContrexvUle,  may  be 
used  during  a  meal.  Lavage  with  nitrate  of  silver  solution  maj-  also  be 
used  as  directed  on  p.  358. 

Of  medicines  other  than  those  intended  to  meet  the  symptoms,  arsenic, 
in  the  shape  of  Fowler's  solution,  is  sometimes  efficient.  Long  courses  of 
it  should  be  practised,  but  large  doses  are  not  often  allowable  because  of 
the  irritation  excited  by  them.  Silver  nitrate  may  also  be  employed  in  doses 
of  1/4  grain  (0.0165  g™-).  in  which  dose  it  is  sometimes  sedative  when 
given  on  an  empty  stomach  or  by  la\'Uge  as  suggested  in  gastritis. 

(2)  Constitutional  treatment  should  be  directed  to  the  cause,  if  it  can  be 
ascertained,  neurosis  by  nervines,  chlorosis  by  iron  and  arsenic.  Of  course, 
it  is  better,  if  possible,  to  prevent  the  excessive  secretion  of  the  juice.  For 
this  purpose  sodium  sulphate  has  been  recommended,  more  particularly  in 
the  shape  of  Carlsbad  water.  Or  the  sodium  sulphate  may  be  dissolved  in 
Vichy,  say  45  to  90  grains  (3  to  6  gm.)  in  a  glass.  It  is  given  in  the  morning 
before  breakfast,  or,  if  necessary,  may  be  given  before  the  other  meals. 

Diet. — While  the  medicinal  treatment  of  hyperchlorhydria  is  in  most 
cases  indispensable,  the  diet  is  equally  important.  It  has  already  been  said 
that  theoretically  a  meat  and  milk  diet  is  indicated,  because  meat  and  milk 
consume  in  their  digestion  the  excess  of  HCl.  On  the  other  hand,  the  starchy 
foods  are  but  imperfectly  digested.     Some  object  to  meat  diet  because  of 


GASTRALGIA  363 

its  overstimulating  effect  on  the  acid  secretion,  and  recommend  vegetables 
instead.  This  is,  however,  fallacious,  and  experience  sustains  the  verdict 
in  favor  of  meat  and  a  minimum  of  starchy  foods.  It  should  be  finely  cut 
and  well  masticated,  while  meat  powder  may  be  substituted.  Milk  should 
be  the  drink,  though  the  alkaline  mineral  waters  may  be  taken  at  meals. 
In  extreme  cases  a  pure  meat  diet,  the  meat  raw  or  nearly  so,  finely  minced 
and  spread  on  bread,  may  be  necessary.  A  meal  may  consist  of  about  3  1/2 
ounces  (100  gm.)  of  raw  meat,  a  couple  of  thin  slices  of  stale  bread  or  zwie- 
back, a  little  butter,  and  a  glass  of  plain  water  or  weak  alkaline  water,  such 
as  Vals  or  Vichy.  Or  an  exclusive  milk  diet  may  be  tried,  in  which  event 
the  milk  should  be  well  alkalized  or  peptonized.  To  these  are  added,  as  the 
case  improves,  raw  meat,  meat  powder  or  meat  juice  and  eggs,  and  later 
still  starchy  foods  may  be  tentatively  given,  associated  with  diastasic  malt. 

In  these  cases  overstimulation  of  the  stomach,  induced  especially  by 
alcohol,  or  by  pepper,  mustard,  and  other  condiments,  should  be  avoided. 
In  like  manner  coarse  food  of  any  land  is  contraindicated.  On  this  account 
constipation  is  sometimes  best  treated  by  enemas,  in  order  to  avoid  the 
administration  of  irritating  medicines  by  the  stomach. 

The  rest  cure  as  originally  suggested  by  S.  Weir  Mitchell  often  is  a  most 
efficient  aid  to  the  successful  treatment  of  hyperchlorhydria. 

It  not  infrequently  happens  that  gastric  analyses  fail  to  find  any  excess 
of  HCl  notwithstanding  other  symptoms  point  to  hyperchlorhydria.  In 
such  an  event  it  may  be  supposed  that  a  previous  condition  of  hyperes- 
thesia of  the  gastric  mucous  membrane  is  present.  The  treatment  would 
be  the  same. 

GASTRALGIA. 

Definition. — A  term  applied  to  recurring  attacks  of  gastric  pain  usually 
some  hours  after  eating,  of  great  severity  without  discoverable  organic  lesion 
or  deranged  funcxion. 

Etiology. — The  disease  is  confined  almost  exclusively  to  women,  but  does 
occur  occasionally  in  stalwart  men.  It  is  more  frequent  in  weak,  anemic 
women,  and  those  subject  to  menstrual  derangement,  in  brunettes  rather  than 
in  blondes.  It  is  especially  frequent  and  severe  about  the  menopause,  but 
does  not  cease  with  it.  When  associated  with  excessive  secretion  of  gastric 
juice,  or  hyperchlorhydria,  gastric  pain  does  not  come  into  the  category  of 
gastralgia.  It  is  usually  independent  of  exciting  cause,  such  as  the  taking 
of  food,  but  it  may  be  induced  by  food. 

Symptoms. — The  attack  may  come  on  suddenly  or  with  gradually 
increasing  severity  first  in  the  neighborhood  of  the  ensiform  cartilage,  whence 
it  radiates  into  the  back  and  around  the  lower  ribs.  It  is  a  boring,  burning 
pain  of  extreme  severity,  sometimes  causing  fainting  and  collapse,  relieved 
by  pressure,  such  as  is  produced  by  boring  the  fist  into  the  epigastrium  or 
pressing  it  against  some  hard  substance.  On  the  other  hand,  it  is  sometimes 
excited  by  pressure.  Its  most  striking  feature,  after  its  agonizing  severity, 
is  its  intermittent,  paroxysmal  character.  The  pain  is  usually  the  sole  symp- 
tom, but  it  may  be  associated  with  nausea  and  vomiting  or  with  nervous 
symptoms,  such  as  globus  hystericus  and  unnatural  hunger.     The  attack. 


364  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

after  a  variable  duration  of  from  a  few  minutes  to  an  hour  or  more,  may 
subside  gradually  or  suddenly  without  other  sj^mptoms,  though  sometimes 
with  vomiting  and  eructations,  at  others  with  the  discharge  of  a  large 
quantity  of  pale  urine.  The  interval  between  the  attacks  varies  greatly. 
It  may  be  a  week  or  it  may  be  months. 

Diagnosis. — Essential  gastralgia  is  to  be  differentiated  from  intercostal 
neuralgia  and  the  so-called  symptomatic  gastralgia  due  to  ulcer,  to  cancer, 
from  the  gastric  crises  of  tabes,  and  from  biliary  and  intestinal  colic; 
also  from  the  pain  of  peritoneal  adhesions  succeeding  operation. 

In  intercostal  neuralgia  the  pain  is  not  so  severe  and  the  paroxysms  are 
of  longer  duration,  while  careful  examination  will  discover  a  tender  spot  in 
an  intercostal  situation  as  compared  wth  an  epigastric.  In  tilcer  of  the 
stomach  there  is  not  that  total  intermission  or  longer  interval  of  total  inter- 
mission characteristic  of  gastralgia,  while  the  general  health  of  the  patient 
with  ulcer  is  commonly  more  seriously  affected.  This  is,  however,  not  al- 
ways so,  as  gastric  tdcer  maybe  associated  with  robustness  of  appearance. 
In  gastric  ulcer  pressure  increases  the  pain,  while  in  gastralgia  it  tends  to 
relieve  it.  Carcinoma,  as  contrasted  with  gastralgia,  always  visibl}''  affects 
the  general  health.  Careful  examination  will  generall}'  discover  a  different 
seat  of  the  pain  in  biliary  colic,  while  the  almost  invariable  presence  of  jaun- 
dice settles  the  question.  In  a  well-established  case  of  tabes  there  need  be 
no  difficulty  in  diagnosis,  but  in  cases  where  the  diagnosis  is  not  well  estab- 
lished there  may  be  much  doubt.  The  history  of  attacks  in  comparatively 
early  life  and  thence  throughout  life  point  to  gastralgia.  Peritoneal  adhesions 
should  always  be  suspected  when  the  pain  succeeds  abdominal  section.  Very 
rarely  the  pain  of  appendicitis  may  resemble  that  of  gastralgia.  The 
greatest  care  must  be  taken  here  as  in  other  gastric  neuroses  that  the  organs 
above  spoken  of  may  not  be  overlooked.  Many  cases  of  hyperacidity  and 
gastralgia  are  in  reality  gastric  ulcer  and  demand  treatment  directed  to  this 
condition. 

Prognosis. — True  gastralgia  never  destroys  life,  but  the  attacks  may 
continue  to  recur  at  intervals  throughout  it. 

Treatment. — The  severest  attacks  of  gastralgia  can  only  be  relieved  by 
the  use  of  morphin,  which  is  best  given  hypodermically  in  the  smallest  doses 
which  will  suffice.  Exceeding  care  must,  however,  be  exercised  to  avoid  a 
morphin  habit.  In  milder  cases  chloroform  may  answer  the  purpose,  or  a 
combination  long  prescribed  in  the  clinics  of  the  University  of  Pennsylvania 
and  desen,'edly  popular  is,  equal  parts  of  chloroform,  compound  tincture  of 
cardamom,  aromatic  spirit  of  ammonia,  and  brandy,  of  which  a  teaspoonful 
may  be  given  every  half  hour  or  15  minutes  until  relief  comes.  If  needed, 
a  few  drops  of  deodorized  tincture  of  opium  may  be  added  to  each  dose  to 
increase  the  anodyne  effect. 

Anemia  should  be  treated  with  iron  and  arsenic,  and  a  change  of  scene 
is  often  beneficial,  while  sea-bathing  is  a  form  of  hygiene  which  is  sometimes 
especially  useful.  The  bowels  should  receive  carefiil  attention.  If  neuras- 
thenia or  hysteria  be  present,  the  rest  cure,  associated  with  massage,  as 
described  under  the  appropriate  section,  is  often  an  efficient  cure.  Gas- 
tralgia may  be  benefited  by  lavage  with  nitrate  of  silver  solution  as  directed 
on  p.  358. 


ANOREXIA  NERVOSA— NERVOUS  VOMITING  365 

ANOREXIA  NERVOSA. 

This  term  is  applied  to  a  condition  in  which  absolute  loss  of  appetite  is 
the  chief  and  characteristic  symptom.  Associated  with  this  are,  natixr- 
ally,  great  debility,  shortness  of  breath,  dizziness,  constipation,  and  some- 
times headache;  rarely,  also,  vomiting;  sooner  or  later,  emaciation.  In 
women,  in  whom  the  symptoms  usually  occur,  there  is  cessation  of  the 
catamenia.     The  name  was  suggested  by  Sir  William  Gull. 

Prognosis. — This  is  favorable,  cases  being  rarely,  if  ever,  fatal. 

Treatment. — The  usual  tonic  measures  are  likely  to  fail  to  excite 
appetite  in  these  cases,  and  nourishment  must  often  be  given  either  by  the 
rectum  or  by  forced  feeding.  The  latter  is  done  as  follows:  A  short  rubber 
tube,  long  enough  to  reach  just  below  the  cricoid  cartilage,  is  introduced  as 
directed  on  page  342.  A  bottle  or  funnel  should  be  attached,  and  from  this 
liquid  nourishment  is  slowly  introduced.  This  may  be  milk,  plain  or  pep- 
tonized, broths  or  eggs.  Estimating  that  3  1/2  ounces  (100  gm.)  of  albumin, 
S  ounces  (150  gm.)  of  fat,  and  10  ounces  (300  gm.)  of  carbohydrates  are  a 
sufficient  amount  per  diem,  Wiessner  recommends  i  quart  (i  liter)  of  milk, 
2  ounces  (60  gm.)  of  butter,  6  eggs,  and  3  1/2  ounces  (100  gm.)  of  sugar  to 
be  mixed  and  warmed  while  stirring.  One-third  of  this  amount  is  intro- 
duced three  times  daily.  The  food  is  usually'  easily  digested,  for  it  is  not 
the  digestion  which  is  at  fault,  but  the  appetite,  and  the  patient,  encouraged 
by  the  result  of  forced  feeding,  is  stimulated  to  eat  for  herself. 

NERVOUS  VOMITING. 

Definition. — A  form  of  vomiting  resulting  from  direct  or  reflex  irritation 
of  the  centers  presiding  over  vomiting,  and  independent  of  anatomical  lesion 
in  the  stomach.  Like  other  gastric  neuroses  it  is  probably  an  expression  of  a 
general  irritable  condition  of  the  gastric  nerves — a  manifestation  of  a  general 
neurasthenia.  It  has  been  suggested  that  the  exciting  cause  is  some  irri- 
tating leukpmain  of  unknown  nature. 

Symptoms. — Especially  characteristic  of  nervous  vomiting  are  the 
absence  of  nausea,  the  suddenness  of  the  act  of  vomiting,  and  the  absence  of 
the  straining.  More  rarely  there  is  nausea.  The  appetite  is  good  and  the 
vomiting  generally  follows  a  meal,  but  it  may  also  occur  at  irregular  intervals. 
In  the  absence  of  organic  nervous  disease  the  patient  may  be  well  nourished. 
There  may  also  be  constipation,  headache,  dizziness,  epigastric  pulsation,  and 
gnawing  sensation  in  the  stomach.  Intense  acidity  of  the  vomited  matter 
may  be  present.  To  this  condition  Rosenbach  has  applied  the  term  nervous 
gastroxynsis.  In  one  of  his  cases  the  HCl  reached  four  per  cent.  In  the 
typical  form,  however,  the  vomitus  is  not  abnormally  acid,  and  in  this 
respect  it  differs  from  acid  dyspepsia  and  Reichmann's  disease.  The  dura- 
tion of  the  vomiting  varies.     It  may  be  a  single  act  or  it  may  last  for  2  4  hours. 

Diagnosis. — This  is  based,  in  the  first  place,  on  the  exclusion  of  those 
organic  diseases  of  the  stomach  which  cause  vomiting,  and,  in  the  second 
place,  on  the  presence  of  any  one  of  the  affections  named  as  possible  causes. 

Prognosis. — Except  when  associated  with  organic  nervous  disease,  this 
is  ultimately  favorable.     George  M.  Garland^  reported  a  fatal  case  of  ap- 

1  Garland,  G.  M.,  "Trans,  of  the  Assoc,  of  Am.  Physicians,"  vol.  iv.,  18S9. 


366  DISEASES  OF    THE  DIGESTIVE  SYSTEM 

parently  pure  nervous  vomiting.  At  autopsy  the  mucous  membrane  of  the 
stomach  was  found  thin,  and  reddened  on  its  inner  surface  with  minute 
hemorrhagic  points.  There  was  slight  interstitial  nephritis  too  insignificant 
to  have  any  effect,  and  the  gastric  changes  were  probably  secondary,  so  that 
the  case  may  be  regarded  as  purely  neiirotic. 

Treatment. — When  vomiting  is  the  result  of  disease  of  the  nervous  sys- 
tem the  fundamental  treatment  must  be  that  of  the  disease  itself.  Tempo- 
rary relief  may  be  afforded  such  cases  by  measures  which  make  a  profound 
nervous  impression.  Such,  pre-eminently,  is  the  blister  to  the  epigastriuni. 
The  suddenness  and  irregularity  of  the  vomiting  make  it  almost  impossible 
to  provide  against  a  given  event.  So  that  ice,  internal  or  external,  sinapisms 
dry  cupping,  and  similar  measures  efficient  in  continuous  vomiting  or  in 
vomiting  preceded  by  nausea  are  scarcely  available.  When,  however,  cir- 
cumstances permit  their  employment,  they  should  be  used. 

Nerve  sedatives,  including  the  bromids  and  valerian,  may  be  used,  but 
hypodermic  injections  of  morphin  are  often  necessary,  and  are  usually  very 
efficient.  Hypodermics  should  be  used  at  the  rarest  instances.  Rectal 
alimentation  should  be  employed  when  the  vomiting  is  obstinate. 

GASTROSUCCORRHEA— REICHMAN . 

HYPERSECRETION. 

A  continuous  or  intermittent  flow  of  gastric  juice  causing  vomiting  and 
pain. 

Symptoms. — Periodical  seizures.  In  the  midst  of  health  the  patient  is 
seized  with  headache,  nausea,  restlessness  and  vomiting  of  large  quantities 
of  gastric  juice.  The  patient  is  ill  for  several  days.  The  clear  fluid  vomited 
is  highly  acid.  The  patient  may  then  be  in  entire  health  for  a  long  period, 
when  he  is  as  suddenly  seized  with  a  second  attack. 

Diagnosis. — Diagnosis  is  made  by  the  periodical  character  of  the  attack, 
and  the  exclusion  of  organic  conditions,  such  as  gastric  ulcer  and  tabes. 

Treatment. — The  patient  must  be  kept  strictly  quiet  and  given  nothing 
to  eat  or  drink  for  24  hours.  Extreme  thirst  may  be  allayed  by  continuous 
enteroclysis  after  Murphy  method;  after  that  food  very  gradually  resumed. 

ACHYLIA  GASTRICA— ANACIDITY. 

This  condition  may  be  a  true  neurosis  with  the  symptom  of  lack  of  nor- 
mal acidity  of  the  gastric  juice,  as  contrasted  with  the  cases  common  in 
cancer  of  the  stomach,  and  other  cases  of  total  absence  of  gastric  juice, 
common  in  atrophy  of  the  mucous  membrane  of  the  stomach. 

Symptoms. — The  symptoms  vary  in  intensity  and  variety.  Some  have 
stomach  symptoms  with  loss  of  appetite,  fullness  and  pain  after  eating, 
headache  and  constipation.  Other  cases  have  no  stomach  sj'mptoms,  but 
intestinal  symptoms,  diarrhea,  alternating  with  constipation,  thirst,  weak- 
ness and  loss  of  strength.     The  course  is  protracted. 

Diagnosis. — The  diagnosis  can  only  be  arrived  at  by  repeated  examina- 
tion of  the  stomach  contents  and  flnding  a  very  small  quantity  of  contents 
with  persistent  lack  of  the  normal  ingredients  of  the  gastric  juice. 


AEROPHAGIA—RUMINA  TION— CARDIOSPASM  367 

It  must  be  separated  from  gastric  cancer,  and  the  achylia  which  accom- 
panies pernicious  anemia. 

Treatment. — Most  cases,  according  to  Einhom,  do  best  with  little  medi- 
cine, electricity  and  bitter  tonics  and  a  diet.  Well-chosen  food  is  a  necessity. 
Vegetable  food  is  well  borne,  meats  should  be  given  in  small  quantities. 

AEROPHAGIA. 

Is  characterized  by  the  eructation  of  large  quantities  of  air.  The  air  is 
usually  swallowed,  or  sucked  in,  as  in  a  horse.  It  is  frequent  in  hysterical 
girls. 

Treatment. — The  treatment  is  that  of  the  hysteria. 

RUMINATION. 

Rumination  is  a  nervous  condition  characterized  by  the  regurgitation  of 
food  and  rechewing  it.     This  is  an  extremely  difficult  condition  to  treat. 

CARDIOSPASM. 

This  is  a  spasm  of  the  cardiac  orifice  of  the  stomach  frequently  followed 
by  dilatation  of  the  esophagus.  Plumner  believes  the  spasm  is  the  primary 
condition.     He  described  three  stages: 

1.  A  spastic  cardia  with  thfe  esophagus  able  to  force  food  through  it. 

2.  Spastic  cardia  with  the  esophagus  unable  to  force  food  through  it, 
and  the  food  is  regurgitated.  Here  the  muscular  tissue  of  the  esophagus 
is  hypertrophied. 

3.  Spasm  of  the  cardia  with  dilatation  of  the  esophagus,  retention  of 
food  in  the  esophagus,  and  regurgitation  at  irregular  intervals. 

Symptoms. — A  sudden  spasm  felt  along  the  line  of  the  esophagus, 
frequently  low  down.  Soon  this  sensation  is  accompanied  by  immediate 
regurgitation  of  food.  In  the  third  stage  there  is  the  knowledge  of  inability 
to  swallow  food.     Liquid  food  may  slowly  pass,  but  solid  food  is  retained. 

Diagnosis. — A  stomach  tube  can  rarely  be  passed  in  these  cases,  but  a 
solid  sound  passes  easily.  When  there  is  dilatation  of  the  esophagus,  food 
may  be  withdrawn  from  the  dilatation.  An  X-ray  taken  after  swallowing 
bismuth  shows  the  bismuth  retained  in  the  esophagus.  Special  sounds 
have  been  devised,  but  the  characteristic  symptoms  with  the  above 
findings,  will  make  the  diagnosis. 

Treatment. — The  relief  of  most  cases,  and  the  entire  cure  of  many  is 
accomplished  by  means  of  a  special  dilating  apparatus,  consisting  of  a 
specially  devised  oblong  rubber  balloon,  connected  with  a  long  rubber  tube, 
in  turn  connected  with  a  water  tap  or  pump,  a  water  gauge  is  attached  to 
regulate  the  pressure.  The  pressure  in  the  tubing  is  very  slowly  raised. 
The  pain  expressed  by  the  patient  is  usually  used  as  a  guide,  but  the  pressure 
must  paralyze  the  sphincter.  If  this  cannot  be  done  by  this  instrument, 
graded  sizes  of  dilators  are  used  until  the  object  is  attained. 

Plummer  reports  40  cases.  The  number  of  treatments  varied  from  two 
to  ten.     There  were  eleven  relapses,  but  no  second  recurrences. 

The  general  strength  of  the  patient  must  be  attended  to,  but  usually  the 
patient  rapidly  improves  with  the  ability  to  swallow. 


368  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

PYLOROSPASM. 

A  contraction  of  the  pylorus,  without  organic  lesion.  This  condition 
is  common  in  hyperchlorhydria  of  ulcer.  There  is  pain,  and  the  gastric 
peristalsis  can  frequently  be  seen. 

It  is  difficult  to  differentiate  from  organic  stenosis  of  the  pylorus.  One 
case  under  our  care,  the  pylorus  could  be  felt  to  thicken  and  become  palpable 
under  the  fingers.     This  proved  to  be  due  to  a  gastric  ulcer. 

GASTRIC  AND  DUODENAL  ULCERS. 

Synonyms. — Ulcus  ventriculi  pepticum;  Peptic  Ulcer;  Simple 
or  Round  Ulcer. 

Definition. — A  loss  of  substance  in  the  mucous  membrane  of  the  stomach, 
of  more  or  less  progressive  character,  and  frequently  extending  through  the 
entire  thickness  of  the  stomach  wall.  As  there  is  no  practical  difference  in 
the  clinical  course  and  treatment  of  gastric  and  duodenal  tilcers,  these 
conditions  are  consided  together.  Three-fifths  of  all  gastric  and  duodenal 
ulcers  are  situated  in  the  duodemun. 

Etiology. — There  is  probably  more  than  one  mode  of  origin  of  gastric 
ulcer.  It  may  have  its  origin  in  mechanical  injury  associated  with  feeble 
nutrition,  which  permits  the  gastric  juice  to  digest  out  the  mucous  mem- 
brane to  various  depths,  resulting  in  the  formation  of  an  ulcer.  Such 
mechanical  injury  may  be  either  internal  or  external.  Intestinal  injuries 
are  due  to  corrosive  substances,  hot  foods  and  hard  articles  of  food.  External 
injuries  maybe  due  to  trauma,  a  blow,  or  to  the  pressure  exerted  in  the  course 
of  one's  occupation,  such  as  shoemaking,  washing,  tailoring,  and  the  like,  in 
which  pursuits  the  costal  cartilages  are  pressed  against  the  stomach. 
Anemia,  chlorosis,  heart  disease,  Bright's  disease,  and  the  like  are  frequent 
precursors  of  the  condition.  Overdistention  of  the  stomach,  it  is  claimed,  may 
be  a  predisposing  cause  by  interfering  with  its  proper  nutrition  and  thus 
favoring  the  action  of  the  gastric  juice. 

Thrombosis  and  embolism  have  been  held  responsible  for  a  certain  mun- 
ber  of  cases  of  ulcer  since  Virchow  called  attention  to  such  causes.  The 
stasis  of  circvdation  thus  resulting  affords  favorable  foci  for  the  solvent 
action  of  the  gastric  juice,  and  certainly  no  theory  explains  so  satisfac- 
torily the  crater  shape  of  many  gastric  ulcers.  Bottcher  ascribed  ulcer 
of  the  stomach  to  micrococci,  numbers  of  which  have  been  found  by  him  in 
the  margins  of  gastric  ulcers.  The  well-known  clinical  fact  that  the  gastric 
juice  in  ulcer  of  the  stomach  exhibits  sometimes  intense  acidity,  while  trau- 
matic ulcers  of  the  stomach  produced  under  ordinary  circumstances  tend 
to  heal  promptly  has  led  to  the  suggestion  that  tmdue  acidity  plays  an  impor- 
tant role  in  the  causation  of  ulcer.  Increased  acidity  is  not,  however, 
always  associated  wath  these  conditions.  Mayo  believes  the  three  great 
etiological  factors  are:  Excess  of  hydrochloric  acid,  traumatism  inflicted  in 
the  grinding  of  the  pyloric  end  of  the  stomach  and  the  upper  part  of  the 
duodenum.     A  third  essential  factor  of  general  character  is  anemia. 

The  statements  of  authors  as  to  the  frequency  of  ulcer  of  the  stomach 
\'ary  greatly.     Thus,  Ewald  says  five  per  cent,  of  Germans  have  ulcer. 


GASTRIC  AND  DUO  DENAL  ULCERS  369 

Truly,  the  disease  is  not  nearly  so  common  in  America.  Yet  the  discovery 
at  autopsies  of  unexpected  ulceration  goes  to  show  that  it  may  be  more 
frequent  than  is  supposed.  Fiedler  found  ulcer  or  its  scar  in  20  per  cent,  of 
autopsies  in  women  and  1.5  per  cent,  in  men.  It  is  evident,  therefore,  that 
women  are  much  more  frequent  victims  than  men.  While  both  the  very 
young  and  the  very  old  are  commonly  exempt,  the  period  being  between  1 7 
and  25,  gastric  ulcer  has  been  found  in  infants  and  in  adults  as  old  as  60. 
In  women  gastric  ulcer  usually  occurs  between  the  ages  of  20  and  30 ;  in  men, 
between  30  and  40. 

Duodenal  ulcer,  on  the  other  hand,  is  more  common  in  males,  in  the 
proportion  of  178  to  41,  in  the  combined  statistics  of  Kraus,  Chvostek, 
Lebert,  Trier,  and  William  Osier.  The  last-named  observer  found  it  once 
in  a  boy  of  1 2 .  In  Mayo's  series  of  200  cases  7  7  were  male,  23  female — while 
in  true  gastric  ulcer  there  were  52  men  and  48  women. 

Morbid  Anatomy. — Gastric  ulcer  must  be  distinguished  from  post- 
mortem softening  or  digestion,  which  is  found  after  death  in  stomachs  in 
which  gastric  juice  happens  to  be  present  at  the  moment  of  death.  In  this 
there  may  be  erosion  of  the  superficial  mucosa,  but  nothing  comparable  to 
ulcer.  The  seat  of  postmortem  softening  is  more  commonlj^  the  fundus  and 
posterior  surface,  where  the  gastric  juice  naturally  collects. 

The  typical  gastric  ulcer  is  circular  in  outline,  often  with  sloping,  clean- 
cut  sides,  furnishing  a  crater  or  truncated  cone  shape,  with  the  broad  end 
looking  toward  the  cavity  of  the  stomach,  a  shape  corresponding  to  that 
of  an  infarcted  area  due  to  embolism  or  thrombosis.  The  term  "punched 
out"  has  long  been  applied  to  characterize  the  appearance  of  a  gastric  tdcer. 
The  sides  are  not  always,  however,  smooth,  being  sometimes  imeven  or 
"terraced."  Very  rarely  ulcer  maybe  multiple.  It  is  far  more  frequent, 
on  the  posterior  wall  of  the  stomach  near  the  lesser  curvature.  W.  H. 
Welch's  extensive  studies  of  hospital  records  furnish  the  total  of  783  cases, 
of  which  288  or  37  per  cent,  were  in  the  lesser  curvature,  225  or  29  per  cent, 
on  the  posterior  wall,  95  or  12  per  cent,  at  the  pylorus,  69  or  9  per  cent,  on 
the  anterior  wall,  50  or  6.75  per  cent,  at  the  cardia,  29  or  4  per  cent,  at  the 
fundus,  and  27  in  the  greater  curvature.  In  Mayo's  experience  90  per  cent, 
of  all  tilcers  which  exist  in  the  stomach  proper  are  in  the  pyloric  end  and  at 
least  one-half  of  gastric  and  duodenal  ulcers  are  in  the  upper  duodeniim. 

The  floor  of  the  ulcer  is  usually  the  muscular  coat,  but  it  may  be  the 
serous  coat,  which  is  sometimes  perforated  so  that  the  floor  may  be  formed 
by  an  adjacent  organ  to  which  the  stomach  has  been  glued  by  adhesive  in- 
flammation. The  ulcer  is  usually  small,  not  larger  than  a  pea,  but  it  may  be 
10  or  even  15  cm.  (4  to  6  inches)  in  diameter,  covering  the  whole  lesser  curva- 
ture and  part  of  the  anterior  and  posterior  walls.  Ulcers  may  heal,  leaving 
a  cicatrix,  which,  if  large,  causes  contraction  and  deformity,  distorting  the 
organ  even  to  an  hour-glass  shape  and  producing  stenosis  of  the  pylorus.  It 
is  not  unusual  to  find  healed  ulcers  at  autopsies.  Or  the  ulcer  may  perforate, 
causing  fatal  peritonitis  when  in  the  anterior  wall;  or,  if  apposed  to  neighbor- 
ing organs,  it  may  cause  a  local  peritonitis  which  results  in  adhesion  of  the 
various  parts,  sometimes  perforating  into  the  lesser  peritoneal  cavity 
resulting  as  an  abscess  which  may  rupture  into  any  of  the  neighboring  organs. 
The  pericardium,  the  mediastinum  and  left  ventricle,  the  spleen,  the  head  of 


370  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

the  pancreas,  the  left  lobe  of  the  liver,  the  gall-bladder,  the  omental  tissues, 
the  pleura,  and  even  the  lungs  have  been  invaded,  while  fistulous  com- 
munications have  been  formed  with  the  duodenum,  the  colon,  and  even  the 
external  air  in  the  neighborhood  of  the  umbilicus. 

It  is  not  unusual  to  see  at  the  bottom  of  an  ulcer  an  eroded  blood-vessel 
from  which  there  has  been  a  fatal  hemorrhage.  The  vessels  invaded  may 
be  the  gastric  artery  of  the  lesser  curvature,  or  the  splenic  artery  in  the  pos- 
terior wall;  or,  in  the  case  of  a  duodenal  ulcer,  the  pancreatico-duodenal 
artery;  or  it  may  be  the  hepatic  artery,  and  even  the  portal  vein.  Small 
aneurysms  have  been  found  in  the  floor  of  an  ulcer. 

Gastric  ulcer  may  be  multiple,  it  is  said,  as  often  as  once  in  every  five 
cases.  Osier  records  a  case  in  which  there  were  five  ulcers  and  refers  to  a 
case,  reported  by  Berthold,  in  which  there  were  34. 

Symptoms. — Chronicity  and  periodicity  of  the  attacks  are  quite  char- 
acteristic. There  is  usually  a  history  of  months  or  years  of  periods  of 
"stomach  trouble."  The  attacks  of  characteristic  pain  and  distress  come 
on  suddenly,  last  for  several  days  or  months  then  a  sudden  disappearance 
of  the  pain  and  apparently  perfect  health  for  varying  periods  of  time. 
The  milder,  less  distinctive  symptoms  of  indigestion,  viz.,  a  sense  of  fullness 
in  the  epigastrium,  acid  eructations,  loss  of  appetite  and  the  like  may  be 
present  in  gastric  ulcer  but  the  most  prominent  symptoms  are  pain,  tender- 
ness, vomiting,  hemorrhage,  and  sometimes  a  tumor,  but  none  of  these  is 
invariably  present. 

Pain,  with  tenderness,  is  the  most  constant  symptom.  According  to 
Mayo,  if  the  ulcer  is  in  the  stomach  proper  the  pain  is  usually  most  acute 
from  the  median  line  to  the  left.  If  the  ulcer  is  in  the  duodenum  proper,  the 
pain  and  tenderness  come  on  several  hours  after  meals  and  extend  from  the 
midline  to  the  right.  According  to  Graham,  in  Mayo's  clinic,  taking  of  food 
does  not  give  immediate  pain  in  any  form  of  peptic  ulcer  but  relieves  it.  The 
longer  pain  is  relieved  by  food  the  farther  down  the  ulcer  is  found.  The  pain 
comes  on  in  definite  periods  of  attacks  two  to  four  hours  after  meals. 

The  patient  will  sometimes  bend  over,  pressing  his  fist  into  the  epigas- 
trium or  lean  over  the  back  of  a  chair  to  secure  relief.  It  may  be  excited  by 
spasm  or  by  overdistention  by  gas. 

Tenderness  on  pressure  is  a  characteristic  symptom,  apart  from  the  par- 
oxysms of  pain;  and  in  order  to  guard  against  it,  the  patient  may  wear  the 
waistband  low.  Boas  has  devised  an  instrument  bj'  which  circumscribed 
pressure  may  be  conveniently  induced  and  diagnosis  facilitated.  The 
tendon  point  is  more  frequently  an  inch  or  two  above  the  umbilicus.  In  cases 
of  ulcer  of  long  standing  palpation  may  recognize  a  tumor,  the  result  of 
inflammatory  thickening  in  the  \'icinity. 

Vomiting  is  not  so  frequent  a  symptom.  When  present,  it  occurs 
usuall}',  about  the  same  time  as  the  pain. 

Hemorrhage — from  the  stomach  or  intestines — is  a  most  valuable  sign  of 
gastric  tdcer  when  it  is  accompanied  or  preceded  by  symptoms  of  gastric 
distress.  Given  a  copious  hemorrhage  of  pure  red  blood  from  the  stomach, 
with  the  symptoms  described,  it  can  scarcely  be  due  to  any  other  cause. 
A  single  large  hemorrhage  may  occur  from  other  causes.  In  a  few  instances 
in  iilcer  the  hemorrhage  is  small,  when,  of  course,  the  diagnosis  becomes  more 


GASTRIC  AND  DUODENAL  ULCERS  371 

difficult.  When  the  hemorrhage  is  large,  blood  quite  black  is  found  also  in 
the  stools.  Indeed,  sometimes  the  presence  of  blood  in  the  stools  is  the 
first  intimation  of  gastric  hemorrhage.  Especially  is  this  the  case  when  the 
ulcer  is  duodenal.  Hemorrhages  from  ulcer  are  also  often  recurrent,  and 
result  at  times  in  intense  anemia  of  the  subject.  They  are  not  rarely  fatal, 
more  frequently  syncopal,  bringing  their  subjects  to  the  verge  of  the  grave, 
from  which  there  are  often  also  surprising  recoveries.  A  hematemesis  of 
ten  pounds  (4  1/2  kilos)  is  said  to  have  been  followed  by  recovery.  Occult 
blood  in  the  stools  is  a  valuable  sign  to  be  sought  for  by  the  various  chemical 
tests,  but  it  must  be  remembered  that  there  are  many  other  sources  of  such 
hemorrhage  than  an  ulcer  in  the  stomach.  Hemorrhoids,  traumatism  and 
ulceration  of  any  portion  of  the  gastrointestinal  tract  must  be  remembered. 

Perforation  is  a  rare  accident  in  ulcer  of  the  stomach.  It  is  variously 
stated  at  from  6  to  18  per  cent,  of  all  cases.  Its  characteristic  symptoms 
are  sudden  and  violent  pain,  extreme  tenderness,  rigid  contraction  of  the 
abdominal  muscles,  profound  shock,  shallow  breathing,  and  absence  of  the 
normal  hepatic  dullness — in  a  word,  the  symptoms  of  peritonitis,  followed 
by  those  of  shock.  Perforation  is  much  more  frequent  when  the  ulcer  is  in 
the  anterior  wall.  Thus,  in  13  cases  reported  by  A.  B.  Mitchell  to  the 
"British  Medical  Journal,"  March  10,  1890,  all  were  in  the  anterior  wall. 

Persons  with  gastric  ulcer  lose  in  weight  and  become  gradually  anemic, 
quite  independent  of  hemorrhage,  as  is  evidenced  by  a  blood  count.  This 
may  be  due  to  the  fact  that  they  refrain  from  taking  food  because  they  fear 
its  consequences.  From  the  combined  effect  of  this  and  actual  loss  of  blood 
results  at  times  an  anemia  which  is  only  second  to  that  of  pernicious  anemia. 
The  hemoglobin  is  correspondingly  reduced. 

Chemical  examination  of  the  stomach-contents  after  a  test-meal  frequentl}^ 
shows  an  increase  of  HCl,  in  fact  the  symptoms  are,  at  least  in  part,  those  of 
hyperchlorhydria,  in  some  part  of  the  course  in  almost  every  case  of  gastric 
ulcers.  Mayo  clinic  statistics  are  valuable  in  showing  the  condition  of 
the  stomach  contents  in  cases  which  came  to  operation,  250  cases  of  gastric 
and  duodenal  ulcers.  Free  hydrochloric  acid  present  237  times.  Below 
normal,  23  cases;  normal  102  cases,  above  normal  in  112  cases.  Exception- 
ally hyperacidity  is  absent,  possibly  due  to  associated  chronic,  gastric 
catarrh. 

Finally,  it  is  to  be  remembered  of  gastric  ulcer  that  it  is  often  latent 
throughout,  quite  without  symptoms  dturing  life,  and  recognized  for  the  first 
time  at  necropsy,  when,  also,  as  already  stated,  healed  ulcers  are  sometimes 
found,  or  the  first  intimation  of  an  ulcer  may  be  a  perforation. 

Course  and  Termination. — The  course  of  ulcer  is  usually  slow,  sometimes 
very  protracted.  A  few  cases  are  acute  and  rapidly  fatal.  The  symptoms 
of  gastric  ulcer  quite  frequently  disappear,  and  after  a  time,  even  consider- 
able time,  recur  giving  rise  to  the  so-called  recurrence.  This  very  reourrence 
as  stated  above  is  one  of  the  characteristics  of  the  disease. 

Hour-glass  contraction  is  one  of  the  terminations  of  gastric  ulcer  when 
a  large  ulcer  in  the  middle  belt  of  the  stomach  has  healed.  It  is  best 
recognized  by  the  Roentgen  ray,  the  stomach  being  previously  partially 
filled  with  a  mixture  of  bismuth  and  water  introduced  after  a  meal.  But 
its  existence  may  be  suspected  in  the  presence  of  the  following  signs  named 


372  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

by  Moynihan:  i.  In  washing  out  the  stomach  a  part  of  the  fluid  may  be 
lost.  2.  If  the  stomach  is  washed  clean  a  sudden  reappearance  of  gastric 
contents  may  take  place.  3.  When  the  stomach  has  apparently  been  emp- 
tied a  splashing  sound  may  be  elicited  by  palpation  of  the  pyloric  end 
(paradoxical  dilatation).  4.  After  distending  the  stomach  a  change  in  the 
situation  of  the  distention  tumor  may  be  seen.  5.  A  gushing,  bubbling  or 
sizzling  sound  heard  on  dilatations  by  CO2  may  be  heard  at  a  point  distant 
from  the  pylons.  6.  In  some  cases  when  both  parts  are  dilated,  two  tumors 
separated  by  a  notch  or  sulcus  may  be  seen  and  felt. 

Diagnosis. — Is  frequently  difficult.  Given  the  characteristic  symptoms 
of  paroxysms  of  pain,  relieved  by  eating  and  occurring  several  hoiu-s  after 
food,  and  these  symptoms  coming  on  in  periods  after  intervals  of  good 
health,  particularly  in  the  fall  and  spring,  the  diagnosis  is  extremely  likely. 
Moynihan  says  the  anamnesis  is  everything  in  making  a  diagnosis.  This 
chronicity  and  periodicity  is  almost  characteristic  when  the  pain  comes  long 
after  eating  and  is  relieved  by  food. 

Gall-stone  colic  and  appendicitis  may  both  give  rise  to  a  chronic  periodical 
pain  accompanied  or  preceded  by  the  symptoms  of  indigestion  accompanying 
gastric  ulcer.  Hyperacidity  and  pylorospasm  may  also  closely  resemble  the 
attacks  of  gastric  ulcer,  but  in  all  these  conditions,  there  is  lacking  the 
machine-like  periodicity,  the  occurrence  in  spells  and  the  complete  relief  by 
food.  It  is  true  the  distinction  becomes  less  marked  as  the  ulcer  approaches 
the  cardia  in  position. 

In  gastralgia,  as  in  ulcer,  hydrochloric  acid  may  be  increased,  and  the 
question  often  becomes  a  most  difficult  one  to  settle.  In  gastralgia,  how- 
ever, the  general  health  of  the  patient  is  less  severely  affected,  there  is  less 
chlorosis  or  menstrual  derangement,  and  the  pain  has  a  less  definite  relation 
to  taking  food — while  in  ulcer  the  symptoms  of  dyspepsia  are  more  constant. 
Above  all,  in  ulcer  there  is  tenderness  on  pressure  between  the  attacks  of 
pain,  a  symptom  absent  from  gastralgia,  while  pressure  always  relieves  the 
pain  of  the  latter.  Indeed,  in  gastralgia  dyspeptic  symptoms  between  the 
attacks  are  generally  absent.  We  may  look  for  assistance  from  the  stand- 
point of  etiology.  Given  the  causes  of  ulcer,  especially  valvular  heart 
disease  with  possible  embolism,  the  vomiting  which  produces  thrombosis, 
the  occupations  which  favor  gastric  ulcer,  their  import  shoiold  be  recognized. 
Gastralgia  occtirs  in  neurotic  individuals — those  subject  to  hysteria  and 
uterine  disease. 

In  tabes  the  gastric  crises  arc  almost  identical  with  the  severe  gastralgic 
attacks  of  tilcer.  But  in  tabes  the  appearance  of  gold  health  is  preserved, 
while  it  is  not  long  before  the  distinctive  symptoms  of  the  disease  show 
themselves,  if  they  are  not  already  present — viz.,  lightning  pains,  ocvdar 
symptoms,  and  absence  of  knee-jerks. 

In  rare  cases  intercostal  neuritis  may  be  mistaken  for  vdcer,  if  there  be 
pain  in  the  epigastriimi  associated  with  accidental  dyspeptic  symptoms. 
But  in  this  affection  painful  points  wHl  also  be  found  in  the  course  of  the 
affected  nerve. 

From  cancer  of  the  stomach  ulcer  sometimes  is  distinguished  with  diffi- 
culty in  the  absence  of  the  more  distinctive  symptoms  of  the  former  disease. 
Heretofore  much  reliance  has  been  placed  on  the  absence  or  extreme  di- 


GASTRIC  AND  DUODENAL  ULCERS  373 

minution  of  free  hydrochloric  acid  in  cancer  as  contrasted  with  its  excess  in 
ulcer.  It  has,  however,  happened  that  the  association  of  chronic  catarrhal 
gastritis  with  ulcer  has  caused  a  relative  diminution  of  HCl.  The  researches 
of  Boas  have  added  a  very  much  more  reliable  diagnostic  sign  in  the  presence 
of  lactic  acid  in  cancer  and  its  constant  absence  in  ulcer.  Other  facts  to  be 
weighed  in  the  balance  as  to  the  existence  of  cancer  are  a  palpable  tumor, 
the  greater  age  of  the  patient,  with  rare  exceptions  over  30,  the  extreme 
emaciation  and  cachectic  appearance,  and  the  intermittent  vomiting  of  large 
quantities  of  accumulated  ingesta,  sometimes  of  blood  mixed  with  mucus, 
or  blood  presenting  the  "coffee-grounds"  character  as  contrasted  with  the 
bright  clear  blood  of  ulcer.  The  presence  of  Oppler  Boas  bacillus  in  the  gas- 
tric contents. 

The  prognosis  depends  largely  upon  the  type  of  ulcer  and  the  treatment. 
Acute  ulcers,  those  giving  symptoms  in  the  very  beginning  of  the  lesion  are 
amenable  to  the  medical  treatment  described  below.  Latent  ulcers  maj- 
end  in  perforation  without  premonitory  symptoms.  Chronic  ulcers  rarely 
end  in  complete  recovery  without  surgical  interference,  though  long  periods 
of  absence  of  symptoms  occur.  Perforation  is  almost  universally  fatal 
without  operation.  Hemorrhage  is  a  bad  prognostic  sign  unless  the  case 
be  treated  surgically  after  recovery  from  the  hemorrhage. 

Prophylaxis. — Anemias  should  be  corrected.  All  cases  of  chronic 
nephritis  should  be  properly  treated.  Patients,  especially  young  female 
mill  workers,  should  be  taught  the  gospel  of  proper  hygiene,  regular  meals, 
proper  food,  fresh  air,  rest  and  exercise. 

Irritating  food  should  be  avoided  that  the  mass  which  grinds  the  pylorus 
may  be  as  little  irritating  as  possible. 

Treatment. — The  treatment  of  ulcer  of  the  stomach  or  duodenum  resolves 
itself  into  medical  and  surgical  methods.  The  last  word  has  not  been  said 
as  to  which  cases  must  be  operated.  It  is  certain  that  many  ulcers  heal 
either  spontaneously  or  as  the  result  of  treatment.  The  following  advice, 
however,  seems  correct.  Cases  to  be  treated  medically  are  the  acute  ones. 
When  a  case  presents  itself  with  acute  symptoms,  pain  relieved  by  eating, 
tenderness,  vomiting  with  stomach  contents  suggesting  the  condition,  the 
first  indication  is  rest.  Rest  both  for  the  stomach  itself  and  for  the  entire 
organism.  The  patient  should  be  still  in  bed,  take  no  food  for  eight  to  ten 
days,  be  given  rectal  enemata  of  eight  ounces  of  peptonized  milk  everj^ 
eight  hours.  While  fasting  they  may  have  a  small  amount  of  water,  and 
should  be  given  bismuth  subcarbonate  or  subnitrate  in  i  gram  (15  grain) 
doses  every  four  hours.  After  eight  or  ten  days  food  may  be  resumed;  first 
one-ounce  doses  of  milk,  either  peptonized  or  with  lime  water,  and  gradually 
increased  lontil  on  the  third  day  of  food  taking  they  get  three  or  four  ounces 
every  three  hours;  then  soft  toast,  potatoes,  chicken,  etc.,  may  be  slowl3' 
added.     All  the  time  bismuth  may  be  taken. 

Some  cases  do  well  with  lavage  of  nitrate  of  silver  i  to  1000  during  the 
entire  time.  Some  do  not  insist  upon  total  fasting  but  give  small  amounts 
of  milk  during  the  entire  time.  Cases  thus  treated  usually  speedily  lose  all 
their  symptoms,  they  either  remain  permanently  well  or  relapse.  Once  a 
diagnosis  of  gastric  ulcer  is  made  a  patient  should  be  given  this  form  of 
treatment  or  some  modification  of  it  or  the  Lenhartz  treatment  detailed 


374  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

below.  If  the  case  relapses  in  a  short  or  long  time  a  retrial  of  the  treatment 
should  be  given,  but  in  our  opinion  the  case  should  be  turned  over  to  the 
surgeon  if  more  than  one  relapse  occurs. 

Surgical  treatment  is  demanded  in  all  relapsing  cases,  in  all  cases  of  a 
chronic  course  whether  relapsing  or  not.  Leaving  out  of  consideration  the 
complications,  the  well-proven  fact  that  50  per  cent,  of  carcinomata  of  the 
stomach  have  their  origin  in  an  ulcer  whose  base  gives  ample  justification 
for  the  employment  of.  a  skillftil  stu-geon  when  a  simple  clironic  ulcer  is  con- 
sidered. All  cases  which  have  had  one  or  more  hemorrhages  should  be 
operated  after  recovery  from  the  hemorrhage,  it  being  remembered  that 
certain  cases  in  young  girls  have  bleeding  from  points  in  the  mucous  mem- 
brane which  cannot  be  discovered. 

All  cases  of  obstruction  of  the  pylorus,  hour-glass  stomach,  demand 
operation.  All  chronic  and  acute  perforations  must  be  operated  on  at  the 
earliest  possible  moment. 

Care  must  be  taken  that  a  surgeon  of  skill  and  experience  be  employed. 

According  to  the  Mayo  clinics,  decided  food  remnants  in  the  stomach 
contents  of  ulcer  cases,  demand  operation.  In  the  Mayo  clinic  a  full 
meal  is  given  the  night  before,  the  contents  are  withdrawn.  In  the  morning 
an  Ewald  test  meal  is  given. 

During  hemorrhage  rectal  alimentation  should  be  relied  upon.  For 
this  purpose  peptonized  milk  is  also  the  best  nutrient.  Great  care  should 
be  exercised  in  the  use  of  enemas  not  to  exhaust  the  toleration  of  the 
bowel.  To  this  end  they  should  be  given  at  first  tentatively,  never  oftener 
than  once  in  eight  hours,  and  should  not  exceed  at  first  at  most,  six  ounces. 
This  quantity  if  well  borne  may  be  increased  to  eight  ounces.  The  various 
meat  peptones,  bouillon  or  beef  juice  may  be  substituted  for  or  alternated 
with  peptonized  milk;  or  an  egg  may  be  beaten  up  with  milk,  though  such 
addition  is  not  often  necessary. "  A  nutrient  injection  which  has  given  great 
satisfaction  at  the  Hospital  of  the  University  of  Pennsylvania  consists  of 
four  ounces  of  milk  (130  c.c),  to  which  are  added  two  eggs,  a  pinch  of  salt 
and  3  drops  of  laudanum,  the  whole  being  predigested  with  pancreatin. 
The  enema  should  be  given  very  slowly  through  a  long  rectal  tube,  the  patient 
having  the  hips  elevated  and  the  position  maintained  for  an  hour  after  the 
injection.  In  this  way  patients  may  be  nourished  for  weeks  with  peptonized 
food,  but  it  is  rarely  necessary  to  continue  the  rectal  alimentation  for  more 
than  a  week  or  ten  days.  As  the  hemorrhage  and  vomiting  cease  the  stom- 
ach may  be  tested,  first  with  small  amounts  of  milk  or  albumen  water, 
gradually  increased;  and  for  a  time  the  two  methods  may  be  pursued 
jointly,  feeding  by  the  mouth  being  increased,  while  that  by  the  rectum  is 
gradually  withdrawn.  Plain  milk  and  beef-juice  may  be  substituted  for 
peptonized  milk,  and  various  thin  gruels  made  with  flour  may  be  used  as  a 
change  is  demanded. 

The  hemorrhage  requires  also  to  be  met  by  remedies.  For  the  present 
all  astringent  remedies  have  given  place  to  suprarenal  extract  or  its  active 
principle  adrenalin,  of  which  one  dram  (5  c.c.)  may  be  given  at  one  dose  by 
the  mouth.  It  has  no  effect  on  the  blood  pressure  unless  it  is  injected  into 
the  blood  thus  large  doses  may  be  used. 

The  Lenhartz   Treatment  of  Gastric   Ulcer. — This  treatment,   to  which 


GASTRIC  AND  DUODENAL  ULCERS 


375 


especial  attention  has  been  called  in  this  country  by  Samuel  W.  Lambert,' 
has  for  its  object  first  to  furnish  nourishment  and  improve  the  patients' 
general  condition;  to  continue  to  nourish  them  by  feeding  by  the  stomach; 
to  use  foods  rich  in  albumen,  in  small  amounts  at  short  intervals,  of  one  hour 
for  the  first  ten  days  from  7  a.  m.  to  9  p.  m.,  and  insisting  on  slow  eating, 
best  accomplished  by  feeding  in  teaspoonful  amounts ;  to  insist  on  a  three  or 
four  weeks'  rest  cure  in  bed.  Other  medical  procedures  are  allowed  if 
indicated;  for  example,  an  ice-bag  to  the  epigastrium  and  bismuth  subnitrate 
internally  for  hemorrhage;  enteroclysis  for  the  effects  of  hemorrhage,  and 
iron  and  arsenic  for  the  anemia.  The  course  of  treatment  covers  two  weeks' 
time  and  includes  the  following  articles  of  diet :  fresh  milk,  iced ;  whole  raw 
egg  beaten  up  and  iced.  Both  the  milk  and  the  egg  are  prepared  in  a 
covered  glass  surrounded  with  cracked  ice;  the  feeding  spoon  is  also  kept 
iced.  Changes  suggested  by  Lambert  are  mixing  of  the  eggs  and  milk  and 
feeding  the  mixtures  instead  of  hourly  alteration ;  the  addition  of  granulated 
sugar  after  the  third  day. 

The  following  table  from  Lenhartz,  modified  by  Lambert,   gives  the 
details  and  the  method  of  feeding : 

LENHARTZ  TREATMENT  OP  GASTRIC  ULCER. 


Day 


Eggs 


Milk 


Sugar 


Scraped  beef 


2  drams  each  dose, 
total,  2  eggs. 

3  drams  per  dose, 
total,  3  eggs. 

5  oz.  per  dose, 
total,  4  eggs. 

5  drams  per  dose, 

total,  5  eggs. 

6  drams  per  dose, 

total,  6  eggs. 

7  drams  per  dose, 
total,  7  eggs. 

4  drams  per  dose, 

total,  4  eggs, 
also,  I  soft  boiled 
egg  every  4  hours, 

total,  4  eggs. 
4  drams  per  dose, 

total,  4  eggs, 
also,  I  soft  boiled 
egg  every  4  hours, 

total,  4  eggs. 
4  drams  per  dose, 

total,  4  eggs, 
also,  I  soft  boiled 
egg  every  4  hours, 

total,  4  eggs. 
4  drams  per  dose, 

total,  4  eggs, 
also,  I  soft  boiled 
egg  every  4  hours, 

total,  4  eggs. 


4  drams  each  dose, 

total,  6  ounces. 
6  drams  per  dose, 

total,  10  ounces. 

I  ounce  per  dose, 

total  13  ounces. 
I J  ounces  per  dose, 

total  I  pint. 
14  drams  per  dose, 

total  19  ounces. 
2  ounces  per  dose, 

total,  22  ounces. 
2  ounces  per  dose, 

total,  25  ounces. 


2|  ounces  per  dose, 
total  28  ounces. 


3  ounces  per  dose, 
total  I  quart. 


Add  cooked 
chopped  chicken 

50  grams,  also 
butter  20  grams. 


20  grams  added 

to  eggs. 
20  grams  added 

^to  eggs. 

30  grams. 

40  grams. 
40  grams. 


40  grams. 


40  grams. 


■  36  grams  m  3 

doses. 
70  grams  with 

boiled  rice 
100  grams  in  3 

doses. 


Beef  same.     Rice 
200  grams,  Zwie- 
back 40  grams  in 
two  portions. 

Beef  same.     Rice 
200  grams.  Zwie- 
back 40  grams  in 
two  portions. 


1 1  to  14.  Intervals  of  feeding  made  2  hours.  Milk  given  in  6  oz.  =doses  with  |  oz.  of 
raw  egg.  Butter  increased  to  40  grams  and  various  additions  made  as  detailed 
above . 


'  The  Lenhartz  Treatment  of  Gastric    Ulcer. 


Jour,    of  ths  Medical   Sciences,"  January.  ipoS, 


376  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

The  resulting  chlorosis  or  anemia  may  be  treated  with  iron  and  arsenic. 
Of  the  former,  the  neutral  preparations  are  to  be  preferred;  of  the  latter, 
Fowler's  solution,  because  of  the  easy  regulation  of  the  dose.  Large  doses  of 
iron  should  not  be  given,  since  the  excess  of  such  doses  remains  unabsorbed, 
astringing  and  irritating  the  alimentary  canal.  The  tincture  of  the  chlorid, 
so  valuable  usually,  is  especially  contraindicated,  because  it  increases  the 
acidity  of  the  gastric  juice  and  thus  favors  the  solution  of  the  gastric  wall. 

CANCER  OF  THE  STOMACH. 

Synonyms — Carcinoma  ventriculi;  Gastric  Cancer. 

Etiology. — ^Little  definite  is  known  of  the  etiolog>'  of  cancer.  Heredity 
is  an  acknowledged  factor,  though  it  is  less  potent  than  is  commonly  sup- 
posed. W.  H.  Welch'  was  able  to  trace  cancer,  or  at  least  a  family  history 
of  cancer,  in  242  out  of  1744  cases,  or  14  per  cent.  Dieulafoy  found  such  a 
family  history  in  16  per  cent,  and  Musser  in  8  per  cent,  of  cases  of  gastric 
cancer.  There  is  some  evidence  to  show  that  abuse  of  the  stomach  by 
eating  and  drinking  may  be  influential  in  causing  the  disease,  though  it  is 
not  conclusive.  The  same  has  been  claimed  for  the  depressing  emotions. 
As  mentioned  under  ulcer,  there  is  better  reason  to  believe  that  ulcer  is  a 
predisposing  cause,  since  autopsies  have  disclosed  cancer  developing  in  the 
floor  of  ulcers  and  in  cicatrices.  Fifty-four  per  cent,  of  cancers  of  stomach 
are  found  to  have  the  base  of  an  old  ulcer  as  their  starting  place.  Mention 
should  be  made  of  the  fact  that  a  parasitic  origin  of  cancer  is  claimed  by  some, 
but  the  subject  is  altogether  too  unsettled  to  justify  more  than  reference  in 
a  text-book. 

Gastric  cancer  is  a  disease  of  mature  life,  three-fourths  of  all  cases 
occurring  between  the  40th  and  70th  year.  One  of  our  patients  was  32 
when  he  first  consulted  us,  and  died  just  one  year  later.  Adolf  Striimpell 
has  seen  cases  between  22  and  25.  George  Dock^  reports  three  cases  occur- 
ring in  his  own  practice,  where  the  patients  were  20,  21,  and  24  years  of 
age,  confirmed  by  autopsy,  and  Marc  Mathieu  published  in  1884  a  mono- 
graph, "Du  cancer  pr^cose  de  I'estomac."  The  disease  is  slightly  more 
frequent  in  men  than  in  women. 

Pathology  and  Morbid  Anatomy. — After  the  uterus,  the  stomach  is 
the  organ  most  frequently  attacked  by  cancer,  a  little  more  than  one-fifth  of 
aU  cases  of  primary  cancer  being  found  in  this  organ — according  to  Welch, 
21.4  per  cent.,  from  an  analysis  of  the  very  large  number  of  30,000  cases.  It 
is  far  more  common  in  the  pyloric  end  and  on  the  lesser  cur^^ature,  1300 
cases  collected  by  Welch  being  distributed  as  follows:  pyloric  region,  791; 
lesser  curvature,  148;  cardia,  104;  posterior  wall,  68;  whole  or  greater  part  of 
the  stomach,  61;  multiple,  45;  greater  cur\'ature,  34;  anterior  wall,  30; 
fundus,  19.  Every  variety  of  cancer  is  found  in  the  stomach,  in  the  follow- 
ing order  of  frequency : 

1.  Cylinder-celled  epithelioma,  most  frequent  at  the  pylorus. 

2.  Medullary  or  soft  cancer,  most  frequent  in  the  smaller  curvature. 


'  "System  of  Medicine  by  American  Authors,"  vol.  ii.,  Philadetphia,  1886. 
'  "Transactions  of  the  Association  of  American  Physicians,"  vol.  xii.,  1897. 


CANCER  OF  STOMACH  377 

3.  Scirrhus,  at  the  pylorus  and  the  smaller  curvatiire,  causing,  especi- 
ally, stenosis  of  the  pyloric  orifice. 

4.  Colloid,  diffuse  infiltration  with  a  tendency  to  spread  to  the  perito- 
neum and  adjacent  organs. 

5.  Melanotic. 

6.  Squamous  epithelioma,  near  the  cardia. 

All  the  forms  start  from  the  gland  cells  of  the  mucous  membrane. 

The  medullary  variety  is  prone  to  ulcerate  and  to  form  extensive  fungoid 
ulcerated  surfaces,  from  which  there  may  or  may  not  be  hemorrhage. 
It  may  be  associated  with  scirrhus.  While  nodular  outgrowths  are  usual, 
the  cancerous  tissue  may  infiltrate  the  walls,  producing  diffuse  thickening. 

Secondary  cancer  of  the  stomach  is  an  occasional  event:  in  17  out  of  37 
cases,  according  to  Welch,  secondary  to  primary  cancer  of  the  breast.  We 
have  met  one  case  succeeding  epithelioma  of  the  lip.  Much  more  frequently 
primary  cancer  of  the  stomach  is  a  cause  of  secondary  cancer  elsewhere, 
most  often  in  the  adjacent  lymphatic  glands,  which  were  the  secondary  foci 
in  551  out  of  1574  cases  collected  by  Welch;  the  liver  was  involved  second- 
arily 475  times;  the  peritoneum,  omentum,  and  intestine,  357;  pancreas, 
122;  pleura  and  lung,  98;  spleen,  26;  brain  and  meninges,  9;  other  localities, 
92;  among  the  latter  is  to  be  included  adjacent  integument,  especially 
about  the  navel. 

Marked  changes  in  the  size,  shape,  and  position  of  the  organ  occur  as  a 
result.  Most  common  is  dilatation,  sometimes  due  to  pyloric  obstruction. 
Medvdlary  cancer,  on  the  other  hand,  is  apt  to  produce  a  reduction  in  the 
size  of  the  stomach  and  its  cavity.  A  reduction  in  size  may  attend  obstruc- 
tion at  the  cardiac  orifice,  because  of  disuse  of  the  organ,  while  the  esophagus 
itself  may  be  dilated.  The  same  effect  may  be  produced  by  cancerous 
infiltration  of  the  stomach  walls,  by  which  the  capacity  of  the  organ  is 
greatly  reduced — in  one  instance,  a  case  of  Fussell's.Ho  10  ounces.  Further 
reference  will  be  made  to  extraordinary  dislocation  of  parts  of  the  organ 
in  treating  of  symptoms.  Adhesions  may  also  form  between  the  stomach 
and  adjacent  organs,  and  between  it  and  the  anterior  abdominal  wall.  Peri- 
tonitis may  occur;  also  perforation  into  an  adjacent  organ,  as  the  transverse 
colon,  and  even  the  small  intestine. 

Symptoms. — The  initial  symptoms  in  almost  every  form  of  cancer  of 
the  stomach  are  those  of  indigestion,  including  anorexia,  eructations,  vomit- 
ing, constipation,  discomfort,  and  pain,  more  rarely  acidity.  These  are 
present  for  a  variable  time  before  a  more  serious  condition  is  suspected. 
Occasionally  paroxysmal  pain  in  the  epigastrium  is  the  only  symptom. 
Increase  in  the  severity  of  symptoms  despite  the  use  of  remedies,  progressive 
debility,  emaciation,  and  cachexia  invite  closer  examination,  which  may  or 
may  not  result  in  the  discovery  of  a  tumor.  Before  a  tumor  is  recognized 
there  is  often  tenderness,  which  follows  sooner  or  later,  if  it  does  not  precede 
tumor.  Cachexia  and  wasting  may  also  be  present  a  long  time  before  the 
tumor  is  discovered. 

A  chemical  examination  of  the  gastric  contents  after  a  test -meal  may  dis- 
close the  absence  of  free  and  combined  hydrochloric  acid  or  a  minimum  of 
it.     The  persistent  presence  of  lactic  acid  in  decided  quantity,  to  which,  as 

^  Report  Philadelphia  Pathological  Society. 


378  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

well  as  to  the  absence  of  hydrochloric  acid,  attention  was  originally  called  by 
von  der  Velden,  is  held  by  Boas  to  be  confirmatory.  As  to  hydrochloric 
acid,  it  must  be  remembered  that  it  is  also  diminished  in  gastric  catarrh, 
in  atrophy  of  the  mucous  membrane,  in  amyloid  degeneration,  and  even 
in  nervous  dyspepsia  at  times,  while  in  rare  instances  it  happens  that  hydro- 
chloric acid  is  increased  in  cancer.  The  motor  as  well  as  the  secretory 
and  absorbing  functions  will  be  found  impaired,  undigested  food  being 
found  long  after  the  seven  hours'  limit.     Such  motor  delay  characterizes 


Fig.  loi. — Oppler-Boas  Bacillus,  from  Contents  of  a  Carcinomatous  Stomach — (Hcntmcler). 

more  particularly  the  pyloric  situation  of  cancer,  with  its  resulting  obstruc- 
tion. The  following  are  the  finding  of  the  stomach  contents  of  150  of 
Mayo's  cases  of  cancer  of  the  stomach. 

Free  Hydrochloric  acid  present  in  70        cases 

Average  age  48        years 

Duration  of  symptoms  41/2  years 

Absent  in  80        cases 

Average  age  54        years 

Duration  of  symptoms  9         years 

Free  hydrochloric  acid  present  without  blood,  lactic  acid  or  food  rem- 
nants in  24  cases. 

Free  hydrochloric  acid  present  without  blood,  lactic  acid,  or  food  rem- 
nants in  46  cases,  in  36  of  these  cases  no  palpable  tumor  present;  33  of 
these  cases  had  palpable  tumor  present  (blood  alone  i  s  cases) . 

Blood  present  in  80  cases;  blood  and  lactic  acid  20  cases;  blood  and  food 
remnants,  15  cases;  blood,  lactic  acid,  and  food  remnants,  30  cases. 

Lactic  acid  present  in  64  cases;  lactic  acid  and  food,  3  cases. 

Food  remnants  present  in  63  cases. 

Food  remnants  present  without  blood  or  lactic  acid  in  1 5  cases. 

Palpable  tumor  present  in  79  cases. 

From  this  summary  it  will  be  noted  that  a  large  number  of  cases  of  gas- 
tric cancer  must  be  diagnosticated  independentlj'  of  the  test  meal  findings, 
yet,  on  the  other  hand,  there  are  a  few  cases  in  which  the  subjective  symp- 
toms are  indefinite,  and  where  the  test  meal  throws  the  first  light  upon  the 
real  pathologic  condition  present. 


CANCER  OF  STOMACH  379 

The  Oppler-Boas  bacillus  was  first  described  by  Oppler  in  1895,  as  an 
unusually  long  and  thread-like  bacillus,  nonmotile,  found  in  the  contents  of 
carcinomatous  stomachs.'  The  bacilli  lie  either  end  to  end,  in  long  thread- 
like chains,  or  at  right  angles  to  one  another.  The  stain  readily  with  ani- 
lin  dyes.  They  prefer  a  medium  containing  lactic  acid;  indeed,  Kauffmann 
ascribes  to  the  bacillus  the  power  of  forming  lactic  acid  from  various  kinds 
of  sugar.  Hydrochloric  acid  in  any  large  proportion  causes  it  to  disappear. 
Schlesinger  and  Kauffmann  declare  the  presence  of  large  numbers  of  the 
bacilli  in  association  with  pyloric  stenosis  to  be  an  indication  of  carcinoma, 
and  their  absence,  associated  with  the  absence  of  lactic  acid,  to  be  evidence 
against  carcinoma.  Riegel  does  not  consider  the  organism  pathognomonic 
of  carcinoma,  but  very  important  in  its  diagnosis.  Stockton  says  it  is  often 
present  in  carcinoma,  and  has  not  been  found  in  other  diseases  of  the  stom- 
ach. The  Oppler-Boas  bacillus  and  sarcinae  do  not  coexist  for  any  length 
of  time  in  carcinomatous  stomachs.  The  sarcina  thrives  in  the  presence  of 
hydrochloric  acid,  and  disappears  with  it,  being  replaced  by  the  Oppler- 
Boas  bacillus  and  lactic  acid.  Even  when  introduced  into  the  stomach  in 
cases  of  obstruction  due  to  carcinoma,  the  sarcinae  disappeared  in  twenty- 
four  hours,  the  Oppler-Boas  bacillus  seeming  to  replace  them. 

In  evidence  of  the  value  of  the  Oppler-Boas  bacillus  in  diagnosis  of 
gastric  carcinoma  it  may  be  said  that  Kauffmann^  found  it  in  19  out  of  20 
cases,  and  in  the  one  in  which  it  was  absent  there  was  no  lactic  acid.  John 
C.  Hemmeter  informs  us  that  he  found  the  bacillus  in  52  out  of  55  cases, 
that  he  regards  it  "an  important  diagnostic  sign  in  carcinoma  of  the  stom- 
ach, within  limitations,  and  though  it  is  by  no  means  pathognomonic." 
He  has  found  it  in  a  case  of  benign  pyloric  stenosis,  and  also  in  such  cases 
when  HCl  was  still  present.  Ullman,  of  Buffalo,  N.  Y.,  found  it  in  all  of 
ten  cases. 

At  a  later  stage  periodic  vomiting  of  large  quantities  of  fluid  containing 
the  ingesta  of  hours  and  even  days  previous  is  a  characteristic  sjnnptom, 
and  a  dilated  stomach  may  now  be  easily  demonstrated.  The  vomitus  may 
also  contain  blood,  and  that  peculiar  mixture  of  blood  and  gastric  juice  which 
is  called  "coffee-grounds,"  vomit.  If,  owing  to  their  disintegration,  the 
microscope  does  not  recognize  blood  disks,  Teichmann's  hemin  crystals  may 
be  easily  prepared.  Occiolt  blood  may  also  be  found  in  the  stools  and 
gastric  contents.  The  vomited  matter  is  sometimes  very  foxil-smelling,  as 
are  also  at  times  the  eructations.  Vomiting  is  by  no  means  an  invariable 
symptom,  though  even  when  there  is  no  vomiting,  nausea  is  commonty 
present.  The  absence  of  vomiting  generally  means  that  the  cancer  is  not 
at  the  pylorus.  It  may  be  at  the  middle  belt,  at  the  fundus,  or  at  the  cardiac 
end.  When  at  the  latter  point,  there  is  almost  always  difficult  and  painful 
deglutition. 

By  this  time  the  patient  is  emaciated,  anemic,  cachectic,  with  a  peculiar 
yellowish,  sallow,  swollen  appearance,  and  now  a  tumor  is  commonly  easily 
recognized  by  palpation.  Very  interesting  is  the  varying  situation  of  the 
tumor,  as  well  as  at  times  its  great  mobility.     The  tumor  of  pyloric  cancer 

^  Boas.  "Specielle  Diagnostik  und  Therapie  der  Magenkrankheiten."  Oppler,  "Deutsche  naedicinische 
Wochenschrift,"  189s,  No.  s. 

'  Kauffmann  and  Schlesinger,  "  Wiener  klinische  Rundschau,"  1895.  No.  s. 


380  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

is  commonly  found  near  the  normal  situation  of  the  pylorus,  in  the  neighbor- 
hood of  the  umbilicus,  a  little  to  the  right  or  left.  At  other  times  the  weight 
of  the  tumor  drags  it  out  of  the  normal  position,  and  it  may  be  found 
lower  down,  toward  the  symphysis  pubis.  The  tumor  itself  may  be  fixed 
in  the  position  it  assumes,  or  it  may  be  freely  movable.  Its  location  is 
usually  influenced  by  breathing.  It  rarely  gives  a  positive  dull  note  on 
percussion — rather  a  muffled  note.  In  a  certain  number  of  cases  no  tumor 
can  be  detected  throughout  the  whole  course  of  the  disease,  it  is  saitl 
in  20  per  cent.  Especially  is  this  the  case  when  the  disease  is  toward  the 
cardiac  end. 

Toward  the  end  of  life  edema  of  the  legs  and  ankles  appears,  and  an 
intensity  of  cachexia,  which  simulates  pernicious  anemia — in  fact,  even 
furnishes  the  blood  changes  characteristic  of  this  affection — with  extreme 
weakness  and  death.  The  urine  is  often  scanty,  and  may  give  a  decided 
reaction  for  indican.  In  a  few  cases  afebrile  movement  makes  its  appearance 
with  chills  and  sweating  at  intervals,  probably  due  to  intercurrent  inflamma- 
tion. To  these  symptoms  are  often  added  those  of  secondary  cancer, 
especially  of  the  liver,  including  enlargement  of  this  organ  and  jaundice. 
The  signs  of  secondary  cancer  elsewhere  than  in  the  liver  should  be  sought. 
The  duration  of  cases  of  gastric  cancer  is  from  one  to  two  years;  it  may  be 
less,  especially,  if  the  cancer  is  ingrafted  on  a  pre-existing  ulcer.  Slow  de- 
velopment is  said  to  be  characteristic  of  cases  in  younger  persons. 

Diagnosis. — This  is  generally  easy  if  time  and  opportunit}^  be  allowed 
for  the  study  of  a  given  case,  but  one  should  not  waste  time  in  waiting  for 
all  of  the  following  symptoms.  Ulcer  is  perhaps  the  disease  which  furnishes 
most  difficulty,  especially  as  cancer  may  succeed  it.  On  the  other  hand, 
the  earliest  symptoms  of  gastric  cancer  are  also  those  of  gastric  catarrh. 
which  in  many  cases  is  mistaken  for  cancer.  The  pain  and  the  peculiar  in- 
termittent voitiiting  are  the  first  distinctive  signs,  and  while  coffee-grounds 
vomit  may  occur  whenever  moderate  quantities  of  blood  are  poured  into 
the  stomach  and  mixed  with  gastric  juice,  the  causes  other  than  cancer  are 
rare.  The  copious  hemorrhage  of  ulcer  gives  bright  red  blood.  Bloody 
vomiting  is  by  no  means  always  present  in  cancer.  To  the  symptoms  de- 
scribed are  soon  added  the  emaciation  and  cachexia,  and  the  palpable  tumor 
more  evident  after  the  stomach  has  been  emptied  out  by  vomiting  or  wash- 
ing. In  the  meantime,  however,  the  gastric  contents  will  have  been  ex- 
amined, and  furnish  their  quota  of  information,  not  pathognomonic,  but 
contributory.  Very  rarely  does  it  happen  that  in  the  vomitus  or  washings 
of  the  stomach  we  obtain  particles  of  morbid  growth  whose  examination 
will  disclose  the  structure  of  cancer.  Most  frequently  cancer  for  a  long 
while  is  considered  simply  a  chronic  indigestion.  It  should  always  be 
remembered  that  a  chronic  indigestion  may  be  cancer,  gallstones,  ulcer,  or 
appendicitis. 

There  is  not  usually  much  difficulty  in  fixing  the  location  of  the  tumor 
supposed  to  be  in  the  stomach.  If  there  is  doubt,  it  may  be  eliminated  in 
part  or  altogether  by  filling  the  stomach  with  air  and  noting  the  effect  upon 
the  tumor.  Expert  examination  of  the  stomach  by  means  of  X-ray  and 
bismuth  will  often  lead  to  an  early  diagnosis.  There  will  be  seen  loss  of 
motility,  notching  of  one  or  the  other,  curvature  and  other  signs  of  in- 


CANCER  OF  STOMACH  381 

terference  with  the  stomach  wall.  There  is  usually  less  interference  with 
digestion  in  cancer  of  the  gall-bladder,  no  mobility  of  the  tumor,  and  often 
suppuration  with  incident  fever. 

The  distinction  of  gastric  from  pancreatic  cancer  demands  some  con- 
sideration. The  tujnor  may  be  in  the  same  position,  but  in  a  large  pro- 
portion of  cases  of  cancer  of  the  pancreas  there  is  jaundice.  The  tiunor  of  a 
pancreatic  cancer  is  often  inaccessible.  In  the  latter  there  are  also  symp- 
toms of  indigestion,  like  those  of  gastric  cancer,  but  there  is  often  also  diar- 
rhea, and  frequently  the  liquid  stools  contain  oil.  Such  diarrhea  may  be 
checked  for  a  time  by  ordinary  remedies,  but  in  a  few  days  the  liquid  dis- 
charges seem  to  burst  through  a  barrier  which  held  them  temporarily  in  check. 
The  pancreatic  tumor,  if  felt,  is  also  more  immovable. 

Tumors  of  the  liver  and  spleen  are  continuous  with  these  organs,  while 
the  gastric  tiunor  is  generally  easily  distinguished  from  them  by  palpation  or 
by  an  intervening  tympanic  area.  A  cancer  of  the  transverse  colon  may 
occupy  much  the  same  position  in  the  abdomen  as  one  of  the  stomach,  and 
be  also  quite  movable.  The  filling  of  the  colon  and  stomach  with  air  vaSiy 
also  be  availed  of  in  diagnosis.  As  the  growth  in  the  intestine  increases, 
obstruction  may  result  and  the  tumor  increase  by  the  accumulation  of  fecal 
matter  behind  the  stenosed  portion.  A  rare  complication,  increasing  the 
difficulty  in  diagnosis,  is  adhesion  between  the  bowel  and  stomach,  re- 
stricting motion  and  possibly  causing  perforation,  through  which  fecal  mat- 
ter may  enter  the  stomach.  Still  more  difficult,  nay,  even  impossible,  in 
most  instances,  is  the  distinction  between  duodenal  and  gastric  cancer.  The 
absence  of  hydrochloric  acid  would  point  to  gastric  cancer,  though  such 
absence,  being  due  to  atrophy  of  the  gastric  tubules  caused  by  dilatation, 
may  also  occur  in  obstructive  duodenal  cancer.  The  acid  might  also  be 
neutralized  by  regurgitated  bile,  regurgitation  being  favored  by  the  stenosis 
of  the  gut.     The  presence  of  jaundice  would  point  to  duodenal  cancer. 

Gastric  tumors  may  be  confused  with  omental  tumors,  which  may  also 
cause  dyspeptic  symptoms.  But  the  omental  tumor  is  usually  a  more 
nodular,  uneven  tumor,  and  is  sooner  or  later  associated  with  peritoneal 
effusion. 

Moreover,  every  tumor  of  the  stomach  is  not  a  cancerous  tumor,  al- 
though most  of  them  are.  A  thickened  pylorus  may  be  associated  with  gas- 
tric ulcer.  Such  a  circumscribed  thickening  and  induration  are  always 
possible.  We  may  have  the  same  pyloric  stenosis  and  secondary  dilatation. 
Similar  noncancerous  thickening  may  even  occur  without  ulcer.  Other 
forms  of  morbid  growths,  such  as  fibroma,  sarcoma,  and  the  like,  are  too  rare 
to  demand  notice  from  the  clinical  standpoint. 

Finally,  the  gastric  tiunor  is  not  always  demonstrable,  and  may  not  be 
throughout  the  whole  course  of  its  existence.  It  is  said  to  be  absent  in  about 
20  per  cent,  of  cases.  Then  the  diagnosis  must  be  made  from  the  symp- 
toms, especially  the  rapid  wasting  and  cachexia,  which  are  rarely  simu- 
lated, even  in  ulcer.  The  age  of  the  patient,  generally  past  40,  the  defi- 
ciency in  HCl,  and  the  presence  of  lactic  acid  must  be  allowed  due  weight. 
The  cachexia  of  pernicious  anemia  resembles  very  closely  that  of  cancer  of 
the  stomach,  and,  in  the  absence  of  appreciable  tmnor  in  the  latter,  may 
occasion  difficulty.     But  a  study  of  the  blood  will  in  most  cases  clear  up  a 


382  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

doubt.  The  number  of  red  blood-cells  in  cancer  of  the  stomach  is  rarely 
below  2,000,000  while  in  pernicious  anemia  it  is  often  below  1,000,000 
per  cubic  millimeter.  This  difference  exists  even  while  the  cancerous  sub- 
ject exhibits  more  emaciation  and  weakness  than  that  of  pernicious  anemia. 
As  F.  P.  Henry  well  puts  it:  "In  cancer  of  the  stomach  the  reduction  in  the 
number  of  red  corpuscles  docs  not  keep  pace  with  cachexia ;  in  anemia  the 
cachexia  does  not  keep  pace  with  the  destruction  of.  red  corpuscles. ' '  Cancer 
of  the  stomach  may  be  latent  throughout. 

Prognosis. — This  is  inevitably  fatal  when  one  waits  long  before  making 
a  diagnosis,  but  something  may  be  done  toward  prolonging  life  and  even 
saving  it  by  early  diagnosis  and  prompt  surgical  treatment,  the  proper 
cleansing  out  of  the  stomach,  the  selection  and  regulation  of  food,  and 
measures  to  aid  its  digestion. 

Treatment. — An  active  treatment  is  siunmed  up  in  very  early  diagnosis 
and  an  immediate  surgical  interference.  The  old  method  of  waiting  for  a 
positive  diagnosis  and  a  tumor  must  be  supplanted  by  a  careful  diagnosis 
by  modem  methods  and  the  performance  of  an  exploratory  operation  in 
every  suspicious  case.  Many,  very  many,  cases  of  carcinoma  in  their 
early  and  possibly  curable  stage  masquerade  as  chronic  indigestion.  The 
practitioner  never  suspects  cancer  until  a  tumor  stares  him  in  the  face. 
Frequently  to  wait  for  a  positive  diagnosis  is  to  wait  for  death.  Since  many 
cases  of  cancer  of  the  stomach  come  to  us  late,  treatment  must  be  directed 
toward  prolonging  the  patient's  life.  An  operation  in  indicated  at  any 
stage  when  there  is  not  secondary  involvement  of  some  other  organ,  and 
it  is  quite  sure  that  a  great  deal  more  can  be  done  than  is  commonly  thought 
possible.  The  limit  of  life  of  the  victim  of  established  gastric  cancer  docs 
not  exceed  two  years  without  surgery. 

The  stomach  has  no  purpose  other  than  the  preparation  of  the  food  for 
absorption.  It  is  not  a  vital  organ  in  the  sense  that  the  heart  and  the 
lungs  are  vital  organs.  It  is  important  so  far  as  it  prepares  the  food,  but  if 
the  food  can  be  prepared  for  absorption  outside  of  the  body,  its  importance 
is  diminished.  So  it  is  if  we  introduce  artificially  digested  food  by  the  rectum. 
Or  we  may  use  both  of  these  methods.  We  can,  by  the  use  of  prepared  food, 
diminish  the  labor  of  the  stomach,  and  by  using  the  rectum  we  can,  while 
doing  so,  relieve  the  stomach  of  all  labor.  This  is  rendered  easier  at  the 
present  day  by  the  use  of  peptonized  foods  of  various  kinds. 

However  careful  the  preparation  of  food,  when  taken  into  the  stomach  in 
these  cases,  only  a  part  is  used  up,  and  there  accumulates  gradually  a  quan- 
tity of  unabsorbed  material  which  does  not  pass  the  pylorus,  and  to  this  a 
copious  mucous  secretion  is  added.  Gastro-enterectomy  under  these  con- 
ditions gives  much  relief  and  often  prolongs  life.  When  for  one  reason  or 
another  this  operation  cannot  be  performed  it  is  desirable,  once  a  day  or 
every  other  day,  to  wash  out  the  stomach  with  water  as  hot  as  can  be  borne, 
or  alkaline  waters,  as  described  in  the  treatment  of  gastric  catarrh.  The 
free  use  of  hydrochloric  acid  as  a  medicine  also  aids  not  only  in  the  solution 
of  the  food  ingested,  but  prevents  the  fermentations,  which  contribute  irri- 
tating acids  to  the  gastric  contents  and  cause  further  mischief  and  discomfort. 
Iron,  arsenic,  and  strychnin  may  be  used  to  help  sustain  the  habit. 


GASTRIC  DILATATION  383 

DILATATION  OF  THE  STOMACH. 

Synonym. — Gastrectasia. 
Definition. — Two    forms    exist — a    chronic    and    an    acute    dilatation. 

Chronic  Dilatation. 

Etiology. — (i)  The  nervo-muscular  atony  causing  dilatation  ma.Y  be 
the  result  of  habitual  overdistention,  especially  by  food  of  defective  quality, 
resulting  in  stasis  and  fermentation;  of  excessive  drinking,  as  in  beer-drink- 
ing by  employees  of  breweries;  of  chronic  gastritis;  of  diseases  producing 
general  nervo-muscular  atony,  such  as  disease  of  the  spinal  cord,  pulmonary 
consumption,  anemia,  chlorosis,  acute  fevers,  affections  of  the  heart,  liver, 
and  kidneys,  and  other  diseases  of  like  import.  (2)  Mechanical  or  obstruc- 
tive dilatation  is  most  frequently  due  to  obstruction  by  cancer  to  cicatricial 
contraction,  or  to  hypertrophic  thickening  at  the  pylorus  or  in  the  duo- 
denum. Such  obstruction  may  also  be  due  to  pressure  from  without,  as  by 
cicatricial  adhesion  or  tumor  of  an  external  organ  or  a  floating  right  kidney. 
It  is  most  frequent  in  middle-aged  persons,  but  may  occur  even  in  children. 
Tight  lacing,  by  producing  dislocation  of  the  stomach  and  obstruction  to 
the  onward  movement  of  its  contents,  may  also  be  a  cause  of  dilatation. 

Morbid  Anatomy. — In  addition  to  the  increase  of  volume  the  coats 
of  the  stomach  may  be  thinned  and  the  glandular  structure  more  or  less 
atrophied.  The  average  normal  stomach  of  an  adult  holds  about  i  1/2 
liters  (three  pints) ,  while  the  abnormally  dilated  organ  may  attain  a  capacity 
of  three  or  four  liters  (six  or  eight  pints),  and  even  more.  Where  the 
dilatation  is  mechanical,  there  is  added  the  lesion  which  is  responsible  for  the 
obstruction. 

Symptoms. — The  symptoms  arising  from  dilatation  are  a  sense  of 
fullness  in  the  epigastrium,  eructations ,  flatulence,  and  vomiting,  often  of 
enormous  quantities.  The  appetite  is  sometimes  poor,  at  others  quite  good, 
and  the  patient  is  hungry  and  thirsty.  The  vomited  matters  are  largely 
water,  but  include  also  remnants  of  food  and  every  variety  of  fungus — viz., 
tjacteria,  sarcinas,  yeast  fungi,  etc.  Their  reaction  usually  exhibits  lessened 
acidity,  because  of  diminished  hydrochloric  acid  secretion,  but  it  may  be 
normal  or  even  abnormally  acid.  Such  abnormal  acidity  is  the  result  of 
fermentations  producing  lactic,  butyric,  and  acetic  acids.  Various  gases 
are  thus  produced,  including  carbonic  acid  and  hydrogen.  The  latter  may 
also  arise  from  decomposition  of  albuminoid  substances,  whence  too  arises 
stdphuretted  hydrogen.  These  fermentations  are  favored  by  the  absence  of 
HCl,  the  importance  of  which  in  preventing  fermentation  has  been  referred 
to,  and  by  a  stasis  of  the  contents  in  the  stomach;  for  not  only  is  absorption 
delayed,  but  the  transit  of  gastric  contents  into  the  intestine  is  also  hindered. 
Indeed,  in  some  cases  the  stomach  is  never  emptied  unless  by  the  tube. 
Nay,  more;  it  would  seem  that  at  times  it  contains  more  liquid  than  was 
ingested — a  possible  condition,  since  the  endosmosis  of  crystalloids  (viz., 
sugar,  dextrin,  alcohol,  and  peptones)  is  attended  with  the  exosmosis  of 
water.  From  such  causes,  too,  occur  torpor  of  the  bowel,  scantiness  of  urine, 
and  dryness  of  the  skin. 

Anemia,  emaciation,  and  debility  sooner  or  later  succeed,  and  in  fatal 


384  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

cases  death  is  commonly  preceded  by  a  drowsiness,  which  may  be  due  to  the 
absorption  of  toxic  substances  arising  in  the  decompositions  going  on  in 
the  stomach.  Dilatation  of  the  stomach  is  also  one  of  the  acknowledged 
causes  of  tetany,  as  first  pointed  out  by  Kussmaul.  The  cramps,  though 
often  quite  severe,  are  of  short  duration.  They  occur  chiefly  in  the  muscles 
of  the  hands,  arms,  and  legs,  von  Leube  suggests  that  this  tetany  may  be 
due  to  a  "drying  out"  of  the  nerves  and  muscles,  but  it  may  also  be  the 
result  of  autointoxication.     Unconsciousness  may  precede  death. 

Physical  Signs. — These  may  be  elicited  by  inspection,  palpation,  and 
percussion.  Inspection  does  not  always  afford  information,  but  in  emaciated 
cases  the  greater  curvature  of  the  distended  organ  maj^  be  recognized  as 
low  as  the  navel  and  below,  instead  of  from  1.2  to  2.8  inches  above  it  (3  to 
7  cm.).  When  the  stomach  is  very  low,  even  the  smaller  curvature  may  be 
recognized  about  two  inches  (s  cm.)  below  the  ensiform  cartilage,  uncover- 
ing the  pancreas.  In  obstruction  of  the  pylorus  the  peristalsis  from  left  to 
right  may  even  be  recognized  stopping  short  at  the  pylorus,  where  the 
tumor-like  thickening  may  sometimes  be  seen.  In  rare  instances  a  reverse 
peristalsis,  from  right  to  left,  takes  place. 

Palpation  may  confirm  inspection,  recognizing  the  contour  of  the 
stomach  by  its  peculiar  consistence,  which  has  been  compared  to  that  of  an 
air-cushion,  but  affords  little  additional  information  unless  there  be  a  tumor 
at  the  pylorus  which  may  be  felt.  Peristalsis,  if  present,  may  also  be  felt, 
and  may  be  stimulated  by  filliping  the  abdominal  walls  with  the  fingers,  by 
which  also  a  splashing  sound  may  be  produced  in  the  water-laden  dilated 
stomach  down  as  low  as  the  greater  curvature.  This  is  to  be  distinguished 
from  a  similar  splashing  which  may  be  obtained  in  the  normal  stomach  and 
adjacent  colon,  the  latter  being  less  constant  and  less  intense. 

If  a  stiff  sound  is  passed  into  the  stomach — its  end  may  be  felt  through 
the  abdominal  walls,  while  the  unusual  extent  to  which  it  may  be  carried 
before  meeting  resistance  will  attract  attention. 

Percussion  affords  the  most  valuable  evidence  as  to  the  presence  of  a 
dilated  stomach,  and  in  the  majority  of  instances  such  evidence  is  con- 
clusive. Auscultatory  percussion  is  especially  satisfactory  in  determinisng 
the  outlines  of  the  stomach,  and  the  stethoscope  may  be  used  \vith  advan- 
tage, made  from  above  downward,  beginning  at  the  edge  of  the  ribs  in  the 
neighborhood  of  the  right  parasternal  line.  The  note  is  t}Tnpanitic  until 
the  upper  curvature  is  reached,  when  it  is  substituted  by  dullness  due  to  the 
liquid  contents,  to  be  succeeded  again  by  tympany  of  the  bowel  when  the 
lower  border  of  the  stomach  is  passed.  If  the  patient  lies  on  his  back,  the 
dullness  disappears  and  is  replaced  by  tympany.  If  there  is  no  liquid  in  the 
stomach,  a  change  in  the  pitch  of  the  tympanitic  note  will  indicate  the 
transition  from  the  stomach  to  the  intestine.  Further  information  can  be 
gained  by  means  of  the  tube,  by  which  the  stomach  can  be  emptied  and 
refilled  with  air  and  its  borders  determined  by  percussion.  This  is  more 
satisfactory  than  filling  the  stomach  with  carbonic  acid  gas,  and  even  such 
procedure  is  not  always  necessary.  If  the  larger  curvature  be  found  by 
percussion  at  the  navel  or  below,  the  stomach  is  certainly  dilated.  The 
X-ray  may  be  used  with  the  greatest  advantage.  A  meal  of  bismuth 
is  given  the  patient  X-rayed  while  standing.     In  this  way  better  than  any 


GASTRIC  DILATATION  385 

other  a  perfectly  correct  idea  may  be  had  not  only  of  the  size  but  of  the 
shape  of  the  stomach. 

Diagnosis. — This  is  usually  readily  made  by  attention  to  the  symptoms 
and  physical  signs  described.  Dilated  stomach  has,  however,  been  mistaken 
for  an  ovarian  cyst,  and  abdominal  section  has  been  made  for  its  relief. 

Dilatation  differs  from  falling,  or  gastroptosis,  though  descent  and 
dilatation  are  often  present  in  the  same  organ.  Different  also  is  enter- 
optosis,  or  visceroptosis,   which  will  be  considered  later. 

Prognosis. — Depends  upon  the  measures  used  in  the  treatment  and  upon 
the  promptness  of  the  diagnosis. 

Surgical  Treatment. — All  care  of  dilatatiom  due  to  obstruction  of  the 
pylorus,  whether  the  obstructing  cause  is  benign  or  malignant  should  be 
given  into  the  hands  of  a  competent  surgeon.  A  pyloroplasty,  a  pylorec- 
tomy  or  a  gastric  jujenostomy  will  frequently  save  lives,  and  practically 
always  will  give  much  comfort.  Cases  of  dilatation  due  to  atony  may  be 
permanently  relieved  by  gastro-jujenostomy. 

Medical  Treatment. — The  most  important  part  of  the  medical  treat- 
ment is  washing  out  the  stomach.  This  may  be  done  daily,  but  sometimes  it 
is  sufficient  to  do  it  on  alternate  days,  occasionally  even  twice  daily.  Wheii 
practised  once  a  day,  it  is  usually  best  done  on  retiring  at  night,  as  the  stom- 
ach is  thus  freed  for  the  night  of  irritating  material  which,  if  retained,  dis- 
turbs rest  and  aggravates  the  local  condition.  The  patient  soon  learns  the 
most  suitable  time  for  lavage,  and  when  it  is  often  necessary,  he  should  be 
taught  to  perform  it.     But  this  only  if  surgery  cannot  be  employed. 

Of  drugs,  hydrochloric  acid  is  the  most  likely  to  be  useful,  not  only 
because  of  its  importance  as  a  digestive  agent,  but  also  as  a  preventive  of 
fermentation.  Nitro-muriatic  acid  may  sometimes  be  substituted  with 
advantage,  especially  when  a  stimulating  effect  is  desired  on  the  liver.  It 
should  be  freshly  prepared,  and  from  three  to  five  drops  of  a  pure  acid  should 
be  given  to  an  adult  at  a  dose.  Strychnin  is  a  drug  which  has  much  to 
recommend  it  from  the  theoretical  standpoint  as  a  muscular  tonic,  and  has 
the  further  advantage  of  easy  absorption.  It  should  be  administered  in 
full  doses  from  a  small  beginning,  1/30  grain  (0.002  gm.)  three  times  a  day, 
increased  to  1/20  grain  (0.003  gm.)  and  even  more.  Extract  of  nux  vomica 
may  be  substituted,  but  it  is  less  easily  absorbed.  Tincture  of  nux  vomica 
is  better.  It  may  be  given  in  gradually  increasing  doses  until  30  drops, 
or  IS  minims,  are  given  three  times  a  day. 

In  addition  to  the  hydrochloric  acid  as  an  antiferment,  other  reme- 
dies for  this  purpose  are  charcoal  and  creasote.  The  power  possessed  by 
charcoal  of  absorbing  gases  cannot  be  utilized,  because  it  possesses  this 
property  only  in  the  dry  state.  Yet  it  does  relieve  flatulence  and  is  antisep- 
tic. Such  antisepsis  may  be'  extended  to  the  intestine.  Doses  of  charcoal 
of  s  to  10  grains  (0.33  to  0.06  gm.)  and  even  more  may  be  given  conven- 
iently in  concils. 

Creasote  is  a  useful  antiseptic,  and  may  be  given  in  pill  form,  in  doses 
of  1/2  grain  to  a  grain  (0.03  to  0.0  ogm.),  or  it  may  be  given  in  sherry  wine, 
whisky,  brandy,  or  tincture  of  gentian.  The  following  one  per  cent, 
solution  of  creasote  is  a  modification,  by  George  Herschell,  of  Bouchard's 
well-known  formula: 


386  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

T^    Creasoti,  lo 

Tr.  gentianae,  20 

Vin.  xerici,  8oo 

Sp.  vini  gallici,  170 

M.  et  Sig.     One  hundred  minims  contain  one  minim  or 

one  grain  of  creasote. 

When  the  condition  is  part  of  the  morbid  anatomy  of  cancer  of  the 
stomach,  only  palHation  may  be  expected,  unless  an  operation  can  be 
performed,  either  of  excision  of  the  cancer  or  drainage  of  the  stomach. 

Dietetic  Treatment. — Most  important  is  the  selection  of  food  in  these 
cases.  Solids  should  be  almost  totally  prohibited,  while  the  typical  nour- 
ishment is  the  various  kinds  of  artificially  digested  food,  such  as  peptonized 
milk.  Beef-juice  and  rare  beef  scraped  are  also  easily  assimilated,  while 
fatty,  and  especially  starchy,  foods  are  to  be  used  sparingly,  if  at  all. 

Acute  Dilatation' 

Definition. — A  condition  of  sudden  enlargement  of  the  stomach  caused  by 
surgical  operations;  by  acute  infections,  or  by  errors  in  diet. 

Etiology. — By  far  the  greater  number  of  cases  of  acute  dilatation  occur 
after  operation.  Whatever  be  the  primary  cause  of  the  condition  here, 
Conner  in  his  noteworthy  work  had  proven  beyond  question  that  certainly 
in  the  later  stages  a  real  obstruction  exists,  due  to  constriction  of  the  duo- 
denum where  it  crosses  the  spinal  column,  under  the  attachment  of  the 
mesentery. 

Operations  need  not  necessarily  be  upon  the  stomach  to  cause  acute 
dilatation.  Any  abdominal  operation  may  be  followed  bj^  this  accident, 
indeed,  operations  in  remote  parts  of  the  body  have  been  followed  bj'  it. 

Pathological  Anatomy. — The  stomach  is  always  greatly  enlarged,  often 
filling  the  entire  abdominal  cavity,  and  filled  to  a  large  extent  with  fetid, 
fecal-like  matter.  The  stomach  wall  may  be  thickened  and  not  thinned. 
This  thickening  is  due  to  infiltration  of  the  tissue. 

As  Conner  has  pointed  out,  when  one  has  met  and  recognized  a  case 
of  acute  dilatation  of  the  stomach,  he  is  not  likely  to  be  misled  bj-  any  case 
which  occurs.  The  diagnosis  in  postoperative  cases  and  in  cases  which  arise 
with  no  apparent  cause  is  more  difficult  than  the  condition  with  pneumonia, 
though  here,  too,  the  diagnosis  must  remain  in  doubt  unless  the  fact  of  a  pos- 
sible gastric  dilatation  is  remembered,  and  a  careful  physical  examination  of 
the  stomach  is  made. 

The  symptoms'  and  physical  signs  of  the  condition  are:  \"omiting, 
abdominal  pain,  abdominal  distention  (due  to  enlarged  stomach),  con- 
stipation (diarrhea  in  a  few  cases),  collapse,  splashing  sounds,  peristaltic 
movement  over  the  stomach. 

I.  Vomiting. — This  is  the  most  frequent  symptom.  It  occurred  in  all 
but  one  of  the  cases  cited  by  FusseU  and  was  present  in  90  per  cent,  of 
Conner's  cases  from  all  causes.  The  vomiting  in  two  instances  in  Fussell's 
series  was  yellowish.  In  two  it  had  a  fecal  odor,  in  the  remainder  it  was  dark 
greenish  or  blackish  in  appearance.  The  quantity  is  usually  large,  one  pint 
or  more,  though  rarely  it  is  small.  The  act  of  vomiting  is  painless,  and  has 
much  the  character  of  that  of  general  peritonitis.     The  vomitus  is  suddenly 

1  Acute  Dilatation  of  the  Stomacli  in  Pneumonic.  Amer.  Jour.  Med.  Sc  Dec,  191 1. 


GASTRIC  DILATATION  387 

and  violently  expelled  from  the  mouth,  without  effort  on  the  part  of  the 
patient. 

2.  Pain  was  complained  of  in  42  of  Conner's  cases.  In  this  series  of 
pneumonia  cases,  it  occurred  twice.  In  one  of  my  cases  it  was  so  severe 
that  morphin  was  required. 

3.  Abdominal  distention  usually  occurs  quickly,  is  frequently  severe,  and 
is  almost  without  exception  in  the  epigastrium,  causing  a  tumor  in  that 
position,  but  on  account  of  the  distention  being  due  to  the  large  stomach, 
and  the  stomach  occupying  an  abnormal  position,  the  whole  abdomen  is 
distended.  In  one  of  this  series  the  outline  of  the  greatly  distended  stomach 
could  be  plainly  seen.  This  is  exactly  in  accordance  with  one  of  Fagge's 
cases.     This  abdominal  distention  completely  disappeared  after  lavage. 

4.  Constipation  is  the  rule.  In  two  of  my  own  cases  the  first  thought 
was  that  probably  the  symptoms  were  due  to  intestinal  obstruction.  In  two 
of  the  pneumonia  cases,  however,  there  was  diarrhea.  This  constipation 
adds  color  to  the  picture  of  intestinal  obstruction. 

5.  Collapse. — The  patient  is  frequently  almost  totally  collapsed.  The 
face  is  pinched  and  anxious.  The  eyes  are  sunken.  The  breathing  is  rapid. 
The  patient  gives  every  indication  of  almost  immediate  dissolution. 

6.  The  Splashing  Sounds. — By  placing  ones  hands  upon  the  lower 
abdomen  and  making  a  quick  percussion  of  the  portion  of  the  abdomen, 
occupied  by  the  tumor  usually  a  splashing  sound  can  be  detected,  which  is 
so  characteristic  of  dilatation  of  the  stomach.  Peristaltic  movement  of  the 
stomach  area  can  occasionally  be  seen.  This  has  been  noted  in  only  a  few 
instances,  and  is  apparently  not  as  marked  in  cases  of  acute  dilatation  as  it 
is  in  cases  of  chronic  dilatation. 

Diagnosis. — The  condition  must  be  diagnosticated  from  general  intes- 
tinal distention  not  due  to  obstruction  or  peritonitis;  from  peritonitis  due 
to  perforation  or  to  extension  of  inflammation;  from  intestinal  obstruction; 
from  pancreatic  cyst;  from  uremia;  from  postanesthesia  vomiting;  and  from 
acute  hemorrhagic  pancreatitis. 

General  abdominal  distention  is  common  in  pneumonia  and  is  more 
frequently  than  not  unaccompanied  by  gastric  dilatation;  that  they  may 
occur  simultaneously  is  certain.  In  simple  distention  peristalsis  may  be 
heard  over  the  entire  abdomen.  The  outline  of  the  stomach  cannot  be 
made  out,  and  the  stomach  tube  introduced  will  not  remove  the  distention; 
frequently  in  these  cases  a  rectal  tube  will  relieve  the  tympany.  There  is 
no  vomiting,  there  is  often  diarrhea. 

General  Peritonitis. — Here  there  is  the  same  rapid  distention  as  in  gastric 
dilatation,  but  the  stomach  cannot  be  seen  outlined.  There  is  much  more 
tenderness  than  in  dilatation  of  the  stomach,  there  is  no  splash,  and  above 
all,  there  is  the  same  collapsed  condition  of  the  patient.  The  stomach 
tube  does  not  dissipate  the  distention. 

Intestinal  Obstruction. — Three  of  the  cases  which  occurred  in  pneumonia, 
were  believed  to  be  due  to  intestinal  obstruction,  and,  indeed,  the  pictiire 
was  very  like  it.  Abdominal  pain,  vomiting,  in  two  instances  almost  fecal 
in  character,  great  distention,  and  constipation.  Indeed,  the  later  view  that 
there  is  always  an  obstruction  where  the  mesentery  crosses  the  duodenimi, 
gives  real  reason  for  the  Ukeness  of  the  pictures.     If  there  is  a  stricture  high 


388  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

up  not  due  to  {gastric  dilatation,  the  differential  diagnosis  would  be  impossi- 
ble. In  intestinal  obstruction,  however,  the  distention  is  originally  general 
over  the  entire  abdomen,  whereas  in  acute  dilatation  of  the  stomach  the 
distention  is  likely  to  be  in  the  epigastrium,  or  at  least  greater  in  that  posi- 
tion. Sometimes  a  marked  epigastric  tumor  is  seen,  occupying  the  entire 
epigastrium  and  the  left  hypochondrium,  also  the  lower  epigastric  region, 
and  in  rarer  instances,  the  shape  of  the  distended  stomach  can  be  made  out 
through  the  abdominal  walls.  Careful  passage  of  the  stomach  tube  will 
cause  the  immediate  disappearance  of  the  abdominal  distention  where  this 
is  due  to  stomach  dilatation. 

Pancreatic  Cyst. — Dilatation  of  the  stomach  has  been  mistaken  for  this 
condition,  but  in  cyst  there  is  the  evidence  of  a  true  mass.  This  mass  is 
dull  to  percussion.  The  stomach  tube  will  not  cause  its  disappearance. 
There  is  no  collapse  in  a  cyst. 

Uremia. — The  dull  unconscious  condition  of  uremia  is  not  like  the 
rather  active  delirium  of  dilatation  of  the  stomach.  There  is  no  collapse. 
There  is  no  distention. 

Acute  Hemorrhagic  Pancreatitis. — In  this  condition  there  is  the  same 
sudden  onset,  with  collapse,  but  the  distention  is  general  and  not  confined 
to  the  stomach.     It  is  easily  differentiated  by  the  stomach  tube. 

Prognosis. — Conner  gives  a  death  rate  of  72.5  per  cent,  in  102  cases. 
Laffer  a  death  rate  of  62.5  per  cent,  in  217  cases.  Judging  from  the  result 
in  pneumonia  cases,  six  deaths  in  eleven  cases,  55.5  per  cent.,  and  in 
operative  cases  where  the  proper  treatment  has  been  instituted  early, 
this  terrific  death  rate  is  probably  largely  the  result  of  the  true  nature 
of  the  case  being  unrecognized,  or  improper  treatment  (surgical)  being 
applied. 

Treatment. — It  would  appear  that  acute  dilatation  of  the  stomach  is 
one  of  the  rare  abdominal  conditions  in  which  medical  men  can  both  advise 
and  administer  the  treatment  to  the  exclusion  of  the  surgeon.  The  first 
requisite  is  earh^  diagnosis.  Sudden  abdominal  distention  occurring  in  the 
course  of  pneimaonia  must  bring  the  thought  of  actite  gastric  dilatation  at 
once  to  the  practitioner's  mind.  Distention,  coUapse,  increased  gastric 
tympanj^  pain,  vomiting,  are  the  suspicious  signs.  Before  the  patient  is 
moribund,  often  before  the  diagnosis  is  definitely  determined,  and,  as  a 
diagnostic  step  a  stomach  tube  must  be  introduced  and  lavage  practised. 
If  the  contents  of  the  stomach  are  foul  and  copious,  or  if  there  is  much 
flatus,  relief  will  be  almost  instantaneous,  and  if  the  dilatation  occur  after 
the  crisis,  recovery  may  be  confidently  expected.  The  lavage  must  be 
])ractised  as  often  as  the  distention  occurs.  When  a  patient  is  collapsed 
\vith  running  pulse,  it  is  often  feared  that  the  passage  of  the  stomach  tube 
may  be  fatal.  This  is  a  mistake.  On  the  contrary,  the  tvibc  is  easily  passed 
and  relief  is  marked  even  in  most  desperate  cases  in  the  midst  of  an  attack 
of  pnetunonia.  The  position  of  the  patient  is  of  some  importance.  In 
distention  of  the  stomach,  as  had  been  stated,  there  is  constriction  of  the 
duodenum,  under  the  root  of  the  mesentery,  and  the  collapsed  small  intes- 
tines are  far  down  in  the  pelvis,  making  the  mechanical  obstruction  still 
more  marked.  By  turning  the  patient  on  the  right  side  or  on  the  face,  this 
clement  is  probably  largely  removed.     All  food  and  drink  by  the  mouth 


VISCEROPTOSIS  389 

must  be  interdicted.     Strychnin  and  eserin  hj'podermically  have  seemed 
of  value  in  two  of  my  cases. 

VISCEROPTOSIS. 

Synonyms. — Splanchnoptosis;  Enteroptosis;  Gastroptosis;  Glenard's  Disease. 

Definition. — A  condition  in  which,  as  a  consequence  of  relaxation  of 
the  ligaments  of  the  abdominal  viscera,  especially  those  of  the  stomach, 
large  intestine,  kidneys,  spleen,  and  liver,  these  organs  fall  below  their 
normal  position.  The  organs  more  decidedly  involved  are  the  stomach 
and  the  transverse  colon,  especially  the  right  half,  and  the  hepatic  flexure. 

Etiology. — A  satisfactory  explanation  of  the  phenomena  of  visceroptosis 
has  not  as  yet  been  offered,  though  several,  more  or  less  applicable,  have 
been  suggested.  First,  there  are  certain  predisposing  or  favoring  conditions, 
among  which  are  debilitating  and  emaciating  diseases  or  loss  of  elasticity 
of  the  abdominal  muscles  due  to  repeated  pregnancies,  to  gastro-intestinal 
auto-intoxication,  to  exhausting  hemorrhages,  or  to  damage  to  abdominal 
muscles  by  pressure  of  clothing.  The  loss  of  fat  in  emaciation,  however 
caused,  undoubtedly  favors  visceroloptosis. 

Glenard,  whose  name  is  so  closely  identified  with  the  subject  that  the 
affection  is  called  Glenard's  disease,  holds  that  a  descent  of  the  right  or 
hepatic  flexure  of  the  colon  followed  by  dislocation  of  the  transverse  colon 
is  the  primary  disturbance  in  enteroptosis.  The  hepato-colic  ligament, 
which  is  the  name  he  applies  to  the  portion  of  the  mesocolon  that  approaches 
the  right  flexure  of  the  colon,  he  says  is  naturally  very  weak,  and  can  be 
loosened  and  stretched  by  the  weight  of  the  transverse  colon,  particularly 
when  this  is  loaded  with  feces.  When  the  hepatic  flexure  of  the  colon  has 
sunk,  the  right  half  of  the  transverse  colon  also  descends  stretching  the 
gastro-colic  ligament  which  is  attached  to  the  pyloric  end  of  the  stomach. 
At  this  point  the  colon  becomes  kinked,  causing  stagnation  of  its  contents, 
followed  by  dilatation  of  the  colon  in  front  of  the  constriction.  Beyond 
this  it  contracts,  and,  according  to  Glenard,  can  be  felt  as  a  tense  cord. 
As  their  ligaments  become  loosened,  the  remaining  abdominal  viscera 
follow  the  descent  of  the  transverse  colon,  the  stomach  being  drawn  down 
by  traction  on  the  gastro-colic  ligament,  the  liver  and  kidney  following. 
Ewald  confirms  Glenard  except  that  what  Glenard  regards  as  the  con- 
tracted portion  of  the  colon  beyond  the  constriction,  and  calls  "corde 
colique  transverse,"  Ewald  believes  to  be  the  pancreas.  He  denies  also 
that  simple  kinking  of  the  colon,  uncomplicated  by  peritoneal  adhesions  or 
by  stenosing  neoplasms,  can  cause  stagnation  of  feces.  Without  assigning 
a  distinct  cause,  Ewald  emphasizes  the  fact  that  long-standing  dj^spepsias 
and  bodily  overexertion  may  create  altered  relations  of  pressure  and  tension, 
and  thus  lead  to  the  condition.  Landau  especially  emphasizes  relaxation  of 
the  abdominal  walls  as  the  primary  cause,  though  cases  are  reported  in 
which  there  is  no  such  relaxation.  Recent  studies  are  disposed  to  call  into 
play  a  congenital  factor  the  action  of  which  may  be  intensified  by  any  of  the 
various  causes  named.  In  late  fetal  life  and  early  extrauterine  life  the 
position  of  the  abdominal  viscera  is  quite  like  that  characteristic  of  the  dis- 
ease.    This  is  especially  shown  by  Joseph  Rosengart,  although  Henle  and 


390  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

other  earlier  anatomists  described  these  positions  of  the  viscera  in  young 
children.  Kussmaul'  and  Leichtenstern  are  among  those  who  regard 
the  vertical  position  of  the  stomach  and  colon  in  adults  as  a  congenital 
anomaly.  The  influence  of  adhesions  in  producing  displacements  of  the 
abdominal  viscera  must  not  be  overlooked,  but  these  are  not  included  in  the 
condition  being  described. 

Visceroptosis  is  far  more  frequent  in  women  than  in  men,  306  out  of 
404  cases  collected  by  Glenard  being  women,  tight  lacing  and  pregnancy 
being  regarded  as  the  chief  causes  of  this  difference  in  the  two  sexes.  While 
it  is  true  that  the  majority  of  cases  met  in  practice  are  true  visceroptoses,  yet 
it  must  be  admitted  that  there  are  instances  in  which  one  organ  only — as, 
for  example,  the  stomach,  the  kidneys,  the  spleen,  or  the  liver — may  be  dis- 
located in  the  manner  referred  to. 

Symptoms. — First  of  all  it  must  be  stated  that  such  a  state  of  affairs 
as  that  described  ma;'  exist  without  producing  any  symptoms.  The  symp- 
toms which  are  characteristic  are,  in  a  word,  those  of  nervous  dyspepsia, 
including  derangement  of  appetite,  and  especiallj^  anorexia,  more  rarely 
false  sensation  of  hunger,  a  sense  of  fullness  in  the  epigastrium,  noisy  belch- 
ing, various  bad  tastes,  and  drjaiess  of  the  mouth.  To  the  fullness  in  the 
epigastrium  may  be  added  various  sorts  of  pain— shooting,  burning,  etc. — 
after  eating.  There  may  be  constipation  or  an  opposite  condition  of  diar- 
rhea. Hard,  scybalous  masses  may  be  removed  by  purgatives  or  enemas, 
also  mucus  in  varying  amounts,  including  casts  like  those  in  membranous 
enteritis.  The  lower  portion  of  the  abdomen  is  distended,  and  sometimes, 
in  persons  with  thin-walled  abdomens,  the  dislocated  viscera  may  be  recog- 
nized by  their  outlines.  Especially  is  this  true  if  thej  be  dilated  with  air 
or  gas.  By  palpation  or  percussion,  displacements  may  be  recognized  with 
more  or  less  ease.  The  transition  from  stomach  to  colon  can  often  be 
recognized  by  change  of  note  on  percussion,  while  the  kidneys,  spleen,  and 
liver  may  be  recognized  by  palpation.  Among  nervous  sj'mptoms  may  be 
named  general  weakness,  depression  of  spirits,  headache  and  fullness  of  the 
head,  vertigo,  cold  feet  and  hands.  There  maj'  be  palpation  of  the  heart 
and  disturbed  sleep  or  insomnia.  As  the  result  of  all  this  disturbance 
the  patient  may  become  so  emaciated  as  to  suggest  malignant  disease. 
Chlorosis  is  often  present,  and  by  Meinert  is  regarded  as  a  constant  symp- 
tom of  the  disease;  indeed,  he  holds  that  gastroptosis  is  the  chief  cause  of 
chlorosis  in  women. 

Treatment. — When  there  are  no  symptoms  produced  by  this  unusual 
state  of  affairs,  of  course  no  treatment  is  indicated.  When  the  sjTnptoms 
are  due  to  displacement,  it  is  e\ddent  that  mechanical  measures  or  operation 
are  alone  likelj'-  to  be  useful  in  restoring  the  organs  to  their  normal  situation. 
The  former  includes  trusses  and  pads,  wliich  must  be  adapted  to  each 
case  after  a  study  by  the  instrument-maker  with  the  aid  of  the  phj^sician. 
In  ^  the  absence  of  more  elaborate  appliances  a  simple  broad  bandage 
may  be  of  ser\nce  in  relieving  the  symptom.  Various  degrees  of  success 
have  been  attained  by  these  measures.  It  is  reasonable  to  suppose  that 
pennanent  relief  can  alone  be  obtained  b}^  operation.  Treves  early  reported 
a  case  of  complete  cure  by  laparotomy  and  stitching  the  stomach.     At  the 

"Zeitschrift  fur  diatetische  und  physikasliche  Therapie,"  Bd.,  i,  1898,  S.  220. 


CATARRHAL  ENTERITIS  391 

present  day  operation  especially  for  gastroptosis  is  not  infrequent  and  is 
commonly  successful.  Our  colleagues  John  G.  Clark,  and  Alfred  C.  Wood 
have  each  devised  an  operation. 

In  a  stomach  thus  dislocated  there  are  apt  to  be  atony  and  sluggish  per- 
istalsis, which  may  result  in  the  accumulation  of  undigested  matters,  which 
are  better  removed  by  lavage.  Other  measures  useful  in  dilated  stomach 
may  also  be  expected  to  be  useful  as  well  as  those  indicated  for  nervous 
dyspepsia. 

DISEASES  OF  THE  INTESTINES. 

SIMPLE  ACUTE  CATARRHAL  ENTERITIS. 

Synonyms. — Acute  Intestinal   Catarrh;  Acute  Diarrhea;  Acute  Ileocolitis. 

Definition. — The  term  employed  is  applied  to  a  diffuse  inflammation 
which  generally  pervades  more  or  less  of  the  small  intestine  and  the  upper 
part  of  the  large  bowel.  More  circumscribed  inflammations  are  described, 
and  doubtless  sometimes  occur,  but  is  it  not  easy  to  localize  them. 

Etiology. — The  usual  causes  of  simple  intestinal  catarrh  are  overeating 
or  eating  improper  food,  and  excessive  drinking,  or  the  swaUo-ning  of  acid 
or  mineral  substances  of  an  irritating  character.  Impurities  in  drinking- 
water  and  in  the  summer  and  autumn,  maripe  fruit  are  frequent  causes. 
The  toxic  products  of  fermented  and  decomposed  food  are  also  causes. 
These  sometimes  arise  from  substances  commonly  harmless,  such  as  milk 
or  preparations  thereof.  Cream-puffs,  and  even  ice-cream,  are  among  these. 
Irritating  minerals  are  corrosive  subUmate  and  arsenic.  Although  hot 
weather  favors  intestinal  catarrhs,  especially  in  infants  and  older  children, 
they  are  not  so  much  the  direct  result  of  the  heat  as  of  its  effect  in  weakening 
the  resisting  powers  of  the  child  and  favoring  the  decompositions  and  fer- 
mentations referred  to.  The  effect  of  heat  on  the  nervous  system  of  the 
very  young  may  reasonably  be  regarded  as  a  factor  in  increasing  irritability 
of  the  gastrointestinal  tract  or  in  so  diminishing  its  functional  power  as  to 
render  the  ingesta  irritating.  Cold,  or  rather  a  chilling  of  the  body  by  a 
fall  in  temperature,  is  often  followed  by  enteritis. 

Secretion  altered  in  quantity  or  quality  has  already  been  mentioned  as 
a  cause  of  simple  noninfectious  intestinal  inflammation.  Much  spoken  of, 
but  of  inferred,  rather  than  of  demonstrated,  import,  is  excessive  biliary 
secretion,  producing  what  is  known  as  bilious  diarrhea.  When  such  diar- 
rhea is  associated  with  a  burning  sensation  at  the  anus  and  with  the  rec- 
ognized presence  of  bUe  in  the  stools,  the  term  may  be  justified,  but  it  is  to  be 
remembered  that  an  acid  reaction  of  the  alvine  dejecta  produces  a  similar 
sensation.  A  scanty  supply  of  bile  to  the  intestine,  by  deprivng  the  gut  of 
the  imporant  antiseptic  property  of  this  secretion,  may  also  favor  the 
fermentations  and  decompositions  mentioned. 

Hyperemia,  however  induced,  favors  catarrhal  enteritis.  Such  is  the 
hyperemia  secondary  to  hepatic  and  cardiac  disease,  and  to  inflammation, 
whether  traumatic  or  infectious,  in  adjacent  tissues,  whence  it  extends  by 
contiguity.  Such  is  the  inflammation  occasioned  by  peritonitis,  by  intes- 
tinal obstruction,  and  the  like.     Cachectic  and  anemic  states,  such  as  are 


392  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

secondary  to  cancer,  to  Addison's  disease,  and  to  the  last  stages  of  Bright's 
disease  and  of  tuberculosis,  are  also  favoring  causes.  Enteritis  is  also  a 
symptom  of  certain  infectious  diseases  through  their  specific  poisons,  which 
act  directly  on  the  mucous  membranes,  as  in  the  case  of  cholera,  dysentery, 
and  typhoid  fever. 

Apart  from  the  effect  of  nervous  influence  already  mentioned,  this  can- 
not be  said  to  cause  simple  enteritis.  It  is  not  unusual  for  fright  and  other 
causes  of  nervous  excitement  to  produce  diarrhea;  but  this  is  not  the  result 
of  an  enteritis,  but  of  an  increased  peristalsis  and  disturbed  vasomotor 
regulations,  and  is  properly  called  nervous  diarrhea. 

Morbid  Anatomy. — The  morbid  changes  of  simple  intestinal  catarrh  are 
variousljr  distinct.  A  hyperemia  is  naturally  to  be  expected,  and  in  the 
more  decided  cases  may  be  manifested  by  a  diffuse  redness  and  injection. 
It  is  not  often,  however,  that  these  are  demonstrable.  A  layer  of  mucus 
covering  the  mucous  membrane  of  the  bowel  more  or  less  interruptedly  is 
more  frequentl}^  present.  Nor  is  swelling  often  evident.  At  times  the  soli- 
tary follicles  are  unnaturally  distinct,  surrounded  by  a  hyperemic  circlet. 
Such  enlargements,  commonly  as  distinct  as  a  pin's  head,  may  be  as  large  as 
a  pea,  and,  becoming  filled  -with  pus,  form  little  abscesses,  which  may  rupture 
leaving  an  ulcer.  They  may  extend  to  Peyer's  patches.  ISIorc  rarely 
chronic  ulceration  results. 

Symptoms. — Diarrhea  is  the  most  constant  symptom  of  enteritis,  in- 
volving the  part  of  the  intestinal  tract  named  in  the  definition.  The  result- 
ing stools  consist  of,  first,  ordinary  fecal  contents  of  the  small  and  large  in- 
testine, often  offensive;  but,  as  they  continue,  they  become  more  and  more 
watery,  almost  colorless.  There  may  be  but  two  or  three,  or  theie  may  be 
20  or  more.  They  contain  more  or  less  mucus,  and  are  often  frothy  and 
associated  with  flatus.  With  diminished  consistence  the  odor  may  grow  less 
obnoxious,  until  totally  absent.  At  other  times  it  is  persistently  offensive. 
Minute  examination  recognizes  in  these  discharges  coliunnar  epitheliimi 
variously  altered,  enlarged,  granular,  and  fragmentary,  -j^'ith  nuclei  ob- 
scured or  absent,  also  various  nonpathogenic  bacilli  and  cocci,  including  the 
bacterium  coli  commune,  yeast  fungus,  crystals  of  triple  phosphate,  oxalate 
of  lime,  cholesterin,  and  undissolved  food  matters.  The  reaction  of  the  dis- 
charge may  be  neutral  or  acid. 

Next  to  diarrhea  is  pain,  usually  colicky,  varying  greatly  in  degree; 
often,  indeed,  in  the  milder  forms,  absent.  There  is  rarely  tenderness,  but 
palpation  may  elicit  gurgling  and  the  signs  of  gaseous  distention.  Thirst 
and  oliguria  are  natural  consequences  of  the  free  discharge  of  water.  There 
is  usually  Httle  fever,  the  rise  of  temperature  rarely  exceeding  one  or  two 
degrees,  and  the  higher  grades  suggest  tubercular  inflammation  of  the 
bowel.  The  appetite,  at  first  little  altered,  ultimately  fails.  Very  rarely 
do  the  ordinary  diarrheas  in  children  and  adults  terminate  in  collapse. 

It  is  reasonable  to  expect  modification  of  the  foregoing  symptoms  as 
the  result  of  locaHzed  inflammation,  as  contrasted  with  those  of  the  more 
diffuse  form  just  described.  Thus,  the  presence  of  jaundice  suggests  the 
Iirobability  that  the  duodenum  is  especially  involved.  In  such  cases  the 
urine  may  also  be  jaundiced,  and  there  may  be  added  other  symptoms 
commonly  associated  with  jaundice.     In  the  absence  of  this  symptom  there 


CATARRHAL  ENTERITIS  393 

is  no  sign  that  points  to  the  duodenum  as  the  special  seat  of  the  inflamma- 
tion. On  the  other  hand,  jaundice  is  by  no  means  always  present,  even  if 
the  duodenum  is  involved.  Duodenitis  is  often  associated  with  acute 
gastritis,  spreading  from  the  stomach — gastroduodenitis.  Inflammation 
limited  to  the  duodenum  is  unattended  with  diarrhea. 

When  there  is  also  involvement  of  the  whole  of  the  large  intestine — 
ileocolitis.  When  this  is  the  case,  while  the  lower  down  the  inflammation, 
the  purer  the  mucus  and  the  more  there  is  of  tenesmus,  the  mucus  remains 
separate  and  unmixed  with  the  fecal  matter,  which  may  contain  undigested 
particles  of  food,  such  as  muscular  fibers,  starch,  and  fat  corpuscles.  A 
diaiThea  in  which  these  undigested  portions  of  food  are  visible  to  the  naked 
eye  is  known  as  lienteric.  Gmelin's  nitric  acid  test  for  the  biliary  coloring- ' 
matters  ceases  in  health  at  the  sigmoid  flexure,  so  that  if  this  reaction  is 
obtainable  in  the  liquid  discharges,  it  implies  that  the  excessive  peristalsis 
has  affected  also  the  large  bowel,  by  which  the  bile  is  carried  through 
with  abnormal  rapidity.  The  green  stools  of  children,  and  more  rarely 
of  adults,  also  indicate  a  large  quantity  of  bile.  Simple  feverish  states, 
however,  may  have  the  effect  also  of  interfering  with  the  proper  digestion 
of  food  matters,  which  may  appear  in  the  discharges  in  consequence. 
Some  information — not,  however,  too  much  to  be  relied  upon — may  be 
derived  from  the  seat  of  tenderness  and  colicky  pains.  When  these  are  in 
the  middle  or  inferior  part  of  the  abdomen,  they  point  to  the  small  intestine; 
when  in  the  upper  and  lateral  parts,  to  the  large.  A  form  of  acute  gas- 
troenteric colitis,  characterized  by  profuse  vomiting,  purging,  and  painful 
cramp,  formerly  called  cholera  tnorbus  demands  special  notice. 

Etiology. — The  intensity  of  the  symptoms  and  their  similarity  to  those 
of  true  cholera  justify  a  suspicion  that  a  specific  organism  is  responsible  for 
cholera  nostras  as  well  as  for  true  cholera.  No  single  bacillus  has,  however, 
been  settled  upon.  Especially  frequent  are  these  attacks  in  the  hot  weather 
of  July  and  August,  though  cold  and  dampness  are  also  regarded  as  predis- 
posing causes.  So  are  fatigue  and  debilitated  state  of  the  system.  Young 
adults  and  persons  in  the  prime  of  life  are  more  frequently  victims  than 
either  the  very  old  or  very  young. 

Symptoms. — The  victim  of  this  form  of  enteritis  is  commonly  seized 
suddenly,  often  at  night,  with  severe  cramp,  vomiting,  and  purging.  The 
first  vomitus  is  the  food  last  ingested,  but  this  is  rapidly  succeeded  by 
bilious  matter,  and  still  later  by  almost  pure  water.  The  same  may  be  said 
of  the  bowel  discharges,  which  follow  each  other  in  rapid  succession — in 
fact,  become  at  times  almost  continuous.  They  present  ultimately  all  the 
physical  characters  of  the  rice-water  discharges  of  true  cholera. 

Diagnosis. — This  diagnosis  of  acute  intestinal  catarrh  is  ordinarily  easy, 
by  attention  to  the  symptoms  previously  detailed,  including  those  more  or 
less  peculiar  to  the  more  circumscribed  localities  referred  to.  From  typhoid 
fever  acute  enteritis  is  usually  easily  distinguished  by  its  short  duration, 
minor  fever,  and  the  absence  of  the  characterisic  course  the  fever  takes  in 
the  infectious  disease,  and  absence  of  the  spots  which  so  invariably  make 
their  appearance  on  the  eighth  day  in  typhoid.  The  Widal  test  in  the  latter 
disease  also  aids  the  diagnosis. 

During  cholera  epidemics  mild  cases  of  this  disease  are  not  recognizable 


394  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

symptomatically  from  the  severer  colliquative  forms  of  diarrhea.  Under 
these  circimistances,  bacteriological  examination  should  be  made.  The 
importance  of  a  correct  diagnosis  will  be  appreciated  when  it  is  remembered 
that  indifference  in  the  treatment  of  simple  diarrhea  may  not  seriously  affect 
the  result,  while  such  treatment  of  a  case  of  cholera,  however  mild,  may 
result  disastrously. 

Prognosis. — This  is  always  favorable  with  prompt  and  judicious  treat- 
ment, recovery  taking  place  in  from  one  to  three  days,  as  a  nile,  rarely 
longer. 

Treatment. — Many  cases  of  acute  catarrhal  enteritis  recover  under  rest 
and  restricted  diet,  the  degree  of  which  necessarily  depends  on  the  severity 
of  the  case.  The  simple  withdrawal  of  all  food,  the  substitution  of  plain 
milk,  or,  in  severe  cases,  of  boiled  milk,  for  the  usual  food,  generally  suffices. 

No  attempt  should  be  made  to  lock  up  the  bowel  until  all  irritating  mat- 
ters are  removed,  and  it  is  often  desirable  to  give  an  aperient,  castor  oil  being 
the  best,  though  the  unpleasantness  of  the  dose  often  precludes  this  valuable 
remedy.  In  such  event  calomel  in  divided  doses,  the  solution  of  the  citrate 
of  magnesium,  Rochelle  salts,  or  Hiinyadi  water  may  be  substituted.  When 
there  is  much  pain,  larger  doses  of  opium  may  be  necessary,  especially  if  hot 
fomentations,  mustard  plasters,  or  turpentine  stupes  fail  to  produce  the 
desired  effect.  When  there  is  elevation  of  temperature,  no  better  means 
than  the  local  application  of  ice  can  be  found  to  relieve  pain.  Astringents 
are  rarely  necessary,  but  in  the  absence  of  other  measures  maj^  be  used. 
Tannic  or  gallic  acid  in  5  grain  doses  (0.33  gm.)  may  be  given  separately 
or  combined  with  opium. 

A  few  grains  of  bismuth  subnitrate  every  two  or  three  hours,  fortified 
with  1/8,  1/4,  1/2  grain  (0.0082,0.015,0.033  gm.)  of  opitun,  or  1/2  ounce  (15.5 
gm.)  of  chalk  mixture  with  a  fluidram  (4  c.c.)  more  or  less  of  paregoric  may 
be  added.  Salol  in  doses  of  3  to  5  grains  is  an  admirable  adjuvant  to  bis- 
muth through  its  antiseptic  properties. 

Treatment  of  Choleraic  Forms  of  Enteritis. — Opium  is  almost  indispens- 
able to  the  successful  treatment  of  an  attack  of  cholera  morbus.  The  best 
method  of  exhibition  is  bj^  the  hypodermic  needle,  more  especially  because 
everjrthing  given  by  the  mouth  is  apt  to  be  promptly  ejected.  For  an 
adult  less  than  1/4  grain  (0.0165  gm.)  of  morphin  is  hardly  to  be  thought  of. 
On  the  other  hand,  such  a  dose  will  often  act  magically.  It  should  be  as- 
sociated with  diffuse  counterirritation  over  the  abdomen  by  mustard,  while 
the  hot  bath  may  be  added,  if  the  symptoms  do  not  jdeld. 

In  the  absence  of  the  hypodermic  needle,  remedies  must  be  given  by 
the  mo\ith.  The  association  with  morphin  of  the  hot  aromatics,  such  as 
ginger  and  cloves,  seems  to  aid  its  retention. 

The  nausea  may  be  controlled  by  ice,  by  cold  carbonated  waters,  by 
pieces  of  ice  swallowed  whole,  or  by  champagne.  The  latter  is  particularly 
appropriate  when  stimulants  are  needed,  as  constantly  happens.  When 
there  is  a  tendency  to  collapse,  whisky  and  ether  may  be  injected  under  the 
skin,  while  enteroclysis  and  hypodermoclysis  may  be  needed  for  the  same 
reasons  as  in  true  chlorea — the  restoration  of  the  water  lost  from  the  system. 

For  the  nausea  counterirritation  by  mustard  plasters  should  be  used, 
pieces  of  ice  swallowed  entire,  while  too  much  water  should  be  disallowed. 


CHRONJC  ENTERITIS  395 

Champagne  and  cold  carbonated  waters  may  be  used  for  this  purpose. 
The  latter  may  be  combined  with  milk,  while  the  old  reliable  remedy  of 
qual  parts  of  milk  and  lime-water  should  not  be  forgotten. 


CHRONIC  CATARRHAL  ENTERITIS. 

Synonyms. — Chronic  Enterocolitis;  Ulcerative  Colitis;  Mttcous  Colitis; 
Chronic  Diarrhea. 

Definition.— A  chronic  inflammation  of  more  or  less  of  the  large  and  small 

intestine,  with  or  without  ulceration. 

Etiology. — Chronic  enteritis  may  remain  after  repeated  attacks  of  the 
acute  form,  or  it  may  arise  de  novo,  however  induced,  favored  by  whatever 
occasions  passive  congestion.  Such  favoring  causes  are  diseases  of  the  liver 
or  heart,  feeble  and  anemic  states,  and  the  defective  nutrition  consequent 
theron.  Chronic  exhausting  diseases,  such  as  tuberculosis  and  Bright's 
disease,  may  act  in  this  way  also.  Dysentery  is  a  frequent  cause  of  chronic 
intestinal  catarrh,  a  remnant  of  the  acute  process. 

Morbid  Anatomy. — The  primary  condition  is  that  of  acute  catarrh,  and 
in  many  cases  the  morbid  changes  do  not  exceed  those  of  acute  catarrh,  being 
simply  permanent,  or  later  more  pronounced.  In  others,  still  more  decided 
changes  are  found,  chiefij^  in  the  lower  part  of  the  ileum  and  colon.  These 
are  mainly  ulcerative,  but  include  also  discolorations  due  to  hyperemia, 
blood  extravasation  and  pigmentation  succeeding  it,  thickening  of  the  coats 
of  the  bowel,  and  contraction  of  partly  healed  ulcers.  There  may  be  stenosis 
or  the  opposite  condition  of  dilatation.  Such  ulceration  is  distinct  from 
that  of  tuberculosis,  typhoid  fever,  and  syphilis.  It  ma}^  be  folliciilar,  as 
often  seen  in  the  diarrheal  affections  of  children,  more  rarely  in  adults,  or 
there  may  be  large  ulcers  or  large  areas  of  ulceration.  The  remna,nt  of 
mucous  membrane  is  often  pigmented  and  slate-colored,  and  a  pseudo- 
polyposis  sometimes  results  from  contraction.  In  the  small  intestine  the 
pigment  is  apt  to  be  deposited  on  the  ends  of  the  villi  and  in  rings  around  the 
solitary  follicles,  or  in  their  centers,  producing  the  "shaven-beard  appear- 
ance." The  surface  of  the  bowel  is  more  or  less  covered  with  mucous  and 
purulent  secretion  incident  to  the  inflammation.  Still  another  sort  of 
ulceration,  from  the  etiological  standpoint,  is  found  at  the  bottom  of  saccules 
of  the  large  intestine  in  which  scybala  or  hard  fecal  masses  have  lain  a  long 
time.  Ulceration,  too,  may  result  though  rarely,  from  encroachment  from 
without  by  various  kinds  of  disease  of  the  peritoneimi,  including  cancer, 
tuberculosis,  and  the  like.  Atrophy  of  the  mucous  membrane  of  the  bowel 
is  also  one  of  the  results  of  chronic  enteritis,  not  usually  recognizable  before 
death. 

There  may  even  be  atrophy  not  only  of  the  mucous  membrane,  with 
destruction  of  the  glands,  but  also  of  all  the  coats  of  the  small  and  large 
intestines. 

Symptoms. — These  are  not  uniform.  While  there  is  often  more  or  less 
diarrhea,  this  may  be  absent,  or  substituted  by  constipation,  while  constipa- 
tion and  diarrhea  frequently  alternate.  More  characteristic  of  the  stools  is 
the  large  amount  of  mucous  matter  contained  in  them.     This  may  be  present 


39G  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

in  the  shape  of  "sago"-hke  masses  or  "mucous"  granules,  yellow  or  brown- 
ish-yellow, bile-stained  also  from  the  small  intestine.  Bile-stained  mucus  is 
present  only  when  there  is  abnormally  rapid  peristalsis  of  the  large  bowel, 
which  causes  the  mucus  to  pass  rapidly  beyond  the  sigmoid  before  the  bile  is 
decomposed.     Ulceration  may  cause  the  presence  of  blood  in  the  stools. 

Mucous  Colitis. — -A  variety  of  chronic  colitis  known  as  mucous  colitis  or 
membranous  enteritis  is  characterized  by  the  discharge  of  large  masses  of 
mucus,  forming  at  times  complete  casts  of  the  bowel.  It  is  more  frequent 
in  women,  this  sex  including  80  per  cent,  of  recorded  cases,  according  to  W. 
A.  Edwards.  It  may  occur  also  in  children.  Its  subjects  are  usually 
women  of  the  nervous  type,  and  most  of  the  symptoms  are  nervous  in  char- 
acter. It  is  commonly  associated  ^'v-ith  constipation.  At  intervals,  however, 
occur  attacks  of  abdominal  pain  and  tenderness,  sometimes  accompanied  Ijy 
tenesmus  and  followed  by  discharges  of  the  mucoid  matter  referred  to. 
vSuch  attacks  may  be  excited  by  mental  emotion  of  various  kinds.  The 
mucoid  material  itself  seems  to  be  the  direct  result  of  an  increased  activity 
of  the  mucous  glands,  which,  with  the  mucous  membrane,  are,  however, 
commonly  intact  after  the  separation  of  the  large  mucous  casts.  These 
casts  are  constantly  mistaken  for  worms  b}'  the  laity.  Minute  examination 
recognizes  more  or  less  numerous  cells,  round  and  columnar,  entangled  in 
the  mucus,  sometimes  also  cholesterin  plates  and  triple  phosphate  crystals. 

Throughout  the  numerous  attacks  nutrition  is  commonly  well  main- 
tained, and  the  woman  subject  appears  plump  and  well  nourished.  At 
other  times  there  is  gradual  emaciation. 

Diagnosis.^ — This  is  always  easy,  except  as  to  the  determination  of  the 
portion  of  the  bowel  involved  or  the  presence  of  ulceration.  Differences  in 
the  character  of  the  mucus,  as  previously  noted,  will  aid  in  the  diagnosis, 
while  the  constant  or  intermittent  presence  of  blood  and  pus  or  fragments  of 
tissue  in  the  stools  point  to  the  ulcerative  condition.  Ulceration  is  some- 
times found  postmortem  where  no  symptoms  were  present  before  death. 
In  the  recttun,  and,  indeed,  as  high  as  the  sigmoid  flexure,  ulcer  may  be 
recognized  by  specular  examination.  Deep-seated  ulceration  may  cause  cir- 
cumscribed peritonitis  or  may  produce  abscess.  The  presence  of  scybala, 
surrounded  with  mucus,  points  to  inflammation  of  the  rectum  or  colon  as 
far  up  as  its  transverse  portion.  It  is  not  possible  to  diagnose  the  presence 
of  atrophy  of  either  bowel. 

Prognosis. — The  prognosis  in  all  forms  of  chronic  intestinal  catarrh  is 
grave  so  far  as  recovery  is  concerned,  and  treatment  avails  little  in  many 
cases.  The  disease,  however,  extends  over  months,  and  even  years,  before 
the  patient  succumbs,  and  recovery  is  sometimes  complete,  quite  inde- 
pendent of  treatment. 

Treatment. — As  in  the  case  of  acute  catarrhal  enteritis,  rest  is  an 
important  condition  of  success  in  the  treatment  of  this  disease.  Next,  we 
must  select  a  diet  with  a  minimum  of  waste,  so  that  there  may  be  as  little 
irritating  residue  as  possible.  Milk,  beef  juice  and  the  albuminous  type  of 
foods  are  the  chief  of  these.  Still  less  irritating  are  they  if  partly  digested 
before  being  taken  into  the  stomach.  Thus,  milk  may  be  peptonized,  and 
meat  also,  but  the  beef  peptonoids  of  the  manufacturers  should  not  be  em- 
ployed.    It  is  difficult  to  ascertain  the  relative  nourishing  power  of  these 


CHRONIC  ENTERiriS  397 

peptonoids  with  the  thought  that  they  in  any  adequate  degree  can  replace 
milk  or  meat  in  the  diet.  This,  then,  should  be  a  fundamental  principle  of 
treatment — to  furnish  a  diet  with  a  minimum  of  waste. 

When  it  is  remembered  that  chronic  intestinal  catarrh  is  seated  mainly 
in  the  large  intestine,  it  is  manifest  that  to  reach  it  with  remedies  admin- 
istered in  the  ordinary  way  is  difficult,  and  that  it  is  more  than  likely  that 
such  remedies  are  absorbed  or  decomposed  before  they  arrive  at  the  seat  of 
the  disease.  It  is  barely  possible  that  after  prolonged  administration 
certain  drugs,  as  nitrate  of  silver,  will  ultimately  reach  the  seat  of  ulceration 
and  stimulate  it  to  heal.  Prolonged  use  must,  therefore,  be  pursued  with 
any  remedies  thus  administered.  Nitrate  of  silver  and  the  sulphate  of 
copper  are  the  two  which  possess  most  reputation.  The  doses  are  1/4 
grain  (0.0155  g™-)  of  each  three  times  a  day,  or  a  smaller  quantity  more 
frequently.  The  acetate  of  lead  may  be  substituted  in  doses  of  2  grains 
(0.132  gm.).  The  latter  is  more  astringent,  but  is  less  likely  to  excite  heal- 
ing. All  these  remedies  are  commonly  combined  with  opium  in  suitable 
doses.  Subnitrate  of  bismuth  in  large  doses,  1/2  to  i  dram  (2  to  4  gm.), 
is  strongly  recommended  by  some.  It  undoubtedly  diminishes  the  dis- 
charges, but  how  far  it  is  curative  is  uncertain. 

The  natural  astringent  waters,  such  as  the  Rockbridge  alum  and  other 
alum  waters  in  this  countrj^-  have  earned  some  reputation  in  the  treatment 
of  chronic  intestinal  catarrh,  but  improvement  under  their  use  is  always  more 
marked  at  the  springs  themselves,  showing  that  some  effect  must  be  ascribed 
to  the  change  of  scene  and  air  and  to  the  salubrious  climate  of  the  localit3-. 

Should  these  measures  fail,  and  there  is  evident  involvement  of  the 
colon,  irrigation  of  the  bowel  may  be  practised.  This  is  done  by  means 
of  a  fountain  syringe,  or  a  funnel  in  connection  with  a  tube,  which  is  carried 
high  up  into  the  bowel,  the  patient  being  placed  on  his  back  with  a  pillow 
under  his  hips.  The  fluids  used  are  solutions  of  nitrate  of  silver,  sulphate  of 
zinc,  and  boric  acid.  At  first  warm  water,  say  at  100°  F.  (37.7°  C),  should 
be  run  in  very  slowly  to  the  amount  of  two  to  three  pints  (i  to  i  1/2  liters). 
Then  solutions  of  any  of  the  foregoing  substances,  of  silver  nitrate  and 
zinc  sulphate,  strength  of  3  to  4  1/2  parts  to  1000  or  i  1/2  to  2  grains  to  the 
oz.  (o.i  gm.  to  0.13  gm.  to  30  c.c);  beginning  with  the  weaker  solutions. 
Salicylic  acid  may  be  used  in  two  per  cent,  solution,  boric  acid  in  one  per 
cent,  solution,  or  a  one  per  cent,  solution  of  salicylic  and  boric  acids  com- 
bined. A  one  per  cent,  solution  of  tannic  acid  is  also  recommended,  as  well 
as  of  corrosive  sublimate,  but  the  latter  is  exceedingly  irritating  and  the 
strength  of  the  solutions  should  not  exceed,  at  first,  i  115,000,  which  may 
be  increased,  if  well  borne.  The  nitrate  of  silver  has,  on  the  whole,  the 
best  reputation.  A  preliminary  anodyne  enema  of  30  minims  (i  gm.)  of 
laudanum  may  be  given,  if  needed,  or  a  suppository  of  extract  of  opium,  say 
one  grain  (0.066  gm.).  Great  care  must  betaken  to  allow  the  solutions  to 
pass  in  slowly,  the  hips  being  elevated  by  a  pad  or  pillow.  To  be  effectual, 
the  treatment  must  be  patiently  prolonged,  especially  the  dietetic  part, 
and  not  weeks,  but  months,  of  patient  perseverance  insisted  upon.  It  has 
been  suggested  that  these  irrigations  should  be  made  in  intractable  cases 
through  the  appendix  whose  opened  tip  has  been  sewed  to  the  abdominal 
wall.     (Weir's  operation  of  appendicostomy.) 


398  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Mention  should  be  made  of  the  opposite  treatment  of  chronic  mucous 
colitis  by  a  coarse  diet  containing  a  large  proportion  of  indigestible  residue, 
especially  cellulose  derived  from  bread  made  from  flour  containing  a  large 
proportion  of  husks  (Graham  bread) ;  all  varieties  of  legimiinous  vegetables, 
peas,  beans,  etc.,  with  their  husks,  vegetables  containing  much  cellulose, 
fruits  with  small  seeds  and  thick  skins,  like  currants,  gooseberries  and  grapes, 
together  with  large  quantities  of  fat,  especially  butter  and  bacon;  also  weak 
saline  mineral  waters,  of  which  Saratoga  water  is  the  type  in  this  country 
and  Kissingen,  Homburg,  and  Racocsky  abroad.  This  diet  is  recommended 
by  von  Leube,  von  Noorden,  Boas,  Einhorn,  Westphallen,  and  Hcmmeter. 
Some,  however,  especially  v.  Noorden  would  make  the  change  suddenly, 
others  gradually. 

The  effect  is  claimed  to  be  to  give  the  stools  after  two  to  four  days  a 
normal  consistence  and  normal  appearance.  No  purgatives  are  required. 
It  is  claimed  that  the  results  of  this  treatment  are  much  more  satisfactory 
than  the  older  light  diet  composed  of  easily  digested  foods,  such  as  milk 
foods,  broths,  white  bread,  and  the  like.  Von  Noorden  calls  it  the  "dietetic 
exercise  treatment  of  the  intestine"  as  contrasted  with  the  older  "protective 
rest  treatment." 

The  treatment  of  the  nervous  state  which  accompanies  mucous  colitis 
deserves  especial  mention.  The  patients  whether  men  or  women  keep  a 
close  watch  upon  each  and  every  stool  passed,  when  mucus  is  present  they 
are  much  depressed,  they  are  elated  when  it  is  absent.  Consequently  all 
patients  should  be  warned  against  looking  at  the  stool,  the  warning  must 
be  constantly  repeated.  In  addition  the  patients  should  keep  mentally 
employed;  to  this  end  they  thould  have  some  light  physical  work  which  is 
not  merely  automatic.  If  they  are  financially  able,  travel  in  new  and  in- 
teresting regions  is  advisable.  Camp  life  with  its  slight  hardships  may  be 
tried. 

DIARRHEAS  OF  CHILDREN. 

The  importance  of  these,  and  some  specialization  in  their  symptoma- 
tology, demand  a  separate  consideration.  Three  forms,  more  or  less  dis- 
tinct, are  recognizable — viz.,  acute  dyspeptic  enteritis,  cholera  infantum, 
and  acute  enterocolitis. 

Acute  Dyspeptic  Enteritis. 
Synonym. — Acute  Dyspeptic  Diarrhea. 

Definition. — An  acute  inflammation  of  the  small  intestine  due  to  diet 
unsuited  to  the  infant. 

Etiology. — The  commonest  cause  by  all  means  is  artificial  food  in  infants 
and  improper  food  in  older  children,  but  the  errors  in  diet  referred  to  do  not 
necessarily  consist  in  unnatural  foods  stibstituted  for  the  mother's  milk. 
The  latter  itself  may  be  altered  in  quality  by  emotional  causes,  by  improper 
food,  and  by  improper  hygiene;  or  the  child  may  be  too  liberally  supplied 
by  overfrequent  nursing. 

Milk  used  for  artificial  feeding,  the  most  carefully  selected,  is  unnatural, 
and  is  probably  the  most  frequent  cause  of  dyspeptic  diarrhea  in  children 


DYSPEPTIC  DIARRHEA  OF  CHILDREN  399 

otherwise  well  cared  for.  Two  factors  in  this  are  active:  first,  the  relatively 
greater  indigestibility  of  the  food  thus  applied;  and,  second,  the  bacteria 
and  their  toxic  products  which  develop  in  it  before  or  after  ingestion.  In 
infantile  diarrhea  the  number  of  species  of  bacteria  is  greatly  increased, 
but  no  one  or  more  species  has  as  yet  been  shown  to  possess  a  specific  causal 
effect. 

There  are  also  predisposing  influences  which  facilitate  the  action  of  the 
essential  causes.  These  are,  especially,  dentition  and  the  extreme  heat  of 
summer.  The  effect  of  the  former  is  learned  in  the  experience  of  every 
mother,  while  the  extraordinary  frequency  of  infantile  diarrhea  in  summer 
attests  the  latter.  It  is  evident,  too,  that  constitutional  weakness  and  bad 
hygiene  must  also  cooperate  to  diminish  the  resisting  power  of  infants  to 
other  causes.  Hence  it  is  that  the  children  of  the  delicate,  the  poor,  and  the 
unclean  suffer  most. 

Morbid  Anatomy. — This  seldom  exceeds  the  stage  of  catarrhal  swelling, 
alread}^  described  when  treating  of  the  enteritis  of  adults. 

Symptoms. — Usually  there  is  an  intoxication  shown  in  the  beginning 
restlessness,  with  slight  fever,  which  seldom  becomes  high.  Such  restlessness 
may  be  due  to  nmisea  or  to  colicky  pain.  The  nausea  may  go  on  to  vomiting 
or  not,  but  purging  soon  occurs.  Sudden  onset  is  characteristic.  Some- 
times the  first  symptom  is  diarrhea.  The  stools  are  at  first  copious  and 
offensive,  often  yeasty  and  sovir,  and  general!}^  contain  particles  of  coagu- 
lated milk  or  other  undigested  food,  such  as  unripe  fruit,  if  the  child  is  old 
enough  to  eat  it.  At  first  infrequent,  they  become  more  mmaerous,  more 
scanty,  acquire  sometimes  a  green  color  and  sometimes  contain  mucus,  rarely 
blood.  In  other  words,  the  condition  passes  over  into  enterocoUtis.  There 
may  be  but  three  or  four  stools  or  there  may  be  20  or  more  in  the  24  hours. 

In  other  cases  fever  is  more  decided,  and  the  temperature  may  rise 
rapidly  to  104°  P.  (40°  C.) ;  there  are  great  thirst  and  scanty  urine.  Even 
when  there  is  no  fever,  emaciation  is  rapid,  and  the  child  falls  away  amazingly 
in  a  few  days. 

Diagnosis. — The  sudden  onset  and  the  character  of  the  stools  are  dis- 
tiactive  and  scarcely  mistakable.  The  small  amount  of  mucus  distinguishes 
them  from  those  of  Ueo-colitis,  and  the  absence  of  serous  discharge  from 
those  of  cholera  infantum. 

Prognosis. — This,  among  the  better  classes,  is  commonly  favorable, 
but  among  the  weak,  puny,  and  half-star\-ed  children  of  the  poor  large 
numbers  perish,  especially  in  hot  weather.  The  disease  may  pass  over  into 
the  much  more  serious  affection  of  entero-colitis. 

Prophylaxis. — Proper  food  is  the  keynote  to  both  prevention  and  treat- 
ment of  all  the  diarrheal  diseases  of  childhood.  Infants  should  be  nursed 
whenever  practicable,  either  by  the  mother  or  a  wet  nurse.  Holt  fovmd 
only  2%  of  194s  cases  summer  diarrhea  had  been  totally  breast  fed.  This 
failing,  some  proper  modification  of  cows  mUk  shovdd  be  used  in  children 
under  1 2  months  of  age  (the  reader  is  referred  to  the  books  on  Diseases  of 
Children  by  Holt  and  by  Rotch  for  the  details  of  these  measures) .  Older 
children  shovdd  also  be  fed  rationally  and  rules  governing  this  feeding  can 
also  be  foimd  in  the  voliunes  referred  to.  Especial  care  is  directed  to  sum- 
mer-time.    The  researches  carried  on  under  the  auspices  of  Rockerfeller 


400  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Institute  show  that  mortality  from  these  diseases  was  2.5%  in  winter  and 
10.5  %  in  summer.  Avoidance  of  patent  infant  foods  is  an  important  point 
in  preventing  these  diseases. 

Treatment. — The  regiilation  of  diet  is  of  the  utmost  importance.  It  is 
better  to  give  the  child  nothing  except  a  little  cold  water  or  barley  water 
than  unsuitable  food,  while  any  food  that  is  given  should  be  very  much 
diluted,  and  should  be  scanty  rather  than  overabundant.  Too  much  food 
is  often  given.  Nothing  is  better  than  milk  properly  modified.  This 
modified  milk  may  be  peptonized  under  certain  circumstances,  if  the 
mother's  milk  or  that  of  a  wet-nurse  be  unobtainable.  Plain  fresh  cow's 
milk  well  diluted  may  do  as  well  in  older  children.  In  fact,  all  milk  foods 
should  be  diluted  with  Vichy  water,  lime-water,  or  plain  water.  Animal 
broths,  however  dilute,  are  not  advised,  though  occasionally  beef  juice  is 
well  borne  when  milk  has  not  been,  especially  in  children  two  or  more  years 
old.  Albiimen  water,  made  by  mixing  the  albumen  of  one  or  two  eggs  with 
I  pint  (1/2  liter)  of  sterilized  water,  is  much  more  suitable. 

The  principles  of  treatment  are  similar  to  those  of  enteritis  in  adults. 
A  primary  purge  is  commonly  indicated.  Calomel  and  calcined  magnesia 
are  very  suitable,  though  castor  oil  is  here  also  useful.  After  the  piirge, 
bismuth  subnitrate  or  prepared  chalk,  in  doses  of  2  1/2  grains  (0.165  gm.) 
for  a  child  a  year  old,  with  1/2  grain  (0.033  g™-)  of  salol  may  be  given 
every  two  or  three  hours.  If  there  is  pain,  1/24  to  1/12  grain  (0.0027  to 
0.0054  gm.)  of  opium  maj^  be  added  each  time  or  every  other  dose,  as  may 
be  demanded  by  circumstances.  An  attempt  should  first  be  made  to 
relieve  pain  by  gentle  counterirritation,  as  by  weak  mustard  plasters  or  a 
plaster  of  mixed  spices,  wet  in  whishy  or  alcohol,  and  known  as  a  "spice 
plaster,"  and  worn  continuously.  Deodorized  tincture  of  opium  or  pare- 
goric may  be  substituted  for  the  whisky.  Astringents  are  seldom  necessary 
in  childi-en's  diarrhea.  Chalk  mixture,  to  which  a  few  drops  of  paregoric 
may  be  added,  is  an  efficient  remedy. 

The  hygienic  surroundings  of  the  child  are  important.  Frequent  bath- 
ing; light,  cool  dressing  in  warm  weather;  and  fresh  air  at  all  times  are  indis- 
pensable. The  patient  should  be  removed  from  cit}^  air  to  the  country 
or  seaside,  when  possible;  and  when  this  is  not  possible,  frequent  excursions 
should  be  made  to  the  country  or  on  an  adjacent  river.  It  is  not  desirable 
to  keep  the  child  on  the  lap  any  more  than  is  necessary. 


Acute  Ileo-colitis. 

vSynonyms. — Acute  Entero-colitis;  Follictdar  Enteritis;  Follicidar  Dysentery. 

Definition. — An  inflammation  more  severe  than  dyspeptic  enteritis, 
chiefly  of  the  ileum  and  colon,  affecting  especially  the  lymph  follicles. 
■  Etiology. — Entero-colitis  is  also  a  disease  of  the  hot  months  and  of 
teething.  It  is  met,  however,  in  the  cooler  seasons.  It  is  produced  by  the 
same  causes  as  dyspeptic  diarrhea.  It  is  more  frequent  between  the  ages 
of  sbc  and  eighteen  months — second  summer — and  is  not  infrequent  in  the 
third  and  fourth  years.  It  may  be  a  termination  of  dyspeptic  diarrhea  or 
of  cholera  infantum. 


ILEO-COLITIS  OF  CHILDREN  401 

Morbid  Anatomy. — The  morbid  changes  are  more  positive  than  in 
acute  dyspeptic  diarrhea,  and  are  found  chiefly  in  the  ileum  and  colon.  In 
the  first  stage  the  mucous  membrane  is  congested  and  swollen,  while  the 
solitary  follicles  and  Peyer's  patches  are  more  distinct.  The  epithelium 
is  exfoliated  in  places.  As  the  disease  continues  into  the  second  stage,  say 
after  the  first  week,  the  enlarged  follicles  and  Peyer's  patches  become  ulcer- 
ated. The  changes  may  end  here  or  may  become  more  extensive,  constitut- 
ing the  third  stage,  the  ulcers  enlarging  and  deepening  to  the  muscular 
coat,  with  the  separation  of  a  slough.  Or  there  may  be  a  diffuse  infiltration 
of  the  bowel  with  small  cells,  producing  a  decided  thickening  of  the  same, 
with  more  or  less  obliteration  of  its  distinctive  structure.  The  process  may 
be  so  intense  as  to  cause  coagulation-necrosis — false  membrane. 

Symptoms. — The  disease  maj'  begin  as  a  dyspeptic  diarrhea,  also  as  a 
cholera  infantum.  It  is  much  more  serious  than  dyspeptic  diarrhea,  as  evi- 
denced by  the  higher  fever,  which  rises  rapidly  to  104°  F.  (40°  C),  but  still 
remains  lower  than  in  cholera  infantum.  Vomiting  is  less  common  than  in 
dyspeptic  diarrhea  or  cholera  infantum.  There  are  decided  abdominal 
pain  and  a  tense,  swollen  belly.  The  fecal  discharges,  which  are  at  first  pain- 
less, are  small  in  quantity  and  contain  much  mucus  and  even  a  little  blood. 
They  vary  in  frequency  from  15  to  30  in  the  24  hours,  and  occur  more 
frequently  during  the  day.  The  disease  may  abate  at  this  stage  and  con- 
valescence be  established,  though  recovery  remains  slow.  Or  the  symp- 
toms may  increase  in  severity,  the  fever  persist,  and  the  stools  be  painful 
and  small,  consisting  mainly  of  mucus  and  blood.  Commonly  odorless, 
they  may  also  be  extremelj^  fetid.  The  urine  is  scanty,  of  high  specific  grav- 
ity, and  deposits  mixed  urates.  The  child  wastes  almost  to  a  skeleton,  the 
skin  becomes  loose  and  flabby,  and  the  "old  man"  appearance  is  assumed. 
Such  a  case  may  last  five  or  six  weeks,  terminating  fatally,  yet  may,  on  the 
other  hand,  get  well.  A  few  fatal  cases  are  much  more  rapid  in  their  course, 
being  ushered  in  with  convulsions  and  ending  in  from  48  hours  to  five  or 
six  days.  Relapses  after  convalescence  are  not  uncommon,  and  should  be 
guarded  against. 

Diagnosis. — Acute  ileo-colitis  is  characterized  by  a  greater  severity 
than  dyspeptic  diarrhea,  by  the  high  fever,  the  large  amount  of  mucus  in 
the  stools,  the  greater  pain,  and  the  more  rapid  prostration.  From  cholera 
infantum  it  differs  in  its  lower  hyperpyrexia,  and  in  the  absence  of  vomiting, 
of  colliquative  diarrhea,  and  of  collapse. 

Prognosis. — This  is  more  unfavorable  than  in  acute  dyspeptic  diar- 
rhea; more  favorable  than  in  cholera  infantum.  Recovery  is  not  infrequent 
after  a  lengthy  illness  of  four  to  six  weeks,  while  the  severe  dysenteric 
form  is  apt  to  be  early  fatal.  Much  depends  upon  the  promptness  with 
which  treatment  is  instituted  and  the  ability  of  the  parents  to  carry  it  out, 
and  upon  the  previous  vigor  of  the  child,  its  hygiene,  and  its  food. 

Treatment. — The  general  hygienic  and  dietetic  treatment  of  acute 
entero-colitis  is  similar  to  that  of  acute  dyspeptic  diarrhea;  the  medicinal 
treatment  is  somewhat  different.  Anodynes  are  more  imperatively  de- 
manded, because  there  is  greater  suffering.  Otherwise,  drugs  are  not  of 
much  use,  though  bismuth,  in  full  doses,  may  be  given  with  advantage. 

The  colon  may  be  flushed  with  a  one  per  cent,  cold  salt  solution,  or 


402  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

cold  water  or  pieces  of  ice  may  be  introduced  into  the  rectum,  which  may 
also  be  used  for  medication,  more  particularly  by  opium.  If  used,  they 
should  be  very  weak.  Solutions  of  nitrate  of  sUver,  i  grain  to  the  ounce 
(0.666  gm.  to  30  CO.),  and  tannic  acid,  5  grains  to  the  oimce  (0.33  gm.  to 
30  CO.),  are  suitable.  The  mouth  should  be  often  examined  and,  when 
necessary,  the  coming  teeth  scarified,  not  once  only,  but  as  often  as  necessarj'. 

Cholera  Infantum. 

Definition. — A  variety  of  acute  catarrhal  enteritis  of  intense  severity, 
corresponding  in  symptoms  and  course  to  cholera  morbus  in  the  adult,  but 
much  more  serious  in  termination. 

Etiology. — The  same  reasons  that  lead  us  to  expect  a  specific  cause  of 
cholera  morbus  would  suggest  one  also  for  cholera  infantum.  None  has, 
however,  been  found.  It  may  reasonably  be  ascribed  to  toxins  generated  in 
the  decomposition  and  fermentation  of  foods,  since  some  error  of  diet  is 
almost  always  the  apparent  exciting  cause.  There  are  also  predisposing 
causes,  of  which  hot  weather,  dentition,  or  both,  bad  hygiene,  the  previous 
presence  of  dyspeptic  diarrhea  or  entero-colitis,  are  instances.  It  is  less  fre- 
quent than  either  of  the  last-named  affections,  including  only  a  small  propor- 
tion of  the  summer  complaints  of  children — according  to  Holt  not  more  than 
two  or  three  per  cent. 

Morbid  Anatomy. — There  is  little,  if  any,  deviation  from  the  normal 
appearance  in  the  affected  bowel. 

Symptoms. — These  consist  in  copious  serous  stools,  at  first  containing 
some  offensive  fecal  matter,  later  a  few  particles  of  greenish  matter;  but 
ultimately  they  are  almost  aqueous,  being  ejected  also  with  great  force. 
They  contain  numerous  bacteria,  but  no  constant  organism  has  been  found. 
There  is  crampy  pain,  and  the  limbs  are  drawn  up  or  rigidly  extended.  There 
is  decided  fever,  more  than  in  either  of  the  two  other  forms,  the  tempera- 
ture reaching  105°  F.  (40.5°  C);  the  p^ilse  is  frequent  and  feeble,  while 
restlessness  is  a  characteristic  symptom.  The  temperature  should  be  taken 
in  the  rectum,  as  that  of  the  axilla  may  be  misleading.  Indeed,  the  skin 
sometimes  feels  cool  when  the  internal  temperature  is  high.  There  is  in- 
tense thirst,  and  the  child  eagerly  drinks  water.  The  purging  may  come 
on  suddenly  or  may  succeed  dyspeptic  diarrhea  or  ileo-colitis.  Simultane- 
ously there  is  severe  and  obstinate  vomiting,  including  bUe  at  first ;  but  later 
the  vomited  matter  is  also  serous.  The  tongue  is  coated  in  the  beginning, 
but  later  becomes  dry  and  red.  The  child  rapidly  loses  strength  and  as 
rapidly  emaciates.  The  restlessness  is  succeeded  by  apathy  and  indiffer- 
ence, and  the  condition  passes  into  collapse.  The  eyes  become  sunken, 
the  fontanels  depressed,  the  sldn  gray  or  ashen  and  closely  applied  to  the 
frame,  producing  an  appearance  which,  once  seen,  is  rarely  forgotten.  Or 
the  more  severe  symptoms  may  subside,  and  a  condition  of  torpor  or  semi- 
consciousness may  supervene.  The  head  is  retracted,  and  there  may  be 
convulsions;  the  breathing  is  interi-upted  and  of  the  Cheyne-Stokes  type; 
the  pupils  are  irregular;  there  is  clutching  of  the  fingers — in  a  word,  the 
"  hydrencephaloid "  state,  so  called  bj''  Marshall  Hall,  is  present.  These 
"brain  symptoms"  have  often  misled  the  inexperienced,  but  thej^  are  not 


CHOLERA  INFANTUM  403 

associated  with  changes  in  the  brain  or  in  its  meninges.  They  may  be  due 
to  the  toxins  developed  in  the  intestine  by  bacteria. 

Diagnosis. — This  is  not  difficult.  The  serous  vomiting  and  purging, 
rapid  emaciation  and  prostration,  and  the  hyperpyrexia  are  significant, 
while  the  nervous  symptoms  described  as  succeeding  them  confirm  the 
nature  of  the  disease. 

Prognosis. — Unless  the  last-described  symptoms  supervene,  the  course 
is  rapid  to  a  fatal  termination  by  collapse  in  from  a  few  to  24  or  48  hours. 
If  the  hydrencephaloid  state  is  added,  the  disease  may  be  prolonged  a  few 
days  more.  Recovery  is  not  impossible,  and  begins  with  abatement  of  the 
more  serious  symptoms  within  the  first  24  hours,  followed  by  tedious  con- 
valescence. Or  there  may  be  a  delusive  improvement,  followed  by  a  return 
of  the  choleraic  symptoms,  or  the  disease  may  pass  into  entero-colitis. 

Treatment. — All  that  has  been  said  about  food  in  dyspeptic  diarrhea 
and  entero-colitis  applies  here,  but  the  opportunity  for  its  application  can- 
not, indeed,  be  availed  of  unless  convalescence  sets  in.  The  symptoms 
must  be  met  with  the  greatest  promptness  by  the  same  measures  described 
in  the  treatment  of  adults,  but  adapted  to  the  age  of  the  child.  The 
stomach  must  be  emptied  by  thorough  washing  by  a  stomach  tube.  The 
bowel  must  be  flushed  with  normal  salt  solution.  Here,  too,  opiates  are 
indispensable.  Even  morphin  may  be  used  hypodermically  with  great 
caution,  but  never  after  the  diarrhea  has  ceased.  One  two-hundredth  of  a 
grain  (0.00033  gm.)  is  about  the  proper  dose  for  a  child  a  year  old,  and  it 
may  be  associated  with  i/iooo  grain  (0.00005  gm-)  of  atropin.  This 
may  be  repeated  in  an  hour  if  the  symptoms  do  not  subside,  at  a  longer 
interval  if  they  do.  Laudanum  or  deodorized  tincture  of  opium  may  be 
substituted  and  administered  by  the  rectum  in  doses  of  from  2  to  4  drops 
(0.133  to  0.264  gm.)  in  2  drams  of  starch-water.  Minute  doses  of  Dover's 
powder,  say  1/20  grain  (0.008  gm.),  may  be  given  in  combination  with 
bismuth  in  doses  of  2  grains  (0.12  gm.).  For  the  diarrhea  that  may  con- 
tinue after  abatement  of  the  acute  symptoms  preparations  of  silver,  prefer- 
ably, the  oxid,  are  sometimes  of  value.  They  may  be  combined  with  opium, 
the  dose  of  the  silver  being  1/12  grain  (0.0056  gm.),  of  the  opium  1/24  to 
1/12  grain  (0.00275  gm.  to  0.0056  gm.). 

The  hyperpyrexia  must  be  combated  by  hydrotherapj^ — the  bath  at 
80°  P.,  rapidly  reduced  to  70°  F.  (26.6°  to  21.1°  C.) ;  or,  if  this  cannot  be 
done,  the  child  should  be  wrapped  in  sheets  wrung  out  in  cold  water. 
Sponging  is  a  feeble  substitute.     Hyperpyrexia  is  one  of  the  dangers. 

Brandy  is  of  value,  though  iced  champagne  may  be  given  in  small  doses 
often  repeated,  while  the  prompt  rejection  of  liquids  should  not  discourage 
their  readministration.  Inigation  of  the  large  bowel,  spoken  of  above, 
may  be  added,  using  a  flexible  catheter,  which  is  introduced  six  or  eight 
inches  (2.3  to  2.7  cm.).  A  pint  (0.5  liter)  will  suffice  for  a  child  six  months 
old,  and  a  quart  (i  liter)  for  one  of  two  years.  The  water  may  be  tepid, 
or  cold  if  the  temperature  is  high.  The  0.6  per  cent,  salt  solution  may 
be  administered  by  enteroclysis,  and  even  by  hypodermoclysis  in  extreme 
cases  of  collapse.  The  hot  bath  should  be  substituted  for  the  cold  in  col- 
lapse, and  strychnin  may  be  administered  hypodermically  in  doses  of  i/ioo 
grain  (0.00066  gm.)  to  a  child  one  year  old."' 


404  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Should  convalescence  set  in  or  entero-colitis  supervene,  great  caution 
in  the  gi\'ing  of  food  should  be  observed.  Only  peptonized  milk  should 
be  used,  substituted  occasionally  by  raw  beef  juice,  increased,  if  well  borne, 
a  teaspoonful  at  a  time;  or  dilute  egg  albumen  naay  be  tried  if  there  are  not 
retained. 

PSEUDOMEMBRANOUS  ENTERITIS. 

Synonyms. — Croupous  Enteritis;  Diphtheritic  Enteritis. 

Definition. — A  rare  variety  of  intense  inflammation  affecting  either 
bowel,  and  characterized  by  the  formation  of  false  membrane. 

Etiology. — Pseudomembranous  enteritis  occurs  in  connection  with 
such  infectious  diseases  as  pyemia,  pneumonia,  scarlet  fever,  and  even 
typhoid  fever;  also  from  the  toxic  effect  of  mineral  poisons,  such  as  lead, 
mercury,  and  arsenic,  and  during  the  cachexias  which  develop  toward  the 
close  of  cancer,  Bright's  disease,  cirrhosis  of  the  liver,  and  the  like,  as  a 
terminal  infection. 

Morbid  Anatomy. — The  false  membrane  present  varies  in  extent  and 
depth.  It  may  be  limited  so  as  simply  to  tip  the  villi  and  valulae  conni- 
ventes  or  other  folds  with  a  grayish-yellow  film,  or  the  coagulation-necrosis 
may  infiltrate  a  greater  depth  in  flake-like  patches,  or  it  maj'  invade  the 
follicles  and  solitary  glands,  which  may  suppurate.  To  the  false  membrane 
is  commonly  added  a  hyperemic  basis.  The  deep-seated  diphtheritic  in- 
flammation found  in  diphtheritic  dysentery  is  elsewhere  described. 

Symptoms. — These  may  be  so  slight  as  to  be  unnoticeable.  At  other 
times  there  are  diarrhea  and  abdominal  pain,  but  nothing  distinctive. 

Treatment. — This  is  symptomatic,  and  that  of  the  attending  and 
causing  disease. 

PHLEGMONOUS  ENTERITIS. 

This  is  a  rare  disease,  consisting  in  a  diffuse  suppurative  infiltration 
of  the  submucosa,  analogous  to  phlegmonous  inflammation  of  the  stomach. 
It  has  been  found  after  intussusception  and  strangulated  hernia,  and  may 
cause  symptoms  of  peritonitis  by  invasion  of  this  coat  of  the  bowel,  but 
there  are  no  s>Tnptoms  by  which  it  can  be  recognized  before  death.  It  has 
been  met  in  the  duodenum. 

HEMORRHAGIC  INFARCT  OF  THE  BOWEL. 

Definition. — Hemorrhagic  extravasation  in  the  wall  of  the  small  in- 
testine, due  to  embolism  or  thrombosis  of  one  or  other  of  the  mesenteric 
arteries. 

Etiology. — A  warty  vegetation  from  coexisting  valvular  heart  disease 
may  become  the  embolus,  or  the  latter  may  arise  from  the  clot  in  an  aneu- 
r\'sm  of  the  aorta  or  in  the  tip  of  the  left  auricle. 

Morbid  Anatomy. — There  are  congestion,  infiltration,  and  swelling  of 
I  he  jejunum  and  ileum,  and  the  superior  mesenteric  artery  will  generally  be 
found  plugged  with  a  clot,  which  may  be  preceded  by  an  embolus.  The 
mesentery  maj^  also  be  the  seat  of  congestion  and  infiltration. 


APPENDICITIS  405 

Symptoms. — There  may  be  sudden  nausea,  vomiting,  faintness,  ab- 
dominal tympany,  and  pain.  There  may  be  symptoms  of  obstruction,  or 
diarrhea  with  blood-stained  stools. 

Diagnosis. — The  condition  is  so  rare  that  infarction  is  not  apt  to  Vje 
thought  of.  But  should  there  be  valvular  heart  disease  or  aneurysm,  the 
sudden  occurrence  of  the  symptoms  mentioned  might  suggest  this  cause. 

Prognosis  and  Treatment. — The  prognosis  is  invariably  fatal  in  severe 
cases,  and  though  the  occlusion  of  a  small  vessel  may  be  followed  by  re- 
covery, there  is  no  treatment  which  will  avail  further  than  to  abate  the 
symptoms. 

APPENDICITIS. 

Synonyms. — Typhlitis;  Perityphlitis;  Paratyphlitis. 

Definition. — An  inflammation  of  the  veriform  appendix,  catarrhal, 
ulcerative,  or  interstitial,  commonly  extending  to  the  peritoneum  adjacent 
to  it,  producing: 

1.  A  local  adhesive  peritonitis  limited  to  the  region  of  the  appendix 
associated  with  an  exudate  of  plastic  material  which  may  be  absorbed  or 
become  organized  periappendicitis. 

2.  Circumscribed  suppuration  or  abscess — paraappendicitis,  or  peri- 
typhlitic  abscess. 

3.  General  septic  peritonitis. 

Perforation  and  gangrene  are  often  intermediate  incidents. 

Catarrhal  appendicitis  may  not  extend  beyond  the  mucous  coat  of  the 
appendix  in  which  event  the  peritoneal  coat  may  be  intact  at  operation. 

The  term  typhlitis,  so  long  employed,  was  adopted  because  it  was 
thought  that  the  disease  began  in  the  cecum,  or  typhlon.  Modem  studies 
go  to  show  that  true  appendicitis  never  begins  in  the  cecum,  but  that  in 
essentially  all  cases  the  appendix  is  the  root  of  the  evil. 

Etiology. — Exciting  Causes. — All  stages  of  appendicitis  are  probably 
due  to  the  invasion  of  microorganisms,  while  the  foreign  bodies,  concretions, 
and  other  agencies  to  be  mentioned  are  to  be  regarded  as  predisposing  causes, 
furnishing  the  conditions  favorable  to  the  operation  of  the  pathogenic 
bacteria. 

While  in  most  instances  the  bacillus  coli  communis  has  been  found  in 
pure  cultures,  pyogenic  bacteria  have  been  found  associated  with  it.  The 
most  important  of  these  is  the  streptococcus  pyogenes;  after  this  the  staphylo- 
coccus Pyogenes  aureus  and  the  bacillus  pyocaneus;  so  that  the  existence  of 
more  than  one  possibly  infecting  species  may  be  admitted.  The  bacilli  of 
typhoid  fever  and  influenza  are  infective  agents  causing  appendicitis.  In 
these  cases  the  appendicitis  is  part  of  a  general  infection. 

Predisposing  Causes. — The  most  important  predisposing  cause  of 
appendicitis  is  the  appendix  itself.  An  organ  without  fvmction,  and  there- 
fore undeveloped  and  feebly  nourished,  is  correspondingly  feebly  resistant 
to  all  disease.  Its  anatomy  is  such  that  the  entrance  of  irritating  matters  is 
easier  than  their  exit,  while  inflammatory  products  are  not  easily  evacuated. 
As  predisposing  causes,  too,  must  be  considered  certain  influences  which 
formerly  were  regarded  as  exciting  causes,  such  as  overeating,  especially^of 


406  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

unwholesome  and  indigestible  food,  acute  indigestion  from  any  cause,  in 
addition  to  the  foreign  bodies  and  concretions  already  mentioned.  It  can- 
not be  said  that  the  precise  mode  of  operation  of  such  cause  is  certainly 
known.  It  may  be  that  a  hyperemia  or  deranged  circulation  thus  induced 
produces  a  condition  favorable  to  the  action  of  incessantly  present  bacteria. 
Similar  is  the  effect  of  fatigue,  cold,  and  traumatic  causes,  such  as  blows 
and  contusions. 

Appendicitis  is  a  disease  of  children  and  young  adults,  but  may  occiir  at 
any  age.  From  50  to  55  per  cent,  of  cases  occur  under  the  age  of  20,  30 
per  cent,  between  20  and  30,  15  per  cent,  imder  15.  In  3000  cases  operated 
by  Deaver,  61.87  per  cent,  were  in  males  and  38.13  per  cent,  in  females.  It 
has  been  suggested  that  this  is  because  the  lumen  of  the  appendix  is  larger 
in  males,  and  therefore  more  liable  to  receive  fecal  or  foreign  matters. 
Attacks  have  occurred  in  the  first  year  of  life  and  as  late  as  the  76th. 
More  cases  occur  in  summer  than  in  winter.  Occupation  has  no  effect  in 
exciting  it,  but  after  a  first  attack  recurring  attacks  of  appendicitis  are 
more  frequently  in  men  who  do  heavy  work,  such  as  porters  and  carriers, 
or  men  who  stand  on  their  feet  long  each  day. 

Pathology  and  Morbid  Anatomy. — Appendicitis  may  be  divided  into 
acute  and  chronic  forms: 

Acute  Catarrhal  Appendicitis. — Our  knowledge  of  this  is  based  upon  the 
systematic,  minute  study  of  cases  which  come  from  operation.  In  the  first 
or  acute  stage  there  is  a  shedding  of  the  epithelium  of  the  mucous  mem- 
brane, with  detachment,  partial  destruction,  and  extrusion  of  the  follicles 
of  Lieberklihn,  and  some  cellular  infiltration  of  the  retiform  tissue  at  their 
base.  The  lumen  of  the  appendix  contains  mucus,  leukocytes,  exfoliated 
cells,  and  casts  more  or  less  perfect,  of  the  crypts,  with  granular  debris 
from  the  same  sources.  In  the  second  stage  the  basement  membrane  is 
broken  and  dislocated,  and  retiform  tissue  more  closeh'  infiltrated  with 
leukocytes,  and  the  internal  surface  ragged  and  uneven.  In  the  third  or 
still  more  advanced  degree  the  mucous  membrane  is  thickened  by  infiltration 
with  cells.  The  most  important  fact  as  to  catarrhal  appendicitis  is  that  all 
three  stages  offer  vulnerable  foci  for  the  attacks  of  pathogenic  bacteria,  and 
starting-points  of  an  infectiotis  peritonitis .  On  the  other  hand,  by  the  union 
of  the  opposing  surfaces,  obliteration  of  the  lumen  of  the  tube  may  take  place, 
by  which  it  is  rendered  immune  against  further  attacks,  but  this  occurs 
very  rarely.  The  obliteration  may  be  partial,  producing  stricture,  beyond 
which  a  cystic  distention  of  the  tube  in  the  end  nearest  the  cecum  is  not 
infrequent  and  beyond  wihch  a  severe  inflammatory  condition  may  take 
place. 

Acute  Ulcerative  Appendicitis. — In  this  stage  the  mucous  membrane  and 
submucous  tissue  are  destroyed  to  various  depths,  while  it  maj^  even  cul- 
minate in  perforation.  It  is  often  associated  with  a  concretion  or  a  foreign 
body.  The  latter  is  now  acknowledged  to  be  much  more  rare  than  was 
formerly  supposed.  The  error  was  a  natural  one,  omng  to  the  close  resem- 
blance of  fecal  concretions  to  seeds,  grains  of  wheat,  cherrj^  stones,  and 
even  date  stones,  as  the  result  of  a  gradual  molding  of  shape  and  loss  of 
water.  The  concretions  are  sometimes  also  the  seat  of  a  deposit  of  lime 
salts.     They  may  be  multiple  and  may  be  in  the  appendix  a  long  time  with- 


APPENDICITIS  407 

out  producing  harmful  effect,  the  patient  dying  of  other  causes.  The  same 
is  true  of  foreign  bodies,  which  do,  of  course,  occur  and  include  the  objects 
already  mentioned.  Fecal  concretions  are  found  in  from  35  to  50  per  cent. 
of  cases ;  foreign  bodies  in  a  much  smaller  number — say  7  to  1 2  per  cent. 

Acute  Interstitial  or  Parietal  Appendicitis . — This  stage  may  succeed  upon 
either  of  the  two  stages  just  described,  but  occasionallj'-  it  may  arise  de  novo 
by  infection  along  the  lymphatics.  In  the  former  event  it  starts  in  the 
abraded  or  ulcerated  surface  described;  in  the  latter,  in  the  substance  of  the 
appendix  wall.  It  is  commonly  associated  with  necrosis  or  gangrene  of  the 
wall,  but  may  prove  fatal  before  the  necrosis  sets  in.  The  appearances  vary 
greatly.  They  may  be  limited  to  a  mere  point,  scarcely  \'isible,  and  between 
this  and  sphacelation  of  the  entire  organ  there  is  every  intermediate  degree. 
The  gangrenous  organ  is  usually  enlarged  and  distorted.  The  \'irulence 
of  the  appendicular  peritonitis  is,  however,  just  as  great  when  there  is  no 
necrosis.  The  peritonitis  which  ensues  on  perforation  of  the  appendix  is 
virulent,  resulting  from  the  invasion  of  the  peritoneima  by  myriads  of 
bacteria  in  the  fecal  matter  set  free  at  the  time  of  rupture  of  the  bowel. 

The  minute  changes  in  interstitial  appendicitis  are  as  varied  as  the 
macroscopic.  The  cases  which  succeed  on  the  catarrhal  or  ulcerative  form 
are,  of  course,  characterized  by  the  loss  of  tissue  corresponding  to  the  extent 
of  the  disease.  To  these  succeed  destructive  necrotic  processes  in  the  deeper 
structures  of  the  wall.  In  the  first  stage  of  the  latter  the  inflammation  is 
characterized  by  necrosis  of  the  muscular  coats;  in  the  second  by  suppura- 
tion in  them;  and  in  the  third  by  their  infiltration  wdth  leukoc}d;es  and 
inflammatory  exudation.  The  first  is,  by  far,  the  most  common.  In  all 
three  bacteria  are  found  in  the  mucous  and  muscular  coats,  and  all  three  are 
followed  alike  by  \drulent  peritonitis.  There  is  no  sharp  demarcation  be- 
tween these  varieties,  the  condition  evidently  depending  upon  the  degree  of 
the  inflammation  and  the  virulence  of  the  infecting  organism. 

The  appendix  may  also  be  the  seat  of  tubercular  ulceration,  followed,  too, 
by  perforation.  So,  too,  a  typhoid  ulcer  may  form  in  the  appendix  and  perfo- 
rate, with  the  formation  of  a  tumor  mass  in  the  right  iliac  region.  Follicular 
abscess  may  exist  and  occasion  the  usual  symptoms  of  appendicitis.  Actino- 
mycosis has  also  occured  in  the  appendix,  with  the  formation  of  retrocecal 
abscess  and  metastatic  abscess  of  the  liver.  Primary  carcinoma  of  the 
appendix  occurs  frequently. 

Superadded  to  these  conditions  is  often  a  localized  or  general  peritonitis. 
In  lesser  degrees  of  the  localized  peritonitis  the  adhesions  which  form  are 
limited  to  the  appendix  and  adjacent  serous  tissues,  limiting  the  inflamma- 
tion and  acting  as  a  barrier  against  general  peritoneal  infection.  In  higher 
degrees  the  inflammation  attacks  as  well  the  tissues  more  remote  from  the 
appendix  (paraappendicitis) ,  and  forms  the  iliac  phlegmon  or  tumor.  This 
occupies  the  right  iliac  fossa  and  is  variously  constituted.  It  may  consist 
of  serous  and  cellular  exudation,  which  mats  together  coils  of  small  intestine 
and  cecum,  or  there  may  be  a  massive  accumtdation  of  cells  and  liquid 
exudate,  constituting  abscess.  This  appendicular  or  perityphlitic  abscess 
may  rupture  into  the  peritoneum,  not  infrequently  producing  fatal  general 
peritonitis.  The  amount  of  pus  varies.  There  may  be  a  dram  or  two 
(4  to  8  c.c),  or  a  pint  (a  half  liter)  or  more.     The  pus  is  usually  thin  and 


408  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

very  fetid;  at  times  it  is  thick,  yellow,  and  odorless.  It  may  be  mixed  with 
fecal  matter.  The  pus  may  have  escaped  into  the  bowel,  bladder,  or 
vagina,  or  externally  at  some  point  in  the  abdominal  wall — as  the  navel  or 
groin,  as  in  a  case  of  my  own — or  through  the  obturator  foramen  into  the 
hip  or  thigh.  The  iliac  muscle  may  be  destroyed  and  the  iliiun  bared.  The 
abscess,  usually  in  the  iliac  region,  may  be  in  the  lumbar  region,  or  peri- 
nephric, in  the  true  pelvis,  or  under  the  liver.  These  very  diverse  sites  are 
commonly  determined  by  erratic  situations  of  the  appendix.  There  may 
be  secondary  abscesses  of  the  liver  by  pylephlebitis  or  portal  embolism. 
These  may  have  all  the  terminations  possible  to  hepatic  abscess. 

If  general  peritonitis  supervene,  there  are  added  the  usual  anatomical 
appearances  incident  to  this  condition — flakes  of  lymph  scattered  over  the 
intestines,  binding  the  latter  together,  with  pus-cells  in  varying  numbers  in 
the  flakes. 

Symptoms. — The  onset  is  usually  sudden. 

The  first  symptom  is  invariably  pain — sudden  pain.  Its  location- at 
first  is  not  constant ;  it  may  be  anywhere  in  the  abdomen.  Most  frequently, 
perhaps,  it  is  in  the  neighborhood  of  the  umbilicus.  At  other  times  it  is  in 
the  epigastrium;  at  others,  diffuse.  It  is  intermittent,  or  at  least  remittent. 
Usually,  within  the  first  24  hours,  it  settles  itself  in  the  right  iliac  region, 
where  it  remains.  It  may  then  be  mild  or  severe;  more  frequently  it  is 
moderately  severe.  Even  at  this  stage — end  of  24  hours — its  location  is 
not  always  in  the  right  iliac  fossa.  It  has  even  been  most  severe  in  the  left 
iliac  fossa,  under  the  liver,  or  beneath  the  spleen,  anomalous  situations  for 
the  appendix.-  This  pain  is  increased  by  coughing  or  taldng  a  long  breath, 
or  by  turning  over  on  the  side. 

As  constant  as  pain  is  tenderness  in  the  right  iliac  region,  or  if  the  ap- 
pendix happens  to  be  placed  in  one  of  the  unusual  situations  named,  it  will 
be  in  that  situation.  Rather  strong  pressure  may  at  times  be  necessary 
to  elicit  it,  but  usually  moderate  pressure  suffices.  Its  extent  varies.  It 
may  occupy  the  whole  lower  quadrant  of  the  abdomen,  or  may  extend  up 
to  the  costal  margin  and  around  into  the  flank,  but  the  seat  of  maximum 
tenderness  is  oftenest  a  point  known  as  McBurney's — a  point  at  the  inter- 
section of  a  line  drawn  from  the  anterior  superior  spinous  process  of  the 
ilium  to  the  umbilicus  and  another  along  the  right  edge  of  the  rectus  muscle. 
It  is  from  one  and  one-half  to  two  inches  from  the  anterior  superior  spinous 
process  of  the  ilium.  The  patient  almost  invariably  assumes  the  dorsal 
decubitus,  often  with  the  right  leg  drawn  up,  because  of  the  relief  thus 
afforded. 

The  third  cardinal  symptom,  is  rigidity  of  the  right  rectus  abdominis 
muscle  and  other  muscles  overlying  the  focus  of  inflammation.  This  may 
be  associated  with  a  slight  distention  of  the  entire  abdomen.  In  ex])lana- 
tion  of  the  tenseness  it  may  be  said  that  the  rectus  and  other  abdominal 
muscles  recei\'e  their  nerve  supply  from  the  seven  lower  intercostal  nerves, 
while  the  superior  mesenteric  plexus  gets  its  splanchnic  branches  from  the 
same  nerves.  This  primary  tenseness,  after  two  or  three  days,  may  be 
substituted  by  a  tumor.  The  latter  varies  in  size  and  shape,  but  is  more 
commonly  oval  and  about  as  large  as  a  hen's  egg,  with  its  longer  axis  parallel 
^vith  the  upper  part  of  Poupart's  ligament.     It  may  be  much  larger,  occupj-- 


APPENDICITIS  409 

ing  also  the  whole  lower  left  quadrant  and  extending  upward  and  backward 
into  the  flank,  while  its  shape  may  be  quadrilateral  or  triangular.  It  varies 
in  consistence.  Its  composition  has  been  described  in  considering  the 
morbid  anatomy  of  the  disease. 

There  is  usually  impairment,  oj  resonance  to  percussion  over  such  a 
tumor,  though  less  than  might  at  first  be  expected.  This  is  because  we  are 
really  percussing  over  hollow  organs,  though  matted  together  by  exuda- 
tion. At  times,  however,  there  is  a  duller  note,  while  at  others,  it  may  be 
natural.  In  the  latter  event  the  tumor  is  small.  Indeed,  tumor  may  be 
altogether  absent,  but  this  can  never  be  said  of  tenderness. 

Vomiting  is  a  symptom  more  or  less  frequent.  It  is  commonly  regarded 
as  reflex  and  is  variously  severe.  The  matter  vomited  is  first  the  gastric 
contents,  with  the  evacuation  of  which  the  vomiting  usually  ceases,  though 
it  may  recur  in  the  event  of  perforation  or  rupture  of  the  abscess.  If  the 
symptom  is  more  prolonged,  the  vomited  matter  becomes  greenish.  Many 
so-called  "bilious  attacks"  of  past  times  have  really  been  attacks  of 
appendicitis. 

Constipation  is  present  in  a  decided  majority  of  cases  from  the  begin- 
ning of  the  attack.  It  is  due  to  paralysis  of  the  bowel,  and  may  be  so  ob- 
stinate as  to  simulate  obstruction  of  the  bowel,  being  even  attended  at 
times  with  stercoraceous  vomiting.  Indeed,  appendicitis  has  often  been 
confounded  with  obstruction.  On  the  other  hand,  there  may  be  diarrhea, 
recurring  with  each  successive  attack.  There  is  loss  of  appetite.  The 
tongue  at  first  may  be  natural,  but  later  becomes  more  or  less  coated,  and 
in  advanced  stages  dry. 

There  is  usually /CT^r  at  the  outset,  the  temperature  102°,  103°  F.  (38.9°, 
39.4°  C),  and  even  104°  F.  (40°  C),  rarely  higher,  after  which  it  gradually 
falls,  reaching  the  normal  in  from  five  to  seven  days  in  favorable  cases, 
which  terminate  in  resolution.  The  pulse-rate  corresponds  with  the  de- 
gree of  fever,  but  the  force  and  volume  of  the  pulse  vary  with  the  patient's 
strength.  Should  suppuration  take  place,  the  temperature  continues  with 
but  slight  fall,  or  may  even  rise  higher.  Suppuration  may,  be  unattended 
with  fever. 

A  sudden  fall  of  temperature  does  not  always  mean  the  establishment 
of  convalescence.  Not  very  rarely  the  event  has  a  widely  different  mean- 
ing. It  means  that,  instead  of  convalescence,  perforation  has  taken  place. 
It  is  extremely  important  that  this  fact  should  be  realized.  A  high  fever 
means  continued  inflammation,  but  a  normal  temperature  may  not  mean 
convalesence.  Another  even  more  unusual  explanation  of  sudden  fall  of 
temperature  is  the  rupture  of  a  small  abscess  into  the  bowel.  Finally,  too 
much  stress  cannot  be  laid  upon  the  fact  that  there  may  be  gangrenous  appen- 
dicitis in  the  presence  of  normal  temperature. 

Leukocytosis  is  present  in  a  large  nurhber  of  cases,  the  white  cells  often 
amounting  to  16,000  to  20,000.  It  is  an  important  diagnostic  sign.  On  the 
other  hand,  the  absence  of  leukocytosis,  like  the  absence  of  fever,  should 
not  inspire  overconfidence  that  appendicitis  does  not  exist,  as  a  lowering 
blood  count  is  sometimes  evidence  that  nature  has  given  up  the  struggle. 

The  urine  is  scanty,  as  is  usual  in  fever,  and  quite  frequently  contains 
an  abnormal  quantity  of  indican.     It  is  rarely  albuminous,  unless  there  be 


410  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

high  fever,  when  there  may  be  the  slight  albuminuria  characteristic  of  fever. 
There  are  often  irritable  bladder  and  frequent  micturition. 

The  expression  of  the  patient  varies  with  the  severity  of  the  symptoms, 
but  seldom  exhibits  the  anxiousness  characteristic  of  peritonitis,  unless  the 
latter  actually  is  present  in  consequence  of  perforation  or  rupture  of  abscess. 

Rapid  growth  of  the  tumor  and  the  attainment  of  large  size  in  a  short 
time  point  to  suppuration,  but  the  most  valuable  sign  is  the  presence  of  ex- 
treme tenderness  over  the  focus  of  inflammation.  Continued  high  temperature 
is  significant,  though  it  may  be  wanting.  Fully  formed  abscess  has  been 
found  as  early  as  the  third  day.  More  commonly  six  to  eight  days  elapse 
before  a  diminished  tenderness  and  slight  decline  of  swelling  point  to  this 
formation.  Appendicitis  allowed  to  go  on  to  suppuration — i.  e.,  not  re- 
lieved by  operation — usually  terminates  by  rupture  of  the  abscess  into  the 
peritoneum,  followed  by  general  peritonitis  and  death.  The  event  is  va- 
riously delayed  by  the  extent  and  toughness  of  the  protective  adhesions  which 
may  have  formed  about  the  abscess.  A  few  abscesses  rupture  into  the  bowel, 
thus  saving  the  patient's  life.  Two  or  three  cases  in  a  hundred  are 
thus  saved.  The  fecal  fistula  incident  in  this  termination  usually  closes 
eventually,  though  not  always.  In  rare  instances  the  abscess,  especially  if 
deeply  situated  in  the  pelvis,  ruptures  into  the  bladder.  The  termination 
in  these  cases  is  less  favorable,  50  per  cent,  being  fatal.  A  few  also  break 
through  the  groin,  and  are  followed  by  recovery.  Lumbar  abscess  and 
perinephric  abscess  must  be  mentioned  as  possible  terminations,  also  in- 
filtration of  the  abdominal  walls  and  tissues  of  the  thigh,  pylephlebitis,  and 
hepatic  abscess. 

General  peritonitis  may  also  ensue  after  perforation  of  the  appendix. 
The  symptoms  of  the  resulting  general  peritonitis  are  those  characteristic  of 
this  disease  when  suddenly  induced  by  other  causes,  viz. : 

1.  Diffuse  pain,  as  contrasted  with  pain  localized  in  the  right  iliac 
region — pain  of  extreme  severity. 

2.  Generally  distended  and  tender  abdomen. 

3.  Moderate  fever,  succeeded  by  normal  or  subnormal  temperature, 
already  alluded  to  as  often  misleading  the  physician. 

4.  Rapid  and  feeble  pulse. 

5.  Dry  and  coated  tongue. 

6.  The  phenomena  of  collapse — i.  e.,  cold,  clammy  skin,  feeble  pulse, 
anxious  expression,  death. 

Complications  and  Sequelae. — The  most  important  complication  is 
obstruction  of  the  bowels,  by  which  is  not  meant  the  obstinate  constipation 
so  often  met  as  an  early  symptom  of  appendicitis,  but  a  true  obstruction,  the 
direct  consequence  of  constriction  by  adhesions  developed  in  the  course  of 
the  peritonitis.  It  is  one  of  the  causes  of  death,  as  determined  b}'  autopsy, 
while  operation  frequently  discloses  conditions  which  coidd  easily  have 
produced  obstruction. 

Another  complication  is  hepatic  abscess  from  pj-lephlebitis,  due  to 
thrombosis  and  even  embolism  of  branches  of  the  portal  vein;  another  is 
phlebitis  of  the  right  iliac  vein  causi:ig  milk-leg.  In  abscess  of  the  liver  it 
has  happened  that  the  diaphragm  has  been  perforated,  producing  empyema 
and  pyopericardium.     Pj-emic  abscesses  elsewhere  in  the  system,  including 


APPENDICITIS  411 

the  brain  and  lungs,  have  also  been  found  in  rare  instances.  Fecal,  vesical, 
and  umbilical  fistulae  have  been  referred  to.  Fatal  hemorrhage  has  also 
resulted  from  necrosis  of  the  walls  of  the  iliac  vessels.  Appendicitis  may 
occur  in  a  hernial  sac. 

Recurring  and  Relapsing  Appendicitis.  Chronic  Appendicitis. — These 
terms  are  applied  to  cases  of  appendicitis  which  recur  after  a  first  attack. 
The  terms  are  sometimes  used  interchangeably,  but,  strictly  speaking, 
cases  are  recurring  which  repeat  themselves  at  considerable  intervals,  as 
some  months  or  a  year  or  more ;  relapsing,  when  the  attacks  are  very  close — 
at  intervals,  say,  of  one  or  two  weeks,  so  as  to  make  them  almost  continuous. 
In  the  former,  to  which  attention  was  first  called  by  William  Pepper  in  1883, 
it  is  reasonable  to  believe  that  the  patient  has  recovered  in  the  interval  or 
there  exists  a  cystic  appendix  as  an  exciting  cause.  In  the  relapsing  form 
it  seems  likely  that  there  has  not  been  complete  recovery  in  the  interval. 
Certain  it  is  that  one  attack  predisposes  to  another,  so  that,  in  at  least  23 
per  cent,  of  cases  observed,  according  to  Hawkins,  and  44  per  cent,  according 
to  Fitz,  it  is  found  that  there  have  been  previous  attacks.  The  symptoms  of 
a  recurrent  attack  are  the  same  as  those  of  a  primary  one.  In  many  cases 
the  interval  between  the  attacks  is  passed  in  comparative  comfort;  in 
others,  there  is  no  small  amount  of  pain  or  discomfort  in  the  situation  of 
the  appendix.  The  term  chronic  appendicitis  may  also  be  applied  to  such 
cases.  It  must  be  remembered  as  pointed  out  by  Deaver  and  by  other 
surgeons  who  do  much  abdominal  work,  that  chronic  appendicitis  may 
simulate  almost  any  abdominal  condition.  Many  cases  of  indigestion  are 
in  reality  cases  of  appendicitis.  Chrohic  appendicitis  constantly  simulates 
gall  stones,  gastric  ulcer. 

The  lesson  to  be  learned  is,  that  in  all  cases  of  disease  of  the  upper  abdo- 
men, chronic  appendicitis  must  be  thought  of,  and  in  operation  the  appendix 
should  be  explored. 

Diagnosis. — The  diagnosis  of  many  cases  of  appendicitis  is  easy,  and 
becomes  more  so  as  experience  grows.  A  certain  number  of  cases  must 
be  carefully  weighed,  and  in  a  few  diagnosis  is  extremely  difficult.  Sudden 
pain,  becoming  localized,  tenderness,  and  rigidity  in  the  right  iliac  region 
are  three  symptoms,  which,  if  present,  point  almost  unmistakably  to  appen- 
dicitis, particularly  if  they  are  accompanied  by  leukocytosis,  care  must 
always  be  taken  to  exclude  pneumonia  and  pericarditis  which  may  have  the 
same  set  of  symptoms.  A  tumor  in  the  vicinity  of  McBurney's  point  is  less 
frequently  present,  though  it  is  found  in  many  cases,  and  greatly  aids  the 
diagnosis.  The  cases  difficult  of  diagnosis  are  those  in  which  these  symp- 
toms are  vague  or  are  in  unusual  situations.  But,  in  truth,  they  are  less 
often  absent  than  has  been  supposed.  More  frequently  they  are  not  looked 
for,  because  there  is  very  little  to  draw  attention  to  them.  A  rule  should, 
therefore,  be  made  to  search  for  them  carefully  in  any  persons  subject  to 
gastro-intestinal  attacks,  however  induced  and  however  manifested. 
It  is  certain  that  some  cases  of  so-called  catarrhal  enteritis  and  chronic  in- 
digestion are  really  cases  of  appendicitis  as  stated  above. 

Differential  Diagnosis. — Intestinal  obstruction  is  a  condition  with  which 
appendicitis  has  sometimes  been  confounded.  The  special  symptoms  of  the 
various  causes  of  obstruction,  whether  those  of  fecal  impaction,  of  strangula- 


412  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

tion  by  bands  or  twists,  by  intussusception,  or  by  tumor  or  foreign  body, 
should  be  recalled.  Especially  characteristic  of  obstruction  is  the  c.bsence  of 
fever,  unless  the  patient  lives  long  enough  to  permit  peritonitis  to  set  up. 
In  appendicitis  there  is  almost  always  fever  at  the  outset  though  it  may 
abate  later.  The  pain  in  obstruction  is  more  intermittent  at  first,  and 
though,  like  that  of  appendicitis,  it  may  be  anywhere  in  the  abdomen,  it  is 
not  likely  to  localize  itself  in  the  right  iliac  region.  The  constipation  is  more 
complete  in  obstruction,  and  even  the  passage  of  flatus  is  usually  absent. 
The  vomiting,  also,  is  more  severe  and  persistent,  and  is  more  likely  to  be 
stercoraceous.  There  is  more  general  distention  of  the  abdomen,  and 
limited  tenderness  is  less  easily  differentiated.  Inhissusception  occurs  more 
frequently  in  children  younger  than  those  subject  to  appendicitis,  and  is 
often  attended  with  bloody  discharges,  which  seldom  occur  in  appendicitis, 
while  a  tumor  may  often  be  felt  on  examination  per  rectrtm.  Strangulation 
by  bands  or  twists  is  more  common  in  adults.  Malignant  growths  causing 
obstruction  are  usually  in  the  left  iliac  region,  although  cancer  of  the  cecum 
is  to  be  remembered  as  a  disease  of  the  right.  Its  slower  development 
distinguishes  it  from  appendicitis.     (See,  also.  Obstruction  of  the  Bowels.) 

Typhoid  fever  may  be  confounded  with  appendicitis,  especially  when  there 
is  tympany  and  prolonged  tenderness  in  the  right  iliac  region;  but  one  has, 
as  a  rule,  only  to  recall  the  mode  of  beginning  of  the  illness,  the  gradual  de- 
velopment of  the  fever,  its  greater  intensity  and  peculiar  diurnal  variation, 
the  spots  at  the  eighth  day,  to  say  nothing  of  the  Widal  test,  to  be  reassured 
in  the  majority  of  instances.  On  the  other  hand,  there  is  nothing  to  pre- 
vent typhoid  fever  and  appendicitis  from  accidentall}^  coinciding. 

Diaphragmatic  pleurisy  and  especially  pneumonia  in  children  have  been 
ushered  in  with  symptoms  identical  with  those  of  appendicitis,  viz.,  abdomi- 
nal pain,  constipation,  nausea  and  vomiting.  Careful  examination  of  the 
thorax  for  the  physical  signs  of  these  affections  may  avert  an  unnecessary 
operation,  and  the  local  physical  signs  in  the  abdomen  are  frequently 
wanting. 

Pericarditis  may  exactly  resemble  an  attack  of  appendicitis,  there  may 
be  sudden  pain  referred  to  the  right  iliac  fossa. 

A  question  which  one  would  naturally  expect  to  give  rise  to  difficulty  is 
that  differentiating  between  appendicitis  and  the  pelvic  affections  of  women 
when  on  the  right  side,  such  as  a  suppurating  ovarian  cyst  around  a  Fal- 
lopian tube,  or  a  pyosalpinx.  There  can  be  no  doubt  that  before  our  present 
accurate  knowledge  of  appendicitis  was  acquired,  numerous  mistakes  of 
diagnosis  were  made.'  IManj-  smpytoms  are  identical,  but  usually  the 
location  of  the  original  pain  in  the  appendicitis  is  not  in  the  pelvic  cavity  or 
in  close  proximity  of  the  uterus,  even  though  it  be  not  at  McBiu-ney's  point  or 
the  right  iliac  fossa.  The  appendiceal  abscess  itself  is  usually  limited  to  the 
neighborhood  of  the  normal  appendix  and  cannot  be  recognized  per  vaginam, 
while  the  pehnc  abscess  can.  Shovdd  the  appendix  rupture,  as  it  rarely  does, 
into  the  vagina,  the  pus  may  be  recognized  by  its  stercoraceous  odor.  It 
should  be  remembered  that  appendicitis  and  pregnancy  may  be  associated. 
The  onset  of  suppurating  ovarian  cyst  is  much  more  gradual,  and  the  pain 

■  For  evidence  of  this,  see  an  excellent  paper  by  the  late  Paul  F.  Munde  entitled.  "  Perityphlitis  and 
Appendicitis  in  their  Relations  to  Obstetrics  and  Gynecology,"  published  in  "Medical  News, '  May  is. 
1897. 


APPENDICITIS  413 

more  constant  and  duller.  Pyosalpinx  is  in  more  intimate  relation  with  the 
uterus,  while  the  history  differs  from  that  of  appendicitis. 

Many  cases  of  acute  appendicitis  were  formerly  mistaken  for  acute 
indigestion,  but  indigestion  is  imaccompanied  by  tumor  or  tenderness,  while 
the  vomiting  is  more  persistent  and  the  vomited  matter  differs.  Gastro- 
enteritis may  cause  mistake.  Persistent  fever  is  more  characteristic  of 
gastro-enteritis.  There  is  pain  and  tenderness  but  no  rigidity  or  tumor. 
Enterocolitis  occasions  colicky  pains,  but  there  is  no  hardness  or  localization, 
while  there  is  diarrhea  with  mucous  stools.  It  will  be  remembered,  however, 
that  these  symptoms  sometimes  attend  appendicitis,  and  it  should  be  remem- 
bered, too,  that  gastro-enteritis  may  be  a  favoring  cause  of  infection  of  the 
appendix,  indeed  may  be  an  actual  cause,  the  result  of  an  afferent  wave  of 
bacterial  invasion  from  an  irritated  intestinal  tract  as  suggested  by  Arthur 
J.  Patek.i 

Ptomain  poisoning  or  food  infection  may  closely  simulate  the  symptoms 
of  appendicitis,  by  abdominal  pain,  nausea  and  vomiting.  The  patient  will, 
however,  have  taken  food  of  the  kind  known  to  produce  such  illness,  namelj-, 
lobster,  sausage,  ham,  canned  meats,  cream  puffs,  old  ice-cream  and  the  like. 

Acute  Epididymitis  (Right-sided). — Right-sided  epididymitis  sometimes 
gives  rise  to  abdominal  pain  so  severe,  to  fever  and  letikocj'tosis,  that  an 
operation  may  be  contemplated.  One  glance  at  the  testicle  will  make  the 
diagnosis.  We  have  seen  a  case  prepared  for  appendiceal  operation  which 
was  suffering  from  epididymitis. 

In  hepatic  colic  the  pain  is  higher  up,  in  the  region  of  the  gall-bladder, 
while  jaundice  is  often  present,  and  sometimes  there  is  pain  under  the  left 
shoulder;  there  is  no  fever.  In  nephritic  colic  the  pain  extends  from  the 
limaar  region  into  the  groin  and  testicle  and  blood  or  pus  is  found  in  the  urine. 
A  floating  kidney  with  twisted  ureter  is  movable,  as  contrasted  with  the  iliac 
tumor  of  appendicitis;  there  is  sometimes  flattening  of  the  corresponding 
lumbar  region,  while  sudden  relief  of  symptoms,  which  characterizes  the  un- 
twist, is  altogether  peculiar.  The  presence  of  blood  in  the  urine  under  these 
circumstances  is  conflrmative  of  renal  origin.  In  pyonephrosis  there  is  ten- 
derness in  the  region  of  the  kidney,  as  well  as  pus  in  the  urine.  Perinephric 
abscess  occasions  tenderness  in  the  lumbar  region  while  the  pain  radiates 
into  the  groin,  as  in  nephritic  colic.  It  is  to  be  remembered  that  perinephric 
abscess  may  be  occasioned  by  suppurating  perityphlitis,  when  the  position 
of  the  appendix  is  posterior  to  the  cecum. 

Gastric  or  duodenal  ulcer  have  usually  a  symptomatology  of  their  own, 
hyperacidity,  pain  recurring  long  after  eating,  just  when  the  gastric  juice  be- 
gins to  flow  over  the  ulcerated  area.  Relief  from  taking  food.  However, 
the  first  attack  of  pain  may  be  due  to  a  perforating  ulcer.  The  pain  is  not 
usually  severe  as  appendicitis  but  may  be.  The  resistance  and  tenderness 
are  usually  above  the  imibilicus.  There  may  be  occult  blood  in  the  stool 
(this  cannot  be  ascertained  at  the  first  visit) .     There  is  no  leukocytosis. 

Hyperacidity. — This  is  mentioned  in  this  place  because  many  of  the 
supposed  cases  of  simple  hyperacidity  are  in  reaHty  gastric  or  duodenal 
tilcers,  or  appendicitis,  or  gall  stones,  and  should  not^be  confounded  with 
these  diseases. 


*  "American  Medicine,"  April  i,  1902. 


414  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Appendicular  colic  is  a  vague  condition  of  pain  in  this  region,  which 
has  been  ascribed  to  peristaltic  contraction  of  the  appendix,  constituting 
an  effort  to  expel  fecal  pellets  and  certainly  occurs.  A  case  has  been 
described  by  one  of  us  in  which  the  pain  occurred  as  the  result  of  the 
attempt  to  expel  some  links  of  tapeworm. 

It  is  sufficient  for  the  physician  to  diagnose  the  existence  of  appendicitis 
without  attempting  to  point  out  the  particular  variety  of  appendicitis,  and 
while  the  possibility  of  such  diagnosis  cannot  be  denied  serious  errors  have 
been  made  by  those  claiming  such  ability  that  little  confidence  can  be  placed 
in  their  claims. 

Mention  should  be  made  of  carcinoma  of  the  cecum  or  appendix  as 
presenting  identical  symptoms  with  appendicitis.  It  has  occurred  to  us  to 
make  the  diagnosis  of  appendicitis  where  operation  showed  the  presence 
of  cancer  of  the  cecum.  '■ 

Prognosis. — It  is  a  difficult  matter  to  consider  fairly  the  prognosis  of 
appendicitis,  or  rather  of  the  periappendicitis  growing  out  of  disease  of 
ths  appendix.  For  if  we  separate  the  cases  which  do  not  go  on  to  suppura- 
tion, recovery  from  the  immediate  attack  is  apparently  the  rule.  But  a  re- 
lapse is  very  likely  to  occur. 

It  is  impossible  to  say  of  any  case,  however  mild,  that  if  left  alone  it  u-ill 
not  terminate  in  suppuration,  and  a  large  number  of  cases  still  perish  because 
of  imperfect  diagnosis  and  delayed  operation.  Chronic  cases  cause  pro- 
longed ill  health. 

Treatment. — Appendicitis  is  a  surgical  disease.  As  soon  as  the  diagno- 
sis is  established — indeed,  pending  its  settlement — a  competent  surgeon 
should  be  associated  with  the  physician,  for  the  reason  that  in  practically  all 
cases  operative  treatment  is  demanded.  The  diagnosis  being  thoroughly 
established,  operation  should  be  immediately  performed  in  all  cases  in 
which  any  operation  is  permissible.  The  sooner  an  operation  is  performed 
after  the  onset  of  symptoms  the  less  the  mortality.  During  1912  in  Mayo's 
clinic  977  cases  were  operated  and  3  died. 

When  to  Operate. — The  habit  of  waiting  to  obser\'e  whether  a  case  will 
subside  without  operation  is  pernicious  in  the  extreme.  Operate  at  once. 
No  one  can  by  any  single  sign  or  set  of  symptoms  tell  the  gravity  of  every 
case.  There  is  no  sure  sign  which  distinguishes  a  catarrhal  from  a  gangren- 
ous appendicitis.  Delay  is  much  more  dangerous  than  operation.  All 
advanced  thinkers  of  experience  are  agreed  to  these  statements  in  very  early 
cases. 

There  has  within  the  last  few  years,  however,  arisen  among  surgeons, 
some  difference  of  opinion  as  to  whether  immediate  operation  should  be 
performed  in  late  cases.  In  the  hands  of  some  expert  surgeons  this  wovdd  ap- 
pear to  be  safe,  but  the  only  safe  rule  for  the  general  practitioner  is  to  look 
upon  every  case  not  ill  wath  some  intercurrent  disease,  such  as  pneumonia, 
or  any  acute  infection,  alcoholism,  etc.,  as  an  operative  case.  Do  not 
meddle  with  so-called  medical  treatment.     Operate  at  once. 

It  must  be  remembered  that  operation  for  appendicitis  is  a  major  opera- 
tion and  should  be  performed  only  by  a  surgeon  of  experience  andtraining. 


'See  also  a  paper  on  "Primary  Cancel  of  the  Tip  of  the  Appendix,",  by^  J.  Riddle  Goffe,"  Medical 
Record,"  July  6,  I90I.3 


INTESTINAL  OBSTRUCTION  415 

The  habit  of  young  men  doing  operations  of  this  character,  before  thej'  have 
been  surgically  trained,  is  reprehensible. 

Medical  Treatment  should  be  subject  to  the  following  rules.  Do  not 
use  medical  treatment  for  the  purpose  of  reaching  an  inten^al,  there  may 
be  no  interval.  Cases  must  occur,  however,  in  which,  from  various  compli- 
cations, medical  treatment  is  necessary.  Operation  may  be  declined  even  if 
urgently  advised.  A  surgeon  may  not  be  immediateh'  at  hand,  or  some 
acute  infection,  advanced  lung  conditions,  alcoholism,  or  heart  disease  will 
make  the  risks  of  an  operation  greater  than  the  risks  of  waiting. 

First  of  all,  absolute  rest  in  bed  must  be  insisted  upon  as  the  first  essential 
condition  of  abatement  of  the  inflammation.  Many  a  fatal  case  would  have 
been  saved  had  this  been  carried  out.  The  patient  should  take  nothing 
by  the  mouth,  should  be  placed  in  Fowler's  position  and  receive  normal 
salt  solution  by  the  drop  method  or  by  the  interrupted  method.  Purga- 
tives should  not  be  given.  Cases  which  are  doing  well  may  become  extreme- 
ly severe  by  the  use  of  laxatives  or  purgatives.  Ice  may  be  applied  to  the 
appendiceal  region. 

Next,  relief  of  pain  is  demanded.  Only  when  relief  cannot  be  secured  by 
the  ice-bag  or  by  hot  fomentations  should  opium  be  given  in  moderate 
doses.  One-eighth  of  a  grain  (.008)  of  morphin  may  be  given  hypoder- 
mically.     There  is  no  question  here  of  masking  symptoms  or  the  diagnosis. 

INTESTINAL  OBSTRUCTION. ^ 

Definition. — The  words  intestinal  obstruction  explain  themselves. 
Obstruction  to  the  descent  of  fecal  matter  is  the  fundamental  idea,  but  the 
absence  of  alvine  discharges,  though  common,  is  not  essential.  For  in  the 
course  of  our  studies  it  will  be  found  that  in  intussusception,  for  example, 
frequent  loose  bowel  movements  occur,  and  that  in  fecal  obstruction  they 
may  be  present  throughout  the  whole  course  of  the  disease,  while  in  other 
forms  of  obstruction  they  are  not  infrequent  at  the  beginning.  Intestinal 
obstruction  is  further  divided  into  acute  and  chronic,  according  to  the  rate 
of  development  of  its  symptoms,  the  same  causes  at  times  producing  acute, 
and  at  others  chronic  forms. 

Acute  obstruction  is  produced  by  strangulation,  intussusception,  foreign 
bodies,  twists  and  knots,  strictures,  and  morbid  growths. 

Chronic  obstruction  is  produced  also  by  stricture,  intussusception,  morbid 
growths,  and  fecal  impaction. 

I.  Obstruction  by  Internal  Strangulation. 

Synonyms. — Constriction  of  the  Bowel;  Hernia  within  the  Abdomen. 

Definition. — By  internal  strangulation  is  meant  stricture  of  the  bowel 
by  inflammatory  bands  or  adhesions,  by  vitelline  remains,  omental  or  mesen- 
teric slits,  adherent  appendix,  and  the  like. 

Occurrence. — This  is  probably  the  most  frequent  cause  of  acute  intes- 

1  Reginald  H.  Fitz's  able  paper  in  the  "Transactions  of  the  Congress  of  American  Physicians  and  Sur- 
geons," 1899.  Leichtenstern's  article  in  Ziemssen's  "  Cyclopffidia  of  Practical  Medicine,"  and  Frederick 
Treves'  book  on  "Intestinal  Obstruction,"  1884,  are  important  modern  papers  to  which  I  am  indebted^or 
much  of  theTinatter  in  this  section. 


41()  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

tinal  obstruction,  though  intussusception  closely  approaches  it  in  frequency. 
Thus,  Reginald  H.  Fitz  found  it  in  35  per  cent,  of  295  cases  of  obstruction, 
as  against  32  per  cent,  of  intussusception. 

Etiology. — The  causes  of  strangulation  have  been  carefully  worked  out 
by  Fitz  in  his  loi  cases,  collected  from  reports  since  18S0.  Of  these  in  84 
the  strangulation  was  caused  by  bands  and  cords,  of  which  63  were  simple 
inflammatory^  bands  or  adhesions  and  21  were  vitelline  remains,  represented 
by  Meckel's  diverticulum,'  or  by  the  persistent  remains  of  vitelline  blood- 
vessels. Meckel's  diverticulum  is  usually  attached  by  these  remains  to 
some  part  of  the  abdominal  wall  near  the  navel  or  to  the  mesentery,  or  it 
may  be  adherent  because  of  peritonitis.  The  persistent  vitelline  vessels 
may  themselves  be  the  strangulating  cord  in  the  absence  of  Meckel's  diver- 
ticulum. Other  causes  were  adherent  appendix,  mesenteric,  omental  slits, 
peritoneal  pouches,  adherent  Fallopian  tube,  and  pedunculated  tumor.  To 
these  must  be  added  diaphragmatic  hernia.  This  was  the  cause  of  strangu- 
lation in  ten  per  cent,  of  Leichtenstern's  cases,  but  Fitz  found  none  reported 
between  1880  and  1888.  Two  cases  of  diaphragmatic  hernia  were  reported 
by  Tyson  in  1893,^  both  of  some  standing,  the  immediate  cause  of  death 
being  acute  strangulation. 

The  seat  of  the  strangulation  is  in  the  small  bowel  in  a  decided  majorit}' 
of  cases — nearly  90  per  cent.  In  83  per  cent,  the  strangulated  part  lay  in 
the  lower  abdomen,  and  in  67  per  cent,  in  the  right  iliac  fossa. 

Seventy  per  cent,  of  cases  occur  in  males,  and  at  least  40  per  cent, 
between  the  ages  of  15  and  20,  the  causes  in  these  being  inflammatory  ad- 
hesions twice  as  often  as  vitelline  remains.  Strangulation  in  early  youth  is 
relatively  uncommon,  and  when  it  does  occur,  it  is  usually  caused  by  vitelline 
remains. 

II.  Intussusception — Invagination. 

Definition. — In  this  condition  one  part  of  the  bowel  has  slipped  into 
another,  always  from  above  downward,  and  may  readily  be  illustrated  by 
slipping  one  part  of  a  coat  sleeve  into  another. 

The  external  or  receiving  portion,  known  as  the  intussuscipiens ,  has  its 
mucous  surface  in  contact  with  the  mucous  surface  of  the  middle  or  inter- 
mediate portion,  whose  peritoneal  surface  is  in  contact  ^ith  the  peritoneal 
surface  of  the  internal  or  returning  portion,  whUe  the  two  mucous  surfaces  of 
the  returning  portion  are  apposed.  The  internal  and  middle  part  are  called 
the  intussHscepttim.  The  resultant  is  a  cylindrical  tumor  which  varies  from 
half  an  inch  to  a  foot  or  more  in  length.  The  annexed  diagram  gives  a  very 
good  idea  of  the  different  parts  of  the  tumor. 

Intussusceptions  maj'  occur  in  any  part  of  the  bowel  from  the  duodenum 
to  the  rectum,  and  are  named  in  accordance  with  the  part  of  the  bowel  in- 
volved. According  to  Leichtenstern,  52  per  cent,  are  ileo-cecal  and  ileo- 
colic, 30  per  cent,  are  enteric,  and  18  per  cent,  rectal  and  colico-rectal. 

It  will  be  remembered  that  intussusception  is  almost,  if  not  quite,  as 

'  Meckel's  diverticulum,  a  remnant  of  the  omphalo-mesenteric  duct,  through  which,  in  the  early  embryo, 
the  intestine  communicates  with  the  yolk-sac.  is  a  finger-like  projection  from  the  ileum,  usually  within 
18  inches  of  the  ileo-cecal  valve.  The  length  of  this  tube  is  on  an  average  three  inches,  while  it  has  attained 
at  times  a  length  of  ten  inches. 

'  "Transactions  of  the  .'Usociation  of  American  Physicians."  1893. 


INTESTINAL  OBSTRUCTION 


417 


frequent  a  cause  of  obstruction  as  strangulation,  under  which  the  percent- 
ages were  given. 

Etiology. — Diarrhea  and  habitual  constipation  are  probable  exciting 
causes,  having  preceded  in  13  and  12  cases  respectively  out  of  51.  Other 
possible  causes  are  so  infrequent  as  to  be  unworthy  of  mention.  Experi- 
ments with  faradism  would  seem  to  show,  however,  that  spasm  plays  a  more 
important  role  than  relaxation. 

As  to  sex,  two-thirds  are  found  in  males  and  one-third  in  females.  It  is 
especially  an  accident  of  the  young,  occurring  in  34  per  cent,  under  one  year 
and  56  per  cent,  under  ten  years. 


Fig.  ioi. — Vertical  and  transverse  Sections  of  an  Intussusception. 

I,  The  Sheatli,  or  Intussuscipiens;   2,  The  Entering,  or  inner  layer;  3,  The  Returning  or 

middle  layer. 

Intussusception  of  the  dying  should  be  mentioned  in  passing,  as  a  form 
of  intussusception  which  often  takes  place  a  short  time  before  death,  more 
frequently  in  children,  and  is  probably  caused  by  certain  irregular  peristaltic 
movements  toward  the  end  of  life.     It  produces  no  symptoms  during  life. 

III.  Twists  and  Knots — Volvulus. 

The  majority  of  cases  are  axial  twists — i.  e.,  the  bowel  is  twisted  on  its 
mesenteric  axis — this  being  the  case  in  40  out  of  Fitz's  42  cases,  two  only 
being  knots.  Eighty-seven  per  cent,  of  cases  occur  in  the  large  intestine, 
the  remainder  in  the  small  intestine,  one-half  are  in  the  neighborhood  of  the 
sigmoid  flexure,  and  nearly  one-third  in  the  ileo-cecal  and  cecal  region. 

It  is  more  frequent  in  males  in  the  proportion  of  two  to  one.  Most 
cases  occtir  between  the  ages  of  30  and  40. 


IV.  Obstruction  by  Abnormal  Contents  or  Foreign  Bodies. 

The  majority  of  these  are  gall-stones — 23  cases  out  of  44  of  obstruction 
by  foreign  bodies  collected  by  R.  H.  Fitz;  19  were  fecal  impactions  and  two 
enteroliths.  Obstruction  by  gall-stones  appears  to  be  three  times  as  common 
in  females  as  in  males.  They  enter  the  bowel  usually  by  ulcerating  through 
the  gall-bladder,  commonly  into  the  small  intestine,  more  rarely  into  the 
colon. 

The  seat  of  obstruction  by  gall-stones  is  most  frequently  the  ileo- 
cecal region;  after  this  lodgments  are  in  the  small  intestine^  wth  diminishing 


418  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

frequency  as  we  ascend.  The  ages  are  pretty  uniformly  distributed  from 
eight  to  eighty.  One  of  the  enteroHths  was  made  up  of  shellac,  found  in  a 
man  who  had  been  in  the  habit  of  drinking  alcoholic  solution  of  shellac. 
Usually,  enteroliths  are  made  up  of  triple  phosphate  of  lime  and  magnesia, 
about  a  nucleus  which  may  be  a  mass  of  hair  or  other  foreign  bod3^  Cour- 
voisier  collected  131  cases,  in  70  of  which  the  stone  was  spontaneously 
passed  per  anum.  Some  were  very  large.  Six  were  found  in  diverticula  or 
in  the  appendix.  A  coil  of  lumbricoid  worms  has  caused  obstruction,  as 
has  the  acciimulation  of  certain  medicines,  such  as  magnesia  and  bismuth. 

In  a  few  instances  obstruction  is  caused  b}'  substances  introduced  by  the 
mouth,  but  the  objects  thus  introduced,  as  pennies,  buttons,  pins,  fruit- 
stones,  and  the  like,  are,  as  a  rule,  promptly  expelled  with  the  stools. 
In  the  George  B.  Wood  Museum  of  the  University  of  Pennsylvania  is  a 
plaster  cast  showing  obstruction  of  the  intestine  toward  its  cecal  end  by 
plum-stones,  followed  by  inflammation  and  abscess. 

V.  Strictures  and  Morbid  Growths. 

A  comparatively  small  number  of  obstructions  occur  from  these  causes. 
They  are  always  found  in  adults,  four-fifths  after  the  age  of  40,  and  are  ap- 
parently twice  as  common  in  women  as  in  men.  By  far  the  largest  number 
is  met  in  the  large  intestine  and  lower  abdomen,  the  majority  being  in  the 
left  iliac  fossa . 

Strictures  may  be  (i)  Congenital,  illustrated  by  imperforate  anus  and 
defective  union  between  the  pylorus  and  duodenum. 

(2)  Cicatricial,  from  healed  ulcers.  Tubercular  ulcers  in  their  healing 
have  produced  decided  and  fatal  obstruction,  especially  in  the  rectum. 
Syphilis  is  also  though  to  produce  stricture  in  the  same  locality. 

Of  morbid  growths,  the  most  frequent  is  the  cylinder-celled  epitheUoma, 
which  may  form  a  ring  in  the  vicinity  of  the  sigmoid  flexure,  where  colloid 
cancer  is  also  met.  Any  of  the  varieties  of  benign  tumors  may  produce  ob- 
struction, while  inflammatory  processes  external  to  the  bowel,  especially  in 
the  pelvis,  may  cause  obstruction  by  pressure  from  without. 

VI.  Fecal  Obstruction. 

Synonym. — Ileus  paralyticus  vel  nervosus. 

Occurrence. — Fecal  obstruction  occurred  19  times  in  Fitz's  44  cases  of 
obstruction  by  foreign  bodies.  It  is  more  frequent  in  females  and  in  adults, 
especially  in  the  aged.  It  occurs  more  frequently  in  the  large  intestine, 
especially  in  the  cecum,  and  in  the  lower  part  of  the  bowel.  The  fecal 
tumors  found  in  appendicitis  are  now  regarded  as  the  result  of  the  inflamed 
appendix,  rather  than  as  the  cause  of  the  cecal  inflammation. 

A  local  peritonitis  may  also  be  developed  about  the  paralyzed  and  dis- 
tended intestine.  Mention  is  made  under  chronic  constipation  of  the  enor- 
mous masses  of  fecal  matter  thus  accumulated.  The  wall  of  the  intestine 
above  the  accumulation  ma}"  also  be  hypertrophied  because  of  the  propulsive 
efforts  of  the  muscular  coat. 


INTESTINAL  OBSTRUCTION  419 

Etiology  of  Fecal  Impaction. — Fecal  impaction  is  favored  by  con- 
stipation and  its  causes,  although  a  tendency  to  fecal  obstruction  is  some- 
times congenital.  Nervous  influence  is  not  to  be  ignored;  the  tendency  to 
constipation  is  seen  in  the  chronic  insane,  in  the  hysterical  and  hypochon- 
driacal, and  in  affections  of  the  spinal  cord.  Chronic  enteritis  and  chronic 
peritonitis  favor  it;  so  may  anatomical  peculiarities  of  the  colon.  These 
causes  weaken  the  muscular  coat  which  moves  the  contents  of  the  bowel 
onward,  resulting  ultimately  in  an  absolute  paralysis  of  a  segment  of  the 
bowel,  arrest  of  motion  of  contents,  and  finally  obstruction.  The  plug  of 
fecal  matter  grows  harder  and  larger,  and  compresses  and  stenoses  the 
adjacent  bowel,  resisting  any  further  onward  movement,  and  increasing  the 
impediment  to  the  restoration  of  a  natural  condition,  culminating,  finally, 
in  stretching  of  the  muscular  fibers  and  paralysis — ileus  paralyticus.  The 
so-called  "stercoral  ulcer"  of  the  cecum,  on  which  the  older  writers  laid  much 
stress,  and  which  was  ascribed  partly  to  gangrene,  due  to  pressure,  and  partly 
to  the  irritating  effect  of  impacted  fecal  matter,  is  to-day  regarded  as  ex- 
tremely rare. 

Symptoms  of  Obstruction. — As  most  of  the  important  symptoms  are 
common  to  the  dift'erent  causes  of  obstruction,  they  will  be  considered  from 
the  general  standpoint,  emphasizing  any  special  relation  which  a  given 
symptom  may  bear  to  a  special  cause.  In  addition  to  the  usual  absence  of 
bowel  movement  there  is : 

First,  abdominal  pain.  This  is  the  most  constant  of  all  symptoms, 
being  present  in  a  decided  majority  of  cases  of  obstruction  from  whatever 
cause.  The  pain  is  one  of  the  earliest  symptoms  in  every  form  of  acute 
obstruction.  It  is  usually  sudden  and  very  severe,  and  may  be  intermittent 
or  constant  with  exacerbations.  It  may  occur  in  any  part  of  the  abdomen, 
regardless  of  cause,  though  most  frequent  in  the  neighborhood  of  the  um- 
bilicus, so  that  its  location  is  of  no  diagnostic  value. 

Nausea  and  vomiting  are  almost  as  frequent.  The  vomitus  at  the  onset 
consists  of  the  food  last  taken,  but  soon  becomes  biHous,  yeUow,  and  finally 
fecal.  Vomiting  is  relatively  infrequent  in  strangulation  and  intussuscep- 
tion, while  it  is  relatively  frequent  in  volvulus,  stricture,  and  tumor.  The 
vomitus  is  especially  apt  to  become  fecal  when  caused  by  strangulation — ■ 
usually  from  the  third  to  the  fifth  day. 

Tympany  is  next  in  frequency.  It  is  a  symptom  of  later  occurrence 
than  pain  and  vomiting,  presenting  itself  usually  from  the  second  to  the 
sixth  da3^  It  varies  greatly  in  degree,  increasing  as  a  nile  with  the  dura- 
tion of  the  obstruction  and  being  sometimes  enormous.  It  is  of  least  im- 
portance in  obstruction  by  intussusception,  and  most  marked  in  volvulus. 
It  is  sometimes,  but  not  always,  accompanied  by  tenderness. 

Inability  to  pass  flattis  is  as  constant  as  the  absence  of  bowel  move- 
ment. 

Tenesmus  is  a  frequent  symptom  when  there  is  obstruction  in  the  large 
bowel,  as  in  15  per  cent,  of  cases  of  volvulus  and  55  per  cent,  of  acute  intus- 
susception.    Fecal  vomiting  succeeds  in  some  cases. 

Tumor,  under  which  are  included  circumscribed  visible  intestinal  coils 
as  well  as  swelling  characterized  by  absolute  dullness,  is  a  rare  symptom 
except  in  intussusception,  when  it  is  characteristic,  having  been  present  in 


420  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

69  per  cent,  of  Fitz's  cases,  more  particularly  when  in  the  large  intestine, 
where  it  is  also  sometimes  associated  with  a  relaxed  sphincter.  The  tumor 
of  intussusception  is  more  frequently  found  in  the  left  iliac  region  in  the 
<lescending  part  of  the  large  bowel,  because  the  invagination  extends  in  that 
direction  and  often  does  not  form  an  appreciable  tumor  till  that  part  of  the 
bowel  is  reached.  Tumor  occurs  sometimes  in  obstruction  by  foreign  bodies. 
In  strictures,  morbid  growths,  and  invagination  it  may  be  recognized  by 
rectal  examination.  Tumors  with  dullness  on  percussion  are  not  seen  in 
twist,  though  visible  coils  are  sometimes  present. 

Fever  is  infrequent — in  fact,  its  absence  is  rather  characteristic,  espe- 
cially in  the  beginning.  Records  of  elevated  temperature  are,  however,  found 
in  from  22  to  28  per  cent,  of  all  cases,  the  maximum  record  being  102°  F. 
(38.9°  C). 

Hiccough  is  an  occasional  symptom,  and  appears  to  be  more  frequent  in 
\-olvuIus.     Jaundice  is  often  found  in  obstruction  by  gall-stones. 

The  urine  has  been  irregularly  studied  in  acute  obstruction.  It  is  not 
infrequently  spoken  of  as  scanty  and  containing  an  increased  amount  of  in- 
dican,  especially  in  obstruction  in  the  small  intestine,  not,  it  is  said,  of  the 
large.  Albumin  is  rarely  present.  It  is  to  be  remembered  that  peritonitis 
causes  an  increased  indican  reaction. 

Tumultuous  peristalsis  is  frequent  above  the  seat  of  obstruction. 
Bloody  stools  and  tenesmus  may  be  present  when  there  is  intussusception. 
They  are  important  in  the  diagnosis,  the  former  occurring  in  three-fifths  of 
the  cases,  the  latter  in  two-fifths.     They  may  occur  early  or  late.     Blood- 
stained stools  also  occur  in  connection  with  cancer  of  the  lower  bowel. 

Local  peritonitis  is  caused  by  volvulus  and  obstructing  gall-stones,  caused, 
in  the  latter  case,  rather  by  the  destructive  results  incident  to  the  passage  of 
the  stone  into  the  bowel  from  the  common  duct. 

Collapse  is  the  terminal  symptom  in  fatal  cases,  due  to  the  profound 
impression  on  the  nervous  system,  and  presents  the  lowered  temperature, 
leaking  skin,  and  feeble  piilse  characteristic  of  collapse  from  other  causes. 
Cases  are  reported  in  which  operation  during  collapse  was  followed  by 
recovery. 

The  same  train  of  symptoms  may  succeed  stricture  and  tumors,  to  be 
followed  at  times  by  partial  relief,  which  is  a  gain  succeeded  by  similar 
symptoms  leading  to  tdtimate  total  obstruction  and  death.  Such  sj-mptoms 
will,  of  course,  be  associated  with  the  anemic  d^^scrasia  and  emaciation 
which  belong  to  the  causing  diseases,  and  which  more  frequently  lead  to 
death  without  obstruction  than  with  it.  Meteorism  in  the  right  inguinal 
region  is  said  to  be  more  or  less  characteristic  of  obstruction  by  Meckel's 
diverticulum. 

In  chronic  obstruction  due  to  fecal  impaction,  more  rarely  to  stricture, 
cancerous  disease,  or  foreign  bodies,  these  symptoms  are  less  marked  and 
succeed  each  other  more  slowly.  Though  initial  symptoms  may  occur 
suddenly.  In  fecal  impaction,  what  appears  to  be  simple  constipation  at 
first  is  succeeded  by  permanent  retention,  which  may  last  for  weeks  without 
causing  inconvenience.  Examination  per  rectum  will  often  disclose  this 
tube  filled  with  hard  fecal  matter  which  may  be  cleaned  out  with  the  finger 
or  a  spoon-handle.     There  may  even  be  diarrhea,  due  to  irritation  of  the 


INTESTINAL  OBSTRUCTION  421 

bowel  above  the  impaction,  when  the  catarrhal  secretion  may  channel  out 
the  mass  and  carry  a  portion  with  it.  Gradually,  however,  the  impaction 
becomes  impregnable  to  all  remedies,  natural  and  artificial,  the  abdomen 
swells,  there  are  fullness  and  weight  within,  and  pain  in  the  genitals  or  thigh 
from  pressure  on  the  sacrolumbar  nerves;  the  appetite  fails,  the  tongue  is 
coated,  and  the  breath  offensive;  sometimes  a  condition  of  lethargy  and 
indifference  supervenes  along  with  great  weakness,  and  the  patient  dies  of 
exhaustion.  At  any  time,  on  the  other  hand,  may  follow  with  suddenness 
the  train  of  symptoms  already  described — pain,  tympany,  nausea  and 
vomiting,  ultimately  of  fecal  matter,  with  collapse  and  death. 

In  many  cases  of  impaction  sooner  or  later,  a  fecal  tumor  presents  itself 
— a  tumor  formed  by  the  mass  of  retained  feces,  chiefly  in  the  right  iliac 
fossa,  the  region  of  the  cecum,  corresponding  to  the  outer  half  or  Poupart's 
ligament.  It  is  sometimes  hard,  at  others  soft  and  yielding,  and  sometimes 
tender  and  painful,  probably  because  of  a  mild  local  peritonitis.  In  the  as- 
cending colon  the  tumor  is  soft,  and  in  the  hepatic  flexure  it  may  give  rise 
to  the' notion  of  an  enlarged  liver.  It  may  move  in  the  more  loosely  attached 
parts  of  the  colon,  and  may  drag  the  transverse  colon  down  toward  the 
pubis.  In  the  descending  colon  and  sigmoid  flexure  it  is  usually  harder, 
and  may  be  subdivided  into  scybala.  It  is,  of  covuse,  easier  of  detection  in 
persons  with  thin  abdominal  walls,  and  may  be  obscured  by  flatulent  dis- 
tention. When  recognized,  it  is  of  great  diagnostic  value.  Such  tumors 
have  been  mistaken  for  tumors  of  the  stomach,  liver,  spleen  and  kidneys, 
and  for  pregnancy. 

Diagnosis. — The  importance  of  early  and  correct  diagnosis  is  intensified 
at  the  present  day  by  the  fact  that  operative  interference  promises  by  far 
the  best  results,  while  to  be  effectual  it  must  be  early.  The  diagnosis  has 
three  principal  objects:  first,  the  existence  of  obstruction  per  se;  second,  its 
seat,  and  third,  its  cause.  The  first  is  by  far  the  most  important,  as  opera- 
tion is  indicated  in  one  variety  or  situation  almost  as  much  as  in  another. 

First,  as  to  the  presence  of  obstruction  in  general,  the  absence  of  bowel 
movements,  the  presence  of  abdominal  pain  and  tympany  are  suggestive 
symptoms.  In  the  beginning  of  obstruction  increased  peristalsis  is  marked, 
later  it  disappears.  As  to  differential  diagnosis,  it  has  happened  that  a  case 
of  intense  enteritis  has  presented  all  the  symptoms  of  obstruction.  Fever 
is  commonly  present  in  such  enteritis,  while  it  is  absent  in  chronic  obstruc- 
tion, at  least  at  first.  Enteritis  is  characterized  by  diarrhea,  obstruction  by 
constipation. 

Acute  poisoning  associated  with  vomiting,  such  as  is  caused  by  poison- 
ous mushrooms,  biliary,  renal,  and  intestinal  colic,  the  pain  caused  by 
twisting  of  the  ureter  in  a  movable  kidney,  all  present  symptoms  more 
or  less  like  those  of  obstruction;  but  the  combination  of  signs  necessary  to 
the  picture  of  obstruction  is  still  wanting. 

Much  more  common  is  the  mistaking  of  appendicitis  for  obstruction. 
In  this  there  are  pain,  vomiting,  and  constipation,  as  well  as  tumor  in  the 
neighborhood  of  the  cecum,  but  the  differentiation  between  these  two  con- 
ditions was  considered  when  treating  of  acute  appendicitis.  Peritonitis 
itself  presents  symptoms  common  to  it  and  obstruction,  including  abdominal 
pain,  distention,  constipation,  and  collapse,  with  increase  of  indican.     But 


422  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

the  presence  of  fever,  the  absence  of  tumor  and  of  fecal  vomiting,  point  to 
peritonitis. 

Acute  dilatation  of  the  stomach  is  frequently  taken  for  obstruction  of 
the  bowels.  The  large  area  of  tympany  over  the  stomach  will  make  the 
diagnosis  and  passage  of  a  stomach  tube  will  be  of  more  certain  value.  If 
the  distention  is  in  the  stomach  it  will  disappear  by  the  passage  of  a  stomach 
tube. 

The  symptoms  of  incarcerated  hernia  are  also  those  of  intestinal  obstruc- 
tion, and  in  all  cases  careful  search  should  be  made  for  a  concealed  hernia. 
Such  hemiae  have  been  found  in  the  external  ring  and  in  the  obturator  foramen 
at  autopsy  by  William  Osier,  who  has  also  met  a  case  of  acute  hemorrhagic 
pancreatitis  presenting  the  symptoms  of  acute  obstruction. 

Having  excluded  hernia  by  a  careful  examination  for  a  seat  of  strangu- 
lation, examination  per  rectum  should  be  made,  also  per  vaginam.  By 
either  method  a  tumor  may  sometimes  be  recognized.  Especially  is  this 
true  of  a  l umor  caused  by  intussusception .  A  stricture  may  also  be  detected 
by  digital  examination  of  the  recttun,  as  may  obstruction  by  foreign  bodies. 

On  the  other  hand,  the  rectum  may  be  totally  empty  of  feces  and  con- 
tinue so,  whence  it  is  probable  that  the  obstruction  is  in  the  small  intes- 
tine or  high  up  in  the  large.  The  position  and  size  of  the  uterus  and  ovaries 
may  also  be  ascertained  by  rectal  examination.  The  rectum  can  be  more 
thoroughly  explored  by  suitable  specula  in  the  knee-elbow  position.  The 
hard  rectal  tube  has  produced  perforation,  while  the  flexible  tube  so  coils 
itself  up  as  to  be  valueless  in  diagnosis.  Sometimes,  if  the  distended  intes- 
tine is  filled  with  hard  fecal  matter,  it  can  be  felt  as  an  vineven  mass  in  the 
course  of  the  bowel. 

Moderate  distention  in  the  upper  part  of  the  abdomen,  with  flatness 
below  and  in  the  sides,  rapid  collapse  and  oliguria,  point  to  obstruction  in 
the  duodenum  and  jejunum.  Such  distention  is  temporarily  diminished  by 
vomiting,  but  is  uninfluenced  by  fecal  discharges  secured  by  enemas.  Nor 
is  the  vomiting  always  fecal  in  duodenal  and  jejunal  obstruction;  when  the 
obstruction  is  in  the  ileum  and  cecum  the  distention  is  more  central,  the 
region  of  the  colon  being  flatter  until  covered  in  by  the  extending  tympany, 
and  the  vomiting  is  more  likely  to  be  fecal. 

When  obstruction  is  seated  in  the  colon  tympanitic  distention  is  greatest, 
yet  the  difference  between  it  and  that  of  obstruction  in  the  ileum  is  not  so 
great  as  to  possess  much  diagnostic  value.  If  in  the  lower  colon,  there  may 
be  tenesmus  and  discharge  of  blood  and  mucus.  Measuring  the  capacity 
of  the  large  bowel  by  air,  gas,  or  water  has  been  recommended  as  an  aid  to 
diagnosis.     These  substances  may  be  made  to  pass  the  ileo-cecal  valve. 

Third,  the  presence  of  obstruction  being  recognized,  the  nature  of  the 
obstructing  cause  may  sometimes  be  determined  -^s-ith  a  degree  of  probability. 
First  to  be  considered  is  the  relative  frequenc}-  of  the  different  morbid  states. 
Adopting  Fitz's  figiires,  strangulation  and  intussusception  together  make 
up  70  per  cent,  of  all  cases,  the  two  being  nearly  equal.  After  that  come 
volvulus  with  15  per  cent.,  gaU-stones  with  eight  per  cent.,  and  stricture  or 
tumor  six  per  cent. — that  is,  the  twists  about  equal  obstruction  from  gall- 
stones and  tumor  and  stricture  together. 

Again,  if  the  obstruction  be  found  in  the  large  intestine,  it  is  more  likely 


INTESTINAL  OBSTRUCTION  423 

to  be  intussusception,  twist,  or  stricture  and  tumor,  since  of  the  obstruc- 
tions in  the  large  bowel  51  per  cent,  are  intussusception,  30  per  cent,  twists, 
and  12  per  cent,  stricture  and  tumor.  If  in  the  small  intestine,  it  is  most 
likely  strangulation  or  gall-stone  obstruction,  since  72  per  cent,  of  obstruc- 
tions in  the  small  intestine  are  strangvdations  and  14  per  cent,  gall-stones, 
leaving  eight  per  cent,  only  for  intussusception,  five  per  cent,  for  twists, 
and  one  per  cent,  for  stricture  and  tumor.  If  the  attack  has  been  preceded 
by  one  of  jaundice  or  by  other  liver  symptoms,  as  hepatic  colic,  it  is  almost 
certain  to  be  gall-stone,  especially  if  the  patient  be  over  50  years  old. 

If  the  patient  is  under  30,  particularly  if  a  child,  it  is  more  likely  to  be 
intussusception  than  twist,  while  if  there  are  palpable  abdominal  tumor, 
bloody  stools,  and  rectal  tenesmus,  the  case  is  almost  sure  to  be  intussus- 
ception, rendered  still  more  likely  if  the  rectum  has  a  large  capacity  for 
water,  since  intussusception  is  found  near  the  cecvmi  in  75  per  cent.,  while 
twist  is  found  near  the  sigmoid  flexure  in  50  per  cent.  Of  all  forms,  in- 
tussusception presents  the  clearest  clinical  picture  and  is  most  easily 
recognized. 

Twist,  cancer,  and  stricture  are  more  apt  to  be  below  the  sigmoid,  and 
the  last  two  may  sometimes  be  felt  by  the  finger.  In  point  of  fact,  twist 
in  the  large  bowel  is  not  often  recognized.  It  is  a  disease  of  the  adiilt, 
rarely  occurring  under  40;  vomiting  is  less  early  and  less  severe  than  in 
strangulation  by  bands.  Pain  is  often  severe  in  twist.  Some  degree  of 
local  peritonitis  almost  invariably  results,  causing  rigidity  of  the  abdomen, 
while  meteorism  appears  earlj^  and  is  extreme,  the  distended  intestine  often 
displacing  the  solid  viscera. 

If  there  is  a  history  of  previous  peritonitis,  strangulation  becomes  more 
likely,  since  such  inflammation  precedes  in  68  per  cent.,  while  there  is  also 
a  history  of  previous  attacks  in  12  per  cent.  The  pain  in  strangulation  is 
early,  sudden,  and  severe,  and  the  same  may  be  said  of  vomiting.  It  be- 
comes stercoraceous  in  60  per  cent.,  while  the  vomiting  affords  no  relief. 
There  is  little  or  no  distention  unless  peritonitis  supervene.  There  is  great 
prostration,  and  no  tenesmus  or  discharge  of  blood.  The  average  duration 
is  about  five  days.  The  presence  of  diaphragmatic  hernia  as  a  cause  of  in- 
ternal strangulation  must  not  be  overlooked;  it  is  almost  always  the  result 
of  severe  injuries.  The  half  of  the  thorax  containing  the  viscera  is  dis- 
tended and  tympanitic  on  percussion,  while  breathing  movement  is  re- 
stricted, the  breath-sounds  are  feeble,  the  vocal  fremitus  and  vocal  reson- 
ance diminished  or  absent — signs  shared  with  pneumothorax.  The  pitch 
and  intensity  of  the  percussion  note  vary  also  with  the  degree  of  distention 
and  the  position  of  the  viscera  invading  the  thorax,  while  there  may  be 
metaUic  tinkling  of  fluid  in  the  intestine,  due  to  peristalsis. 

Obstruction  by  Meckel's  diverticulum  is  said  to  be  indicated  by  meteor- 
ism in  the  right  inguinal  region. 

Fecal  obstruction  is  recognized  by  the  symptoms  already  described 
under  chronic  obstruction,  and  such  recognition  is  not  very  difficult,  espe- 
cially if  the  fecal  tumor  is  found.  Sometimes,  however,  on  account  of  its 
insidiousness,  fecal  obstruction  is  overlooked  when  presenting  only  the 
more  chronic  symptoms,  and  the  patient  dies  of  supposedly  unknown 
cause  when  accurate  and  careful  study  would  have  led  to  its  discovery. 


424  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Prognosis. — In  fecal  tumors  alone,  of  all  the  causes  of  obstruction  con- 
sidered, is  the  prognosis  favorable  if  the  condition  is  recognized  sufficiently 
early,  while  a  considerable  latitude  of  duration  may  also  be  allowed. 

Treatment. — Obstruction  of  the  intestine  is  a  surgical  disease.  Early 
diagnosis,  best  made  in  consultation  with  an  abdominal  surgeon  and  early 
operation  before  the  patierit  is  exhausted  offer  the  only  measures  for  relief. 

Treatment  oj  Intussusception. — It  is  dangerous  to  attempt  to  reduce  an 
intussusception  by  inflation  or  irrigation,  but  the  method  may  be  tried  in 
very  recent  cases.  If  irrigation  is  decided  upon,  the  fluid — salt  solution  at 
ioo°  F.  (37.8°  C.) — is  best  allowed  to  pass  into  the  large  intestine  slowly  by 
its  own  weight  through  a  long  tube  carried  high  up,  the  reservoir  being  raised 
no  more  than  2  1/2  feet  (0.75  meter)  above  the  etherized  patient.  A 
higher  level  than  this  for  the  reservoir  may  result  in  rupture  of  the  bowel, 
while  the  bowel  may  also  kink  if  the  fluid  be  allowed  to  enter  too  rapidly. 
Some  place  the  patient  head  downward  over  the  back  of  an  inverted  chair, 
suitably  covered  with  a  bolster  and  quilts.  Others  hold  that  inversion  is 
unnecessary.  The  nozzle  should  be  closely  fitted  to  the  anus,  accomplished 
by  simply  compressing  the  buttocks.  One  hand  should  be  kept  flat  on  the 
abdomen,  while  variations  of  pressure  should  be  avoided.  If  success  is 
not  attained  after  a  short  trial  laparotomy  should  be  done.  Long  manip- 
ulation may  rupture  the  bowel  or  allow  gangrene  to  occur  at  the  seat  of 
intussusception . 

Give  no  aperients.  To  relieve  the  excessive  vomiting  after  the  simpler 
remedies  have  been  tried,  the  stomach  may  be  washed  otd  as  suggested  by 
Kussmaul  and  described  under  gastritis.  This  is  at  once  a  harmless  measure 
and  may  be  efficient  for  the  purpose  intended.  It  may  be  done  three 
or  four  times  a  day.  It  may  be  expected  to  be  of  service  in  the  vomiting 
of  any  variety  of  obstruction.  Opium  may  be  administered  hypoder- 
mically  to  allay  the  intense  pain,  and  may  also  relieve  the  vdmiting.  Or 
it  may  be  given  with  a  view  to  ciire,  which  there  is  reason  to  believe  it 
has  accomplished  in  cases  of  intussusception  and  even  strangulation. 
Opium  may,  on  the  other  hand,  be  harmful,  by  obscuring  diagnosis  and 
producing  an  appearance  of  relief,  while  the  local  condition  of  the  bowel 
is  really  growing  worse.  This  should  never  be  given  before  a  diagnosis  is 
made. 

The  nourishment  of  the  cases  demands  careftd  thought.  It  is  irrational 
to  continue  the  administration  of  nutriment  by  the  mouth  when  it  is  rapidly 
rejected.  If  the  obstruction  is  in  the  small  bowel  the  rectum  should  be 
the  only  route  employed,  while  ice  should  be  administered  freely  by  the 
mouth.  On  the  other  hand,  when  the  obstruction  is  in  the  colon,  when 
tenesmus  and  diarrhea  are  symptoms,  and  when  vomiting  is  a  less  promi- 
nent symptom,  small  amounts  of  liquid  nourishment  may  be  introduced  by 
the  mouth. 

Treatment  oJ  Fecal  Tumor. — The  situation  is  altered  when  a  diagnosis 
of  fecal  tumor  has  been  correctly  made.  Here  nothing  is  so  efficient  as 
repeated  large  injections  of  warm  water,  high  up  and  retained  for  from  10 
to  15  minutes  if  the  patient  can  retain  them,  as  he  should  be  encouraged 
to  do.  Good  results  are  sometimes  obtained  from  the  coincident  use  of 
small  doses  of  calomel,  1/8  to  1/5  grain  (0.008  to  0.013  gni-).  given  hourly. 


CONSTIPATION  425 

If  the  fecal  impaction  is  low  enough  down  in  the  rectum,  in  most  cases  the 
finger  covered  with  a  rubber  glove  or  some  mechanical  appliance,  as  a 
spoon-handle,  can  be  used  to  loosen  it. 

Twist,  strangulation  by  bands  and  obstruction  by  gall-stones  can  only  be 
relieved  by  operation,  and  a  surgeon  should  be  associated  in  the  treatment 
from  the  outset. 

For  treatment  of  cancer  of  the  bowel  see  section  on  that  affection. 

CONSTIPATION. 

Synonym. — Costiveness. 

Definition. — Unnatural  retardation  or  delay  in  the  natural  evacuation 
of  the  bowels. 

Though  there  may  be  some  exceptions,  an  evacuation  of  the  bowels 
once  in  24  hours  seems  to  be  nature's  law  in  the  case  of  the  adult  human 
being,  and  any  prolongation  of  this  interval  may  be  said  to  constitute  cos- 
tiveness. A  popular  application  of  the  term  is  also,  however,  to  a  con- 
dition in  which,  though  there  may  not  be  infrequency  of  stools,  the  dejecta 
are  dryer  and  harder  than  natural  and  are  discharged  with  more  or  less 
difficulty  and  pain.  The  physician  should  appreciate  this,  otherwise  mis- 
understanding may  arise  as  to  the  exact  meaning  of  the  patient.  Consti- 
pation is  also  something  different  from  retention  due  to  obstruction  by 
various  causes.  The  interval  between  bowel  movements  in  constipation 
varies  greatly,  ranging  between  a  couple  of  days  and  weeks.  Many  con- 
stipated persons  have  no  dejections  unless  aperient  medicine  is  taken. 

Morbid  Anatomy. — There  are  no  morbid  changes  characteristic  of  con- 
stipation. Dilatation  of  the  colon  in  various  degrees  is  present,  sometimes 
enormous,  as  shown  in  Fig.  102,  and  there  may  be  found  the  remnants  of 
inflammatory  or  other  local  lesions  which  may  be  responsible  for  the  ob- 
struction. The  large  accumulations  of  fecal  matter  found  in  these  cases 
are  known  as  coprostasis. 

Etiology. — The  immediate  causes  of  constipation  are: 

1.  Atony  of  the  colon,  whence  results  a  slow  peristalsis.  Perhaps  the 
most  common  cause  of  atony  is  a  habit,  engendered  through  indifl'erence  or 
necessity,  of  disregarding  nature's  call  for  relief.  Repeated  disregard  of 
such  call  resvilts  sooner  or  later  in  disappearance  of  inclination.  Sedentary 
habits  cooperate  to  produce  such  disinclination.  Atony  may  also  be  the 
result  of  disease  of  the  bowel  and  of  general  disease  causing  debility,  such 
as  anemia,  chlorosis,  and  protracted  illness,  like  typhoid  fever. 

2.  Overdrugging.  Nothing  is  more  common  than  the  pernicious  habit 
of  drug  taking  for  constipation.     It  assures  a  chronic  condition. 

3.  A  deficiency  of  the  natural  stimuli  to  peristalsis  afforded  by  various 
secretions,  especially  the  bile. 

4.  A  loss  of  muscular  power  in  the  abdominal  walls  from  overdistention 
or  obesity. 

5.  Improper  food.  The  foods  which  most  stimulate  peristalsis  are 
vegetables,  especially  those  with  an  insoluble  residue,  such  as  is  afforded  by 
the  outer  coatings  of  grain.  Foods  of  an  opposite  kind  are  represented  hy 
milk  and  the  farinacea. 


426  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

6.  Finally,  stricture  and  displaced  organs — such  as  the  uterus — and  the 
colon  tumors,  and  foreign  bodies  impinging  on  the  bowel  and  delaying  the 
descent  of  the  feces,  become  causes. 

Among  consequences  of  fecal  impaction  are  hemorrhoids,  which  result 
from  pressure  on  the  hemorrhoidal  veins. 

Treatment. — Every  case  of  constipation  should  be  carefully  studied 
mth  a  view  to  determining  its  cause,  and  to  removing  it  when  possible.  If 
such  cause  is  not  found,  the  first  injunction  in  the  management  of  constipa- 
tion is  the  observance  of  regularity  in  going  to  stool  at  a  fixed  hour  of  the  day, 
whether  inclination  prompts  or  not.  The  usual  hour  for  tliis  pui-pose  is 
immediately  after  breakfast,  though  it  matters  not  much  when  it  is,  so  that 
it  is  regularly  observed.  Especially  harmful  is  it  to  disregard  any  inclina- 
tion which  may  appear  at  this  time,  or,  indeed,  at  any  time.  Next  is  the 
use  of  food  of  the  kind  referred  to  under  the  head  of  etiolog\-,  such  as  fresh 
green  vegetables  of  all  kinds  and  succulent  fruits. 

Of  breads,  the  so-called  "brown"  or  bran  bread,  or  glutten  bread,  is 
to  be  preferred.  With  such  food  should  be  conjoined  massage  of  the  ab- 
domen or  compression,  either  by  the  patient  himself  or  by  another.  Pre- 
ferably by  a  trained  masseur.  This  is  a  most  valuable  measure.  A  very  ex- 
cellent daily  practice  is  to  flex  the  body  forward  and  as  far  as  possible  back- 
ward, a  number  of  times  while  in  the  standing  position.  This  has  the  effect 
of  compressing  the  bowels  and  stimulating  peristalsis,  and  is  one  of  the 
most  useful  aids.  It  should  be  practised  once  or  twnce  a  day:  in  the  morn- 
ing and  at  bedtime.  Rising  to  a  sitting  posture  while  lying  on  the  back 
with  the  feet  fixed  is  another  exercise  helpful  in  the  correction  of  constipa- 
tion; so  is  twisting  of  the  body  while  standing.  Daily  exercise,  including 
horseback  riding,  golf,  and  tennis,  has  an  important  influence  in  correcting 
constipation.  We  have  knowTi  dancing  also  to  be  serviceable.  The  free  use 
of  plain  water  is  sometimes  sufficient  to  overcome  the  milder  cases.  Thus, 
a  glass  of  water  may  be  taken  before  breakfast  and  another  at  bedtime. 

Last  of  all  should  aperients  be  employed.  Unfortunately,  these  are 
often  necessary.  The  simplest  and  least  irritating  should  be  employed.  A 
simple  tonic  piU  composed  of  1/3  to  1/2  grain  (0.022  to  0.033  gm.)  of  the 
extract  of  nux  vomica  and  1/12  to  1/8  grain  (0.005  to  0.008  gm.)  of  the 
extract  of  belladonna,  three  times  a  day,  and  kept  up  for  some  time  in 
connection  with  the  dietetic  measures  alluded  to,  is  often  sufficient. 

But  of  actual  aperients,  the  natural  mineral  waters  are  deserving  fa- 
vorites, especially  Friedrichshalle,  Apenta,  Hunyadi  Janos,  and  Carlsbad, 
and,  when  less  active  waters  are  required,  the  American  Saratoga  waters. 
The  Saratoga  waters  are  saline  waters  which  present  quite  a  range  of  pro- 
portion in  their  constituents,  chiefly  sodivun  chlorid,  at  the  various  springs, 
The  waters  of  the  Bedford  Springs,  of  Bedford,  Pa.,  are  also  ver>''  efficient, 
stimulating,  as  does  the  Saratoga  water,  the  secretion  of  bUe.  The  doses 
of  all  of  these  waters  vary  so  much  with  circumstances  that  it  is  impossible 
to  indicate  them  with  deffniteness.  The  minimum  dose  of  the  foreign  ape- 
rient waters  mentioned  is  2  fluidounces  (60  c.c),  increased  to  8  fluidounces 
(240  c.c).  Less  than  the  latter  quantity  of  the  American  waters  is  seldom 
used  at  a  dose. 

Of  drugs,  cascara  sagrada  has  become  deservedly  popular.     The  best 


CONSTIPATION  427 

preparation  is  the  fluid  extract,  as  its  dose  can  be  readily  regulated.  From 
lo  to  30  minims  (0.6  to  2  c.c.)  may  be  given  after  the  evening  meal,  and  if 
this  should  prove  insufficient,  the  same  dose  after  the  midday  meal  is  to  be 
preferred  before  increasing  the  evening  dose.  The  solid  extract  is,  however, 
also  efficient,  and  a  grain  or  2  (0.066  to  0.13  gm.)  more  may  be  added  to 
the  laxative  pill  already  mentioned,  or,  if  a  more  active  aperient  is  desired, 
as  many  grains  of  extract  of  colocynth  may  be  substituted. 

An  old  favorite,  a  pill  composed  of  extracts  of  aloes,  nux  vomica,  and 
belladonna,  in  varying  proportions,  to  be  taken  at  bedtime,  has  been  largely 
substituted  of  late  by  another  made  by  the  mantif  acturers  and  pharmacists, 
of  aloin  1/5  grain  (0.013  gm-)>  strychnin  1/60  grain  (o.ooii  gm.),  and  bella- 
donna 1/8  grain  (0.008  gm.),  of  which  one  or  two  are  a  dose.  To  such  a 
pill  podophyllin,  in  doses  of  1/4  to  1/2  grain  (0.0165  to  0.033  gni-)>  may  be 
added  with  advantage,  or  blue  mass  in  doses  of  1/2  grain  to  2  grains  (0.033  to 
0.132  gm.),  or  rhubard  i  to  2  grains  (0.066  to  0.013).  The  belladonna 
may  be  substituted  by  the  extract  of  hyoscyamus,  of  which  i  to  2  grains 
(0.066  to  0.132  gm.)  may  be  given.  The  compound  Ucorice  powder  in 
which  senna  and  sulphur  are  the  active  ingredients  is  a  favorite  aperient 
with  some,  but  is  bulky,  and  has  a  tendency  to  cause  griping.  The  dose  is 
a  dram  (3.8  gm.)  or  more.  Phenolphthalein  in  doses  of  i  1/2  to  7  1/2  grains 
(o.i  to  0.5  gm.)  in  powder  or  tablet  form  is  a  good  aperient. 

A  glycerin  suppository  or  1/2  dram  (2  c.c.)  of  glycerin  injected  has 
become  a  favorite  means  of  securing  an  evacuation.  It  should  be  remem- 
bered as  a  possible  remedy,  but  it  acts  by  irritating  the  lower  bowel  and  soon 
loses  its  effect.  The  enema  of  plain  water,  i  to  2  pints  (500  to  1000  c.c), 
though  less  convenient,  is  to  be  preferred,  and  some  persons  use  it  regu- 
larly. None  of  these  measures  is  curative.  They  simply  empty  the  bowel 
at  the  time,  and  sj^stematic  effort  should  be  made  to  reduce  them  gradu- 
ally, while  the  hygienic  treatment  is  kept  up. 

It  sometimes  happens  that  an  impacted  fecal  mass  becomes  channeled, 
and  fecal  matter  may  descend  from  above  through  it,  and  thus  lead  to  the 
belief  that  normal  passages  are  being  secured.  The  physician  shotild 
explore  the  rectum  with  the  finger,  and  by  means  of  it  or  the  handle  of  a 
spoon  clear  out  the  mass.  This  is  often  absolutely  necessary  before  an 
evacuation  can  be  secured. 

Treatment  of  the  Constipation  of  Infants. — This  is  best  overcome,  when 
possible,  by  simple  small  enemas  repeated  until  an  effect  is  produced, 
and  carried  out  at  a  fixed  hour  each  day,  preferably  in  the  evening.  The 
child  is  best  held  on  the  mother's  lap,  properly  protected  by  a  mackintosh 
and  a  small  quantity,  say  2  ounces  (60  c.c),  of  tepid  water  is  thrown  into 
the  rectimi.  If  it  returns  unchanged,  after  a  few  minutes'  delay,  another 
syringeful  is  thrown  in,  and,  if  necessary,  another.  Ultimately,  a  fecal 
discharge  is  usually  thus  obtained.  Regularity  of  this  performance  is  im- 
porta,nt.  It  may  be  necessary  to  add  a  little  soap  to  the  hot  water.  Some- 
times shght  titillation  of  the  anus  by  twisted  pieces  of  paper  answers 
every  purpose.  At  the  same  time,  the  belly  of  the  child  should  be  massaged 
by  the  mother.  Small  suppositories  of  soap  or  of  glycerin  may  be  used  if  the 
measures  mentioned  are  inefficient.  For  simple  constipation  in  infants  it  is 
preferable  to  administer  nothing  by  the  mouth  if  it  can  be  dispensed  with. 


428  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Dilatation  of  the  Colon. — This  is  one  of  the  consequences  of  chronic 
constipation,  though  it  may  also  occur  as  an  acute  condition,  the  result  of 
sudden  obstruction,  as  by  a  twist  in  the  meso-colon.  It  may  involve  the 
whole  colon,  but  the  vicinity  of  the  sigmoid  flexure  is  its  usual  seat.     Two 


Fig.  102. — Giant  Congenital  Dilalalion  .it  Human  Colon. 
The  more  distended  end  is  the  sigmoid  fle.xurc.  The  narrow  pari  taking  e.vit  from  it  is  part 
of  the  rectum,  which  was  normal.  The  narrow  distal  end  of  the  preparation  represents  the 
head  of  the  colon  with  the  string  attached  to  a  fragment  of  the  small  intestines.  The  arched 
part  of  the  specimen  represents  a  normal  human  colon  photographed  simultaneously  for  com- 
parison of  dimensions.     Both  were  dried  preparations. 

classes  of  cases  of  idiopathic  dilatation  are  met — first,  that  of  adtilt  males, 
generally  over  50  years  of  age;  second,  that  of  children  in  whom  abdominal 
symptoms  have  been  present  more  or  less  since  birth.  In  the  former  it  is 
thought  that  the  overloaded  sigmoid  hanging  into  the  pelvis  and  bent  on 


DIVERTICULITIS  429 

itself  becomes  occluded  and  responsible  for  dilatation.  The  form  met  in 
children  is  usually  congenital  and  involves  the  lower  portion  of  the  colon, 
which  is  also  hypertrophied.  The  congenital  form  becomes  the  direct  cause 
of  chronic  constipation  or  coprostasis,  which  in  turn  increases  the  dilatation. 
Such  is  a  remarkable  specimen  in  the  museum  of  the  University  of  Pennsyl- 
vania, secured  by  the  late  Henry  F.  Formad'  in  the  course  of  his  work  as 
coroner's  physician.  Two  and  a  half  pailsful  of  feces,  weighing  40  pounds 
(20  kilograms),  were  removed  at  autopsy. 

Symptoms. — They  are  the  same  as  those  of  obstinate  constipation 
extending  over  weeks,  in  addition  to  enormous  distention  and  tympany  of  the 
abdomen.  Physical  examination  in  extreme  cases  recognizes  dislocation 
of  the  adjacent  abdominal  and  thoracic  viscera,  especially  the  liver,  spleen, 
heart,  and  lungs. 

Treatment. — The  treatment  is  that  of  the  resulting  constipation,  which, 
in  cases  of  this  kind,  is  by  enemas  carried  high  up  into  the  bowel,  together 
with  remedies  which  simulate  secretion  into  the  upper  bowel,  of  which  calo- 
mel is  one  of  the  best.  It  should  be  given  in  doses  of  not  less  than  1/4  grain 
(0.016  gm.)  hourly,  until  an  effect  is  produced  in  association  with  that  of  the 
enemas.  Dilatation  probably  residts,  at  times,  from  the  gradual  accumula- 
tion of  fecal  matter,  while  frequent  small  discharges  are  being  obtained 
which  do  not  clear  out  the  bowel.  Hence  the  rectum  should  imhesitatingl}' 
be  explored  by  the  finger  in  doubtful  cases.  Complete  evacuation  of  the 
bowels  is  sometimes  extremely  difficult,  but  if  the  exact  state  of  affairs  is 
appreciated,  perseverance  will  ultimately  conquer.  Operation  with  exsec- 
tion  of  large  portions  of  the  bowel  has  been  done  with  excellent  results  and 
is  the  only  rational  treatment. 

Diverticulitis. 

Inflammation  of  the  diverticula,  commonly  in  the  lower  portion  of  the 
colon,  although  it  may  occur  in  the  cecum. 

The  patients  are  usually  over  forty  years  of  age.  The  patients  are 
otherwise  well,  and  usually  obese.  Cases  reported  b}'  Mayo  occurred  in 
the  sigmoid;  either  an  abscess  forms  intraperitoneally,  obstruction  occurs, 
or  the  case  is  slight  and  receives  no  attention.  Some  of  the  cases  begin 
suddenly  with  pain  low  down  on  the  left  side;  all  had  tumors  in  that  region. 

The  only  treatment  is  resection  of  the  gut  and  removal  of  the  tumor, 
or  if  an  abscess  be  present,  opening  and  draining  of  the  abscess. 

CARCINOMA  OF  THE  INTESTINE. 

All  parts  of  the  intestine  are  subject  to  carcinoma,  which  occurs  in  grow- 
ing frequency  as  the  gut  is  descended.  Thus,  of  all  cases  of  intestinal  cancer, 
barley  5  per  cent,  are  found  in  the  small  intestine,  15  per  cent,  in  the  cecum 
and  colon,  while  80  per  cent,  are  met  in  the  rectum. 

In  the  small  intestine,  in  the  neighborhood  of  the  orifice  of  bile-duct, 
we  meet  most  frequently  the  cylinder-celled  epithelioma  or  adenocarcinoma. 


*" Transactions  of  the  Pathological  Society  of  Philadelphia,"  vol.  xvi.,  1891-93,  p.  23.     Formad  gives 
in  his  paper  a  summary  of  other  cases  reported. 


430  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

In  the  large  intestine  there  is : 

1.  Cylinder-celled  epithelioma,  the  most  common  form  of  cancer,  in  the 
cecum  and  sigmoid  flexure. 

2.  Colloid  cancer 

3.  Scirrhus 

4.  Soft  cancer  [  in  the  rectum. 

5.  Squamous  epithelioma  just  above  the  anus 

6.  Scarcoma,  including  the  melanotic  variety     J 

Benign  tumors  of  the  bowel,  which  may  present  symptoms  similar  to 
those  of  malignant  tumors  or  no  symptoms  at  all,  include  mucous  polypi  and 
fibromata,  more  rarely  lipoma,  myoma,  angioma,  and  lymphoma. 

Symptoms. — There  are  no  symptoms  distinctive  of  cancer  of  the  bowel. 
The  most  constant  local  effect  is  more  or  less  obstruction  of  the  bowel,  and 
we  have  alread}'  seen  in  our  study  of  obstruction  how  far  it  is  contributed  to 
by  cancer.  There  are,  however,  other  symptoms  which,  added  to  those  of 
obstruction,  aid  in  the  diagnosis.  Particularly  is  this  true  in  the  case  of 
the  rectrmi. 

The  symptoms  of  obstruction  met  with  in  cancer  of  the  bowel,  already 
considered  in  treating  of  obstruction,  include,  especially,  constipation,  pain, 
tumor,  anorexia,  nausea,  and,  more  rarely,  vomiting.  The  added  symptoms 
are  cachexia  and  altered  fecal  discharges,  which  may  include  pus,  blood,  occvUt 
blood  and,  in  few  instances,  fragments  of  cancerous  tissue.  Of  the  symp- 
toms of  obstruction  named,  tumor  alone  demands  further  consideration, 
being  the  most  important  of  all  the  symptoms  of  cancer.  In  fact,  without 
it  a  certain  diagnosis  is  scarcely  possible.  On  the  other  hand,  given  a  case 
of  obstruction,  the  presence  of  tumor  points  more  to  cancer  than  to  any 
other  cause  except  intussusception  and  fecal  impaction.  As  contrasted 
with  intussusception,  the  tumor  of  cancer  is  of  long  duration  and  found  in 
adults;  as  with' impaction,  it  is  tender  and  movable,  usually  harder  and 
more  irregular.  While  the  tumor  may  give  a  dull  note  to  light  percussion, 
to  a  hard  stroke  it  is  tympanitic.  It  may  pulsate  also  if  it  lie  over  one  of 
the  large  blood-vessels.  Fecal  tumors  never  do  this.  The  difficulty  of 
distinguishing  from  a  fecal  tumor  is  increased  when  a  fecal  mass  is  added 
to  the  cancerous  tumor,  but  some  of  it  may  be  cleared  up  by  the  use  of 
purgatives  and  injections. 

Cachexia,  added  to  other  signs  of  chronic  obstruction,  points  to  cancer. 
Change  in  the  shape  of  the  formed  feces,  especially  a  band-like  flattening,  is 
much  spoken  of.  It  may  be  produced  by  any  cause  which  protrudes  into 
the  lumen  of  the  large  bowel,  characterizes  rather  disease  of  the  lower  part, 
and,  to  be  of  value  in  diagnosis,  it  must  be  constant.  The  more  or  less  con- 
stant presence  of  sanious  pus,  particvdarlj'  of  fetid  character,  is  important 
evidence  in  favor  of  cancer. 

Sudden  obstruction  of  the  intestine  following  a  long-standing  constipa- 
tion occurring  in  those  past  middle  life,  with  or  without  tumor,  is  strongly 
suggestive  of  carcinoma  (schirrus)  in  the  lower  intestine.  Volvulus,  obstruct- 
ing bands  and  other  common  causes  must  of  course  be  considered. 

Diagnosis. —  i.  Diagnosis  of  the  Part  of  Bowel  Involved.— As  to  the  part 
of  the  bowel  involved,  once  assured  that  the  ttmior  is  of  the  bowel,  some 
indication  of  its  more  exact  location  may  be  obtained  by  noting  its  position, 


CANCER  OF  INTESTINE  431 

which,  if  in  the  right  upper  abdominal  region,  suggests  the  duodenum;  in 
the  vicinity  of  the  umbilicus,  the  transverse  colon;  in  the  right  iliac  fossa, 
the  ceciun,  and  in  the  left,  the  sigmoid  flexure.  It  should  be  remembered, 
however,  that  serious  dislocation  of  the  tumor  from  its  natural  site  may  occur 
as  the  result  of  inflammatory  adhesions  formed  while  the  tumor  is  tem- 
porarily in  a  position  remote  from  its  natural  site.  Often,  too,  a  cancer  of 
the  sigmoid  flexures  gives  no  indication  of  its  presence  to  abdominal  exami- 
nation. Persistent  occult  blood  in  the  stools  is  very  significant  of  carcin- 
oma of  the  intestinal  tract.  Allusion  has  been  made  to  the  presence  of 
jaundice  as  characteristic  of  duodenal  cancer;  also  to  the  retained  natural 
acidity  of  the  gastric  contents  removed  after  a  test-meal  as  compared  with 
gastric  cancer.  Cancer  of  the  rectum  can  generally  be  reached  by  the 
finger  or  some  by  the  aid  of  the  speculum. 

2.  Carcinoma  of  the  duodenum  is  not  easily  distinguished  from  tumor 
of  the  pylorus;  indeed,  it  is  sometimes  impossible  to  separate  them.  Both 
are  movable  tumors.  With  pyloric  tumor  are  associated  symptoms  of 
obstruction  and  dUatation  of  the  stomach.  More  rarely  cancer  of  the 
duodenum  has  the  same  effect.  The  presence  of  jaundice  points  to  cancer  of 
the  duodenum,  as  does  also  the  continued  natural  acidity  of  the  gastric  con- 
tents removed  after  a  test-meal,  but  neither  of  these  symptoms  is  pathog- 
nomonic of  duodenal  cancer.  In  cancer  of  the  stomach  dyspeptic  symp- 
toms occur  earlier  and  are  more  serious.  Carcinoma  of  the  duodenum  may 
terminate  suddenly  by  fatal  hemorrhage.  Cancer  of  the  head  of  the  pan- 
creas also  produces  jaundice,  but  the  tvunor  arising  from  it  is  fixed  and 
immovable,  and  much  more  deep-seated  than  tumors  of  any  portion  of  the 
bowel,  being  behind  the  pylorus  and  the  transverse  colon,  between  the  right 
sternal  border  and  parasternal  line. 

With  the  other  abdominal  tumors  intestinal  cancer  is  not  likely  to  be 
confounded.  The  floating  kidney  is  movable,  but  when  sufficiently  so  to  be 
compared  in  this  respect  with  a  cancerous  tumor,  is  more  movable,  and  may 
be  generally  returned  to  its  natural  seat.  The  kidney  shape  may  not  infre- 
quently be  recognized.  Compression  of  the  kidney  often  produces  a 
peculiar  sickening  pain.  The  presence  of  nervous  symptoms  is  especially 
characteristic  of  floating  kidney,  but  there  is  no  cachexia.  A  movable  spleen 
is  even  less  likely  to  be  confounded,  for  similar  reasons.  It  is,  moreover, 
less  sensitive.  A  laced-off  lobe  of  the  liver,  often  quite  movable,  can  generally 
be  traced  to  its  normal  attachment. 

An  actual  tumor  of  the  kidney,  being  behind  the  peritoneum,  pushes  the 
bowel  and  the  ascending  or  descending  colon  before  it,  and  must  attain  con- 
siderable size  before  it  shows  itself  to  the  usual  examination  from  the  front. 
Such  tumor  very  rarely  compresses  the  bowel  so  as  to  produce  symptoms  of 
obstruction.  The  same  may  be  said  of  tumors  of  postperitoneal  lymphatic 
glands.  An  ovarian  tumor  is  characterized  by  its  deep-seated  origin,  its 
ascending  development,  and  its  relation  to  the  uterus,  as  determined  by 
joint  vaginal  and  abdominal  examination. 

A  circumscribed  peritoneal  exudate  might  be  mistaken  for  a  cancer  of 
the  bowel,  but  the  history  of  its  development,  its  flat  percussion  note,  and 
the  presence  of  some  temperature,  which  characterizes  it,  are  wanting  in 
cancer  of  the  bowel. 


432  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Carcinoma  of  the  cecum  is  frequently  mistaken  for  appendicitis.  Pain 
may  be  the  first  symptom  attracting  the  attention  of  the  patient.  Examina- 
tion will  show  tenderness,  resistence  and  a  tumor  in  the  appendiceal  region. 
Operation  only  revealing  the  fact  that  the  tumor  is  a  new  growth.  If  a 
history  of  long-standing  tumor  can  be  obtained  a  carcinoma  would  be 
suspected,  but  chronic  appendicitis  may  likewise  give  rise  to  a  tumor  lasting 
some  time. 

Chronic  inflammatory  thickening  of  the  bowel  may,  however,  be  a  seri- 
ous stumbling-block.  Especially  apt  to  occur  about  the  sigmoid  flexure,  it 
produces  also  obstructive  symptoms,  and  careful  and  prolonged  study  may 
be  necessary  to  the  making  of  a  correct  diagnosis.  Cachexia  remains  absent 
in  simple  inflammatory  stenosis  for  a  longer  time  at  least  than  cancer. 

Diverticulitis  lately  described  by  Mayo  gives  sometimes  all  the  rational 
symptoms  and  signs  of  carcinoma. 

Cancer  of  the  rectum  exhibits  a  somewhat  special  train  of  symptoms. 
The  rectum  is  subject  to  the  same  forms  of  cancer  as  the  pylorus,  and  in 
somewhat  the  same  order  of  frequency,  the  columnar-celled  epithelioma 
being  most  common. 

The  early  symptoms  of  cancer  of  the  rectum  are  those  of  irritation,  in- 
cluding pain,  tenesmus,  the  discharge  oj  mucus  and  blood,  and,  probably, 
m.ost  cases  of  carcinoma  of  the  rectum  are  mistaken  at  first  for  dysentery. 
In  the  cases  of  colloid  cancer,  the  colloid  material  may  be  discharged  from 
the  bowel  and  reasonably  mistaken  for  mucus.  Early  examination  of  the 
rectum  by  the  finger  should  always  be  made  for  generally  the  disease  can 
be  felt,  either  as  an  ulcerated  mass  infiltrating  the  wall  of  the  bowel,  thus 
intruding  upon  the  lumen,  or  as  one  or  more  nodular  growths  under  the 
mucous  membrane  and  adherent  to  it.  If  ulceration  has  occurred,  bloody 
and  mucoid  matter,  characterized  by  extreme  and  persistent  fetor,  is  apt 
to  adhere  to  the  finger.  Von  Leube  especially  calls  attention  to  hemor- 
rhoids as  a  symptom  of  cancer  of  the  rectum,  and  saj^s  they  are  seldom 
absent,  because  of  the  resistance  opposed  to  the  return  of  the  venous  blood. 
He  claims  he  has  discovered  rectal  cancer  in  examination  suggested  by 
hemorrhoids  when  no  other  symptoms  were  present.  So,  too,  the  presence 
of  secondary  cancer  of  the  liver  should  suggest  examination  of  the  rectiun, 
since  marked  instances  of  the  former  have  been  found  associated  with  cancer 
of  the  rectum,  otherwise  latent. 

Almost  all  morbid  growths  affecting  the  rectum  of  adults  are  cancerous 
Polypi,  mucous  and  fibromatous,  occasionally  foimd  in  children,  produce 
dysenteric  symptoms,  including  bloody  discharges,  while  they  may  project 
from  the  rectum  dtiring  stool.  Lipomata  and  other  histioid  tumors  have 
been  found  at  autopsy  without  having  caused  symptoms. 

Prognosis  and  Treatment  of  Cancer  of  the  Intestine. — The  prognosis 
of  cancer  of  the  bowel  is  always  unfavorable.  Occasionally  operative  pro- 
cedures have  prolonged  the  life  of  the  patient  at  the  expense  of  an  artificial 
anus  in  the  lumbar  or  abdominal  region,  while  resection  has  even  been  made 
with  success.  Especially  favorable  have  been  the  residts  in  some  cases  of 
excission  of  the  tumor. 

The  propriety  of  operation  should,  therefore,  always  be  considered. 
Should  it  be  decided  against,  the  patient  must  be  nourished  by  easily  assimil- 


ABNORMAL  LIVER  433 

able  foods,  such  as  peptonized  milk,  b}'  the  mouth  or  bowel,  as  circum- 
stances may  determine.  A  regular  and  sufficient  evacuation  of  the  bowels 
should  be  carefully  looked  after,  lest  impaction  add  its  inconveniences  to 
the  others  present. 

INTESTINAL  SAND. 

Intestinal  sand  occurs  in  women.  Not  infrequently  it  is  a  true  mineral 
gritty  substance,  in  one  case  seen  by  us  exactly  resembling  the  red  sand  sup- 
plied for  the  care  of  canary  birds.  A  false  intestinal  sand  occurs,  due  to 
remains  of  vegetable  materials  which  have  been  partially  digested  and 
incrusted  with  mineral  salts. 


DISEASES  OF  THE  LIVER. 

ABNORMALITIES  IN  THE  SHAPE  AND  POSITION  OF 
THE  LIVER. 

Altered  Shape. — The  only  abnormality  in  the  shape  of  the  liver  requir- 
ing special- mention  is  the  "laced-ofE"  or  "corset"  liver.  In  this  the  right 
lobe  is  divided  by  a  transverse  furrow,  more  or  less  deep,  into  two  nearly 
equal  parts.  In  extreme  cases  the  connecting  furrow  is  a  mere  fibrous 
band,  and  the  liver  can  be  folded  on  itself;  in  others  it  contains  more  or  less 
liver  parenchyma.  It  is  said  to  be  caused  by  the  pressure  of  a  tight  waist- 
band or  corset,  and  accordingly  is  more  frequent  in  women,  but  it  is  met 
also  in  men. 

It  seldom  gives  rise  to  any  symptoms,  but  sometimes  leads  to  confusion 
in  diagnosis,  being  frequently  mistaken  for  a  movable  kidney  or  an  abdomi- 
nal tumor,  for  the  inferior  portion  may  extend  as  low  as  the  crest  of  the  ilium. 
This  confusion  is  increased  if,  as  occasionally  happens,  a  loop  of  intestine 
lies  in  the  furrow  and  gives  a  tympanitic  note  on  percussion;  whence  the 
inference  that  the  lower  portion  is  a  separate  organ.  Skillful  palpation  is 
a  valuable  means  for  determining  the  true  nature  ,of  such  a  condition. 
The  edge  of  the  liver  should  be  followed  around  from  the  epigastrium  into 
the  right  lumbar  and  iliac  regions.  If  the  continuity  with  the  supposed 
tumor  is  uninterrupted,  the  latter  must  be  a  portion  of  liver  laced  off.  It 
is  not  unlikely  that  such  a  condition  may  occasion  symptoms  of  dragging 
and  weight,  with  the  nervous  strain  frequently  incident  to  them,  like  that 
which  is  so  characteristic  of  floating  kidney.  The  corset-liver  is  said  to 
be  one  of  the  favoring  causes  of  cholelithiasis,  by  reason  of  its  interference 
with  the  natural  onward  movement  of  the  bile. 

Abnormality  of  Position. — The  liver  in  cases  of  transposed  viscera  is 
found  on  the  left  side.  More  frequently  it  is  simply  turned  downward  or 
upward,  anteverted  or  retroverted  as  it  may  be  on  its  transverse  axis,  chiefly 
as  a  consequence  of  tight  lacing  in  women.  It  may  be  pushed  upward 
above  its  normal  site  by  ascitic  fluid  or  abdominal  tumors,  and  downward 
by  pleuritic  effusion  on  the  right  side  or  by  emphysema  of  the  right  lung. 

The  floating  liver  is  by  far  the  most  interesting  of  these  conditions. 
When  it  occurs,  the  natural  site  of  the  liver  is  vacant,  especially  when  the 


434  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

patient  is  in  the  upright  position,  occupied  usually  by  hollow  viscera,  or, 
in  rare  instances,  by  morbid  growths.  The  condition  of  such  mobility  is 
a  long  suspensory  ligament  and  a  coronary  ligament  so  stretched  as  to  form 
a  sort  of  mesohepar,  which  permits  the  liver  to  fall  out  of  its  normal  posi- 
tion. It  occurs  usually  in  women  past  middle  life,  with  loose  abdominal 
walls,  and  is  favored  by  tight  lacing.  It  has  been  met  wath  in  men.  It  is 
sometimes  responsible  for  the  condition  known  as  the  pendent  belly.  It  is 
a  rare  condition. 

The  organ  itself  is  usually  easily  recognized  as  a  large,  hard,  but  movable 
tumor,  below  the  normal  place,  and  having  also  the  shape  and  size  of  the 
liver,  while  the  normal  site  is  tympanitic  on  percussion  or  occupied  by 
organs  which  do  not  give  the  same  outline  on  percussion.  The  suspensory 
ligament  may  also  be  felt.  The  organ  may  generallj^  be  restored  to  its 
normal  position  when  the  patient  is  recumbent.  A  deceptive  form  of 
movable  liver  occurs  in  the  late  stages  of  portal  cirrhosis.  The  liver  is 
tilted  on  its  transverse  axis,  the  lower  edge  extending  far  below  the  margin 
of  the  ribs,  the  upper  margin  being  the  posterior  border  of  the  liver  is  found 
about  at  the  normal  upper  limit  of  the  liver  dullness,  namely,  at  the  fifth 
rib.  This  closely  resembles  a  large  liver  and  is  constantly''  mistaken  for 
such. 

The  same  dragging  symptoms  mentioned  as  characteristic  of  the  con- 
stricted liver,  with  the  usual  contingent  of  nervous  symptoms  which  succeed 
upon  it  and  the  movable  kidney,  may  be  present  here. 

Treatment. — The  treatment  for  both  of  these  conditions — the  con- 
stricted and  the  displaced  liver — must  consist  in  some  instrmnental  means 
by  which  the  organ  or  constricted  portion  can  be  held  in  position. 

Diseases  of  the  Bile  Passages  and  Gall  Bladder. 

JAUNDICE  OR  ICTERUS. 

Jaundice  is  not  a  disease,  but  a  symptom,  consisting  in  a  yellowish 
discoloration  of  the  skin  and  other  tissues  and  fluids  of  the  body  by  coloring- 
matters  derived  from  the  bile.  The  shades  of  coloring  range  from  a  very 
pale,  scarcely  appreciable,  yellow  to  a  brown-olive  hue.  It  is  a  sjTnptom 
present  in  so  many  different  diseases  and  so  associated  with  other  symptoms 
more  or  less  constant  that  its  separate  consideration  is  justified. 

Obstructive  Jaundice. — Reabsorption  of  bile  takes  place  when  there 
is  obstruction  to  its  onward  movement,  such  as  results,  for  example,  from 
impaction  of  a  gall-stone  in  the  hepatic  duct  or  common  bile-duct;  from 
closure  of  the  duodenal  end  of  the  common  bile-duct  by  inflamed  and 
swollen  intestinal  mucous  membrane;  from  complete  or  partial  obliteration 
of  the  duct  by  adhesive  inflammation ;  and  from  pressure  from  without  by 
morbid  growths.  These  growths  may  be  enlarged  glands  in  the  fissure  of 
the  liver,  or  tumor  in  the  gall-bladder,  in  the  liver  itself,  in  the  pancreas, 
and  in  the  stomach,  and  especially  cancer  of  the  pylorus  and  duodenum. 
More  rarely  tumors  of  the  kidney  or  omentum,  abdominal  aneurysm  of  the 
celiac  axis  or  aorta,  or  enlargement  of  the  uterus  may  occasion  obstruction. 
So  may  fecal  accumulation.     The  morbid  states  in  the  liver  which  may 


JAUNDICE  435 

produce  jaundice  are  cancer,  abscess,  hydatid  cysts,  and  cicatrices,  all  of 
which  will  be  referred  to  again.  It  is  reasonable  to  suppose  that  the  bile 
is  absorbed  from  the  overdistended  biliary  vessels  by  the  adjacent  capillary 
vessles  of  either  portal  or  hepatic  vein  system  facilitated  by  pressure.  Re- 
duced pressure  in  the  blood-vessels  of  the  liver,  as  contrasted  with  that 
in  the  biliary  vessels  and  ducts,  also  favors  reabsorption  of  bile  from  the 
latter. 

This  is  the  usual  form  of  jaundice.  All  ages  are  subject  to  it.  In  addi- 
tion to  the  discoloration  described  there  is  often  an  annoying  itching  of  the 
skin,  due  to  irritation  of  the  deposited  bile  pigment.  Further  evidence  of 
the  irritation  thus  caused  is  seen  in  occasional  eruptions,  such  as  urticaria, 
lichen,  and  even  furuncles.  A  bright  yellow  discoloration  of  the  sclerotic 
coat  of  the  eye  is  as  constant  as  the  staining  of  the  sldn,  while  the  mucous 
membranes  are  often  similarly  tinged. 

After  the  skin,  the  urine  exhibits  the  most  conspicuous  alteration,  even 
in  mild  cases.  Indeed,  this  is  sometimes  the  first  symptom.  The  color 
may  be  slightly  yellow  or  deep  brown,  like  that  of  porter.  The  presence  of 
bile  pigment  in  the  urine  is  readily  shown  by  Gmelin's  nitrous  acid  test, 
though  ordinary  nitric  acid  answers  nearly  as  well.  A  few  drops  of  the 
urine  and  half  as  many  of  the  acid  are  placed  on  a  procelain  plate  and  gradu- 
ally allowed  to  approach  and  fuse,  when  a  brilliant  play  of  colors  appears, 
in  which  green,  yellow,  red,  and  violet  are  most  easily  recognized.  The 
reaction  is  due  to  the  exidation  of  the  bilirubin  by  the  acid.  One  of  the 
most  reliable  ways  of  recognizing  bile  in  the  vuine  is  by  the  stained  cellular 
elements  which  it  contains.  Under  no  other  circumstances  are  the  bright 
yellow  stained  cells  found,  and  they  are  even  met  with  when  the  quantity 
of  coloring-matter  is  insufficient  to  react  by  Gmelin's  test.  In  a  few  cases 
the  bilirubin  reaction  is  not  obtainable,  when  the  urine  contains  in  in- 
creased amount  its  normal  coloring-matters,  urobilin  or  hydrobilirubin — 
i.  e.,  reduced  bilirubin. 

Of  the  remaining  secretions,  the  perspiration  is  often  stained,  the  milk, 
the  tears,  and  saliva,  are  rarely  stained.  There  is  sometimes  a  bitter  taste 
in  the  mouth,  showing  an  elimination  of  some  constituent  of  the  bile  by 
the  buccal  glands  probably  the  salivary. 

On  the  other  hand,  the  feces  are  often  devoid  of  biliary  coloring-matter, 
and  their  pale-gray  or  pipe-clay  color  has  long  been  significant  of  the  absence 
of  bUe.  For  the  same  reason  the  bowels  are  usually  constipated  and  the 
discharges  pasty,  iU-smelling,  and  acid.  Occasionally  there  is  diarrhea, 
which  may  be  caused  by  irritating  effect  of  the  feces  disposed  to  rapid 
decomposition,  because  of  the  absence  of  their  natural  antiseptic  ingredient. 
For  the  same  reason,  too,  the  absorption  of  fats  is  hindered.  There  may 
be  other  signs  of  gastrointestinal  derangement,  such  as  loss  of  appetite, 
nausea,  fetid  breath,  and  fullness  in  the  epigastrium  after  eating.  Hemor- 
rhage is  common  in  chronic  jaundice.  The  clotting  time  of  the  blood  is 
much  prolonged,  often  being  as  long  as  ten  to  twelve  minutes.  Hemorrhages 
occur  from  many  of  the  mucous  membranes  and  into  the  skin  in  the  form  of 
purpura.  Operations  in  chronic  jaundice  are  dangerous  on  account  of 
bleeding  which  follows.  In  cases  of  long  standing  there  may  be  albuminuria 
as  weU,  with  bile-stained  tube  casts. 


436  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Very  characteristic  of  simple  obstructive  jaundice  is  a  slow  pulse,  which 
may  be  as  infrequent  as  50,  40,  or  30.  The  breathing  rate,  on  the  other 
hand,  is  nonnal. 

The  chief  subjective  symptom  of  jaundice  is  depression  of  spirits,  which 
may  even  amount  to  melancholia.  Irritability  is  also  prominent.  Headache 
and  vertigo  are  frequent.  Vision  is  variousljf  affected:  to  some,  objects 
appear  yellow ;  some  see  better  by  obscure  light — nyctalopia ;  to  others,  the 
approach  of  darkness  is  associated  with  more  than  usuallj'  difficult  vision — 
hemeralopia.  Grave  nervous  symptoms,  rarely  manifested,  are  sudden 
coma,  acute  delirium,  and  convulsions.  These  usually  supervene  in  cases  of 
long  standing,  and  are  attended  by  fever,  rapid  pulse,  and  dry  tongue — the 
symptoms,  in  a  word,  of  the  typhoid  state.  The  term  cholemia  is  applied 
to  the  sum  of  these  symptoms,  and  the  condition  is  regarded  as  due  to  the 
presence  in  the  blood  of  the  constituents  of  bile,  of  which  cholesterin  is  the 
most  important;  whence  also  the  name  cholesteremia. 

The  liver  is  more  or  less  altered,  in  accordance  with  the  disease  which 
may  be  present  in  it  and  responsible  for  the  jaundice.  These  changes  will 
be  considered  in  treating  of  the  diseases  in  which  jaundice  is  a  conspicuous 
symptom.  It  may  also  be  bile-stained,  as  are  other  internal  organs,  es- 
pecially the  kidneys. 

The  duration  of  this  form  of  jaundice  depends  upon  the  disease  which 
is  reponsible  for  it,  and  it  may  be  a  few  days  or  many  months.  In  chronic 
cases  remission  and  exacerbations  occur,  but  the  longer  the  duration,  the 
more  likely  is  there  to  be  some  organic  change  in  the  liver. 

2.  Toxic  Hemolytic  or  Hematogenous  Jaundice. — This  form  of  jaundice 
is  now  recognized  as  in  reality  obstructive  in  character. 

Stadelman  has  shown  that  the  jaundice  is  in  reality  due  to  the  plugging 
of  the  small  bile  ducts  with  viscid  bile,  swollen  epithelial  cells  and  products 
of  blood  destruction.  The  pressure  in  the  hepatic  vessels  being  very  low 
the  bile  is  absorbed  into  the  vessels  and  jaundice  occurs.  The  symptoms 
of  this  form  are  those  of  the  diseases  which  are  responsible  for  the  hemolysis 
— ^viz.,  acute  yellow  atrophy,  phosphorus-poisoning,  yellow  fever,  bilious 
fever,  typhoid,  typhus,  and  relapsing  fevers,  pyemia,  pernicious  anemia, 
snake  poison,  chloroform,  and  other  poisons.  In  all  of  these  there  is  some 
toxic  agent  working  destruction  of  the  blood.  It  should  be  added  that  in 
this  form  of  jaundice  the  stools  are  not  clay-colored.  The  urine  also  is  less 
bile-stained,  though  the  true  urinary  pigments,  notably  urobilin,  are  often 
very  much  increased.  The  patients  are  frequently  delirious,  with  rapid 
running  pulse,  cutaneous  hemorrhages,  and  are  in  a  typical  typhoid  state. 

Recognition  of  Jaundice. — One  of  the  most  frequent  errors  of  the  inex- 
perienced, and  a  constant  one  of  the  laity,  is  to  mistake  for  jaundice  a  dirty 
yellowish  discoloration  of  the  skin,  known  as  sallowness,  which  is  symp- 
tomatic of  general  ill  health.  It  is  probably  an  anemia  and  may  be  dis- 
tinguished from  jaundice  by  the  fact  that  it  is  not  associated  with  staining 
of  the  conjunctiva  and  secretions.  It  is,  moreover,  not  a  yellow,  but  a 
dirty  brown.  One  needs  onl}-  to  have  his  attention  aroused  to  avoid 
error. 

Much  more  closely  does  the  discoloration  of  the  skin  in  Addison's  disease 
resemble  that  of    some   cases  of   jaundice.     In    the  former  there  is  no 


J  A  UN  DICE  437 

discoloration  of  the  sclerotic  coat  nor  of  the  urine,  whUe  the  feces  remain 
natural.  In  Addison's  disease  the  exposed  portion  of  the  body  and  its 
flexures  are  more  deeply  stained.  Great  exhaustion  is  pressed  in  Addison's 
disease. 

The  purpose  of  diagnosis  includes  the  discovery  of  the  cause  and  seat 
of  obstruction.  In  the  first  place,  most  cases  of  acute  jaundice  are  due  to 
catarrhal  inflammation  of  the  common  bile-duct.  If  associated  vnth.  fever, 
it  may  be  assumed  that  the  smaller  ducts  are  involved.  After  this,  obstruc- 
tion by  gall-stones  causes  many  cases;  then  foUow  hypertrophic  cirrhosis 
and  the  various  malignant  diseases  of  the  liver,  hydatid  disease,  abscess, 
pressure  by  enlarged  glands  in  the  fissure  of  the  liver;  also  obstruction,  the 
result  of  kinking  of  the  common  duct. 

Icterus  Neonatorum. 
Synonym. — Jaundice  of  the  New-born. 

Jaundice  occurs  in  new-born  children  in  a  simple  and  harmless  form, 
with  symptoms  comparable  to  obstructive  jaundice,  and  in  a  grave  form 
comparable  to  hemoljrtic  .jaundice.  The  first  is  probably  a  form  of  ob- 
structive jaundice  due  to  like  causes  especially  congestion  of  the  liver. 
It  is  much  the  more  frequent,  and  disappears  in  from  a  few  days  to 
several  weeks.  This  form  occurs  300  times  in  900  births  reported  by 
Holt. 

A  pattdous  ductus  venosus  has  been  suggested  as  an  avenue  through 
which  the  portal  blood  which  contains  bile  enters  the  circulation. 

The  grave  form,  usually  fatal,  has  been  found  associated  wdth  absence 
of  the  hepatic  duct  or  common  duct,  with  congenital  syphilitic  hepatitis, 
and  with  septic  phlebitis  of  the  umbilical  vein. 

Treatment. — The  simple  form  of  jaundice  of  new-bom  infants  demands 
no  treatment.  In  the  graver  forms  when  the  condition  can  be  traced  to 
syphilis,  it  demands  the  treatment  of  that  disease  in  its  tertiarj^  form. 
In  certain  forms  accompanied  by  grave  hemorrhage  the  injection  of  large 
doses  of  human  blood  serum  eft'ects  a  cure.  This  will  be  described  under 
melena. 

Hereditary  jaundice  occurs,  numerous  cases  being  reported  where  all 
the  children  of  a  mother  were  jaundiced  at  or  shortly  after  birth. 

DUODENO-CHOLANGITIS  OR  SiMPLE  CATARRHAL  JAUNDICE. 

Synonym. — Inflammation  of  the  Common  Bile-duct. 

Definition. — The  term  catarrhal  jaundice  is  applied  to  jaundice  due  to 
any  inflammation  of  the  common  duct  not  the  result  of  impacted  gall-stone. 

Etiology. — The  most  frequent  cause  of  such  inflammation  is  the  ex- 
tension of  a  gastro-duodenitis  into  the  common  duct.  To  the  same  cause 
is  ascribed  the  jaundice  sometimes  occurring  with  passive  congestion  of  the 
liver  due  to  mitral  valvular  heart  disease,  also  that  found  in  association 
with  the  infectious  diseases,  especially  pneumonia,  or  with  mental  emotion. 
Catarrhal  jaundice  may  also  be  epidemic. 

Morbid  Anatomy. — Opportunities  of  studying  postmortem  conditions 


438  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

after  catarrhal  jaundice  are  not  often  afforded,  but  when  they  occur,  the 
duodenal  end  of  the  duct — the  pars  intestinalis — has  been  mostly  involved. 
In  it  the  mucous  membrane  is  swollen,  while  its  orifice  and  the  diverticulum 
of  Vater  may  be  filled  with  mucus.  The  inflammation  may  extend  up 
into  the  cystic  duct,  and  even  higher,  into  the  hepatic  duct  and  branches. 
Suppuration  does  not  take  place  in  this  form  of  cholangitis. 

Symptoms.  —  Excepting  the  jaundice,  there  may  be  no  symptoms,  the  first 
indication  of  disturbance  being  the  yellow  color  of  the  skin.  There  may 
be  pain  and  tenderness,  due  to  gastro-intestinal  derangement  rather  than  to 
the  hepatic  state,  though  this  may  cause  it,  while  such  derangement  may 
also  lead  to  general  malaise,  loss  oj  appetite,  coated  tongue,  fetid  breath,  nausea, 
vomiting,  a  .sense  oi  fullness,  constipation,  or  irregular  action  of  the  bowels. 
There  may  be  also  slight /CTer,  particularly  if  the  smaller  biliary  passages  are 
involved.  If  the  gall-bladder  is  distended  and  can  be  felt  at  the  edge  of  the 
liver,  there  is  probably  obstruction  of  the  common  duct.  The  paler  the 
feces,  the  more  complete  must  be  the  obstruction,  and  the  more  likelj'  it  is  to 
be  in  the  common  duct.  Obstruction  of  the  hepatic  duct  is  unassociated 
with  distention  of  the  gall-bladder,  while  there  will  be  jaundice.  Ob- 
struction of  the  cystic  duct  may  still  be  associated  with  distention  of  the 
gall-bladder,  either  through  transudation  or  pus-formation,  but  there  may 
be  no  jaundice,  and  the  feces  may  rem.ain  colored.  In  the  hemolytic  form 
the  jaundice  is  usually  so  plainly  secondary  to  other  symptoms  that  there 
is  little  difficulty  in  recognizing  its  cause. 

Diagnosis. — The  presence  of  acute  jaundice  without  pain  or  other 
symptoms  points  almost  invariably  to  catarrhal  javmdice.  The  same 
diagnosis  is  justified  by  the  presence  of  the  symptoms  of  gastro-intestinal 
catarrh,  of  associated  mitral  disease,  or  of  any  of  the  infectious  diseases. 
If,  however,  jaundice  is  prolonged  into  weeks  there  is  lil'Cely  an  organic 
lesion  of  grave  character. 

Prognosis. — Unless  associated  with  infectious  diseases  or  with  hyper- 
trophic cirrhosis,  the  prognosis  of  catarrhal  jaundice  is  favorable.  In  the 
diseases  referred  to  the  danger  is  not  from  the  jaundice,  but  from  the  diseases 
with  which  it  is  associated. 

Treatment. — The  treatment  of  catarrhal  jaundice  resolves  itself  into 
two  parts:  first,  that  for  the  catarrhal  state;  second,  that  demanded  by  the 
absence  of  bUe  in  the  small  intestine.  Careful  search  must  be  made  for 
a  cause  such  as  heart  disease  and  Bright's  disease,  the  treatment  of  which 
must  be  the  treatment  of  the  jarmdice. 

For  the  catarrhal  inflammation,  either  of  the  duodenum  adjacent  to 
the  duct  or  of  the  duct  itself,  local  depletion  is  indicated.  This  is  accom- 
plished by  the  use  of  saline  aperients  and  the  natural  mineral  waters  which 
act  similarly — i.  e.,  produce  waten.^  stools.  Of  the  former,  Rochelle  salts, 
Epsom  salts,  or  the  solution  of  the  citrate  of  magnesiimi  are  representative ; 
while  the  Saratoga,  Apenta,  Hunyadi  Janos,  Friedrichshalle,  or  Rubinat  and 
Carlsbad  waters  represent  the  latter.  These  should  be  taken  daily  in 
aperient  doses.  These  drugs,  however,  should  be  used  only  as  aperients  not 
tis  purgatives.  The  Bedford  Springs  waters,  near  Bedford,  Pa.,  are  also  use- 
ful, but  not  nearly  so  efficient  as  the  Saratoga  waters.  Of  foreign  waters, 
those  of  Carlsbad  are  especially  valuable,  and  in  Europe  these  springs  maybe 


GALL-STONES  439 

resorted  to.  Their  use  may  also  be  associated  between  meals  with  that  of 
the  alkaline  mineral  waters,  of  which  those  of  Vichy  and  Vals  are  the  type. 
These  waters  are  largely  employed  in  this  country,  and  may  be  availed  of 
at  home.  Calomel  may  be  given  for  its  laxative  effect.  PodophyUin  and 
colocynth  may  be  used  for  the  same  purpose.  Sodivim  salicylate  or  salicylic 
acid  in  some  form  may  be  given  in  'doses  of  ten  grains  (0.6)  for  its  antiseptic 
effect.  Hexamethylenamine  maybe  given  in  five  grain  doses  (0.5)  for  the 
same  purpose.  Irrigation  of  the  large  bowel  with  cold  water  has  been 
recommended  as  a  means  of  stimulating  the  descent  of  the  stone. 

The  second  indication  should  be  met  by  the  use  of  such  food  as  does  not 
require  the  bile  to  facilitate  its  digestion  or  absorption  or  to  prevent  its 
decomposition,  and  which  wiU  not  irritate  the  intestinal  mucous  membrane 
of  the  intestine.  Fats  and  oils  should,  therefore,  be  avoided ;  hence  skimmed 
milk,  animal  broths,  and  egg-albumen,  with  an  abundance  of  liquids,  are 
indicated.  The  liquids  may  be  some  one  or  more  of  the  mineral  waters 
previously  named,  or,  in  their  absence,  plain  water.  Warm  bathing  is 
especially  indicated,  as  it  causes  elimination  by  the  skin  and  reUeves  the 
itching.  Lotions  of  carbolic  acids  and  glycerin  are  also  useful  for  the  same 
purpose. 

CHOLELITHIASIS. 

Synonyms, — Hepatic  calculus,  Biliary  calculus. 

Etiology. — Since  the  great  bulk  of  the  gall-stone  is  cholesterin,  an 
evident  condition  of  its  formation  is  a  precipitation  of  this  chief  constit- 
uent of  the  bile.  The  thicker  the  bile,  the  more  likely  it  is  to  throw 
down  sediment.  Moreover,  studies,  especially  by  Naunyn,  have  shown 
that  micro-organisms  play  an  important  part  in  the  production  of  gall- 
stones, primarily  by  exciting  a  catarrhal  inflammation  which  modifies  the 
chemical  composition  of  the  bUe  and  favors  the  precipitation  of  cholesterin 
and  of  lime  salts,  in  combination  with  epithelial  debris  and  bacteria,  the 
epithelial  debris  and  bacteria  frequently  being  the  nidus  of  the  stone. 
The  typhoid  fever  bacillus  is  an  especially  frequent  cause  of  inflammation  of 
the  gall-bladder.  Naunyn  also  showed  that  cholesterin  and  lime  salts  are  a 
secretion  of  the  mucous  membrane  of  the  gaU-bladder  and  bile-ducts  that 
this  is  especially  active  when  the  mucosa  is  in  a  state  of  inflammation.  If, 
as  is  supposed,  the  chelate  salts  of  sodium  hold  cholesterin  in  solution,  it  is 
plain  that  their  decomposition  or  destruction  may  cause  precipitation, 
which  may  also  be  further  favored  by  micro-organisms. 

Occurrence. — Gall-stones  have  been  met  in  infants  and  in  the  new-bom, 
but  practically  are  found  in  adults  only,  while  their  tendency  to  form  appear 
to  increase  from  the  age  of  30  upward.  Most  patients  who  consult  us  for 
the  effects  of  gall-stones  are  over  40  and  under  50.  Cholelithiasis  is  also 
very  much  more  frequent  in  women  than  in  men;  according  to  Naunyn 
four  times  as  frequent,  and  especially  so  in  women  who  have  borne  children 
or  have  had  abdominal  tumors.  He  says  that  90  per  cent,  of  women  who 
have  gall-stones  have  borne  children ;  also  that  2  5  per  cent,  of  all  women  who 
die  have  calculi  in  the  gall-bladder. 

Lack  of  exercise,   sedentary  habits,   and  tight  lacing  are  held  partly 


■440  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

responsible  for  this,  and  with  some  reason,  since  all  of  these  conditions  are 
calculated  to  impede  the  movement  of  bile.  Cholelithiasis  has  been  found 
associated  with  the  habit  of  free  eating  of  starchy  and  saccharine  foods 
and  in  stout  persons;  cases  occur  among  the  lean  also.  The  movable  liver 
and  the  movable  right  kidney  are  likewise  said  to  predispose  to  cholelithiasis. 
Constipation  and  a  tendency  to  depression  of  spirits  arc  apt  to  be  associated, 
probably  as  effects  rather  than  causes. 

Morbid  Anatomy. — The  gall-stone  itself  is  a  brown  object,  nearly 
spherical,  oval  or  faceted,  and  even  polygonal  in  shape,  usually  the  size  of  a 
pea,  or  as  small  as  a  millet-seed,  producing  in  aggregation  "gall  sand."  The 
faceted  shape  is  produced  by  close  packing  of  a  large  number  of  stones  in  a 
gall-bladder,  as  frequently  happens.  More  rarely  the  stone  is  irregular — 
mulberrv'-shaped,  .single  and  very  large.  In  addition  to  cholesterin,  which 
makes  up  from  70  to  80  per  cent,  of  most  stones,  they  contain  varying  small 
amounts  of  bile  pigment,  calcium  carbonate,  and  organic  matter.  A  few  are 
made  up  almost  entirely  of  bilirubin  and  lime.  On  section,  the  stone  ex- 
hibits either  a  concentric  or  homogeneous  appearance,  with  or  without 
a  nucleus  of  bile  pigment  or  organic  matter,  and  very  rarely  of  some  foreign 
body.  The  cholesterin  stones  are  almost  completely  soluble  in  etherized 
alcohol,  whence  beautiful  crystals  of  cholesterin  may  be  obtained  after 
evaporation. 

In  addition  to  their  enormous  accumiilation  in  the  gall-bladder,  where 
they  may  be  counted  sometimes  by  hundreds,  they  are  found  anywhere  in 
the  biliary  tract  between  the  duodenal  end  of  the  common  duct  and  the 
ultimate  ramification  of  the  bile  vessels.  Outside  of  the  gall-bladder  the 
cystic  duct  and  the  commion  duct  are  the  situations  in  which  lodgment 
most  frequently  occiu"s.  If  in  the  common  duct,  it  is  usually  at  the  orifice 
of  the  papilla  in  the  diverticulum  of  Vater,  and  from  the  duodenal  side  the 
stone  feels  as  though  it  were  directly  under  the  nucous  membrane.  Two  or 
even  more  stones  may  be  found  in  the  duct.  The  common  duct  under  these 
circumstances  may  attain  a  diameter  of  an  inch  (2.5  cm.)  or  more.  Per- 
manent obstruction  of  the  cj'stic  duct  causes  dilatation  of  the  gall-bladder 
— hydrops  vesicce  fellece.  Such  dilatation  may  be  enormous,  filling  the 
entire  abdominal  cavity,  and  has  been  mistaken  for  ovarian  tumor;  usually 
it  is  more  moderate,  but  the  contents  frequently  amount  to  a  pint  (500  c.c.) 
or  more.  The  contents  are  a  colorless,  \ascid,  or  water>'  fluid,  more  or  less 
albuminous,  and  neutral  or  alkaline  in  reaction;  the  greater  the  dilatation, 
the  more  aqueous  and  unlike  bile  do  its  contents  become.  In  any  situa- 
tion the  stone  may  produce  ulceration  and  even  suppiu^ation,  with  perfora- 
tion into  the  peritoneal  cavity  or  adjacent  organs,  the  duodenum,  stomach, 
transverse  colon,  right  renal  pelvis,  ureter,  through  the  diaphragm  into  a 
bronchus,  and  into  the  abdominal  wall. 

Acute  Impaction. 

Sykonym. — -Biliary  Colic. 

Symptoms. — The  characteristic  symptom  of  impacted  gall-stones  is 
biliary  colic,  but  biliary  colic  is  by  no  means  always  present  in  every  case  of 
cholelithiasis.     The  pain  is  the  result  of  infection,  distention  of  the  ducts 


GALL-STONES  441 

during  the  attempted  passage  of  the  stone  and  contraction  of  the  muscular 
elements  of  the  gall-bladder  or  gall  ducts.  The  gall-bladder  is  often  found 
full  of  calculi  without  the  suggestion  of  a  symptom.  Small  stones  even 
pass  into  the  duodenum  without  producing  symptoms.  Commonly,  how- 
ever, they  lodge  while  in  this  transit,  and  give  rise  to  attacks  of  pain  which 
are  known  as  biliary  colic.  Tliis  pain  is  usually  sudden,  verj'  severe,  often 
excruciating,  and  the  patient  writhes  in  agony  and  sometimes  faints  in  con- 
sequence. It  is  usually  referred  to  the  epigastrium,  whence  it  radiates  in  all 
directions  over  the  abdomen  and  at  times  into  the  right  shoulder  and  arm. 
As  a  rule,  however,  it  is  localized  on  the  right  side,  under  the  liver.  It  is  a 
sharp  and  cutting  pain.  There  is  always  tenderness  in  this  region,  which 
varies  in  degree.  It  is  sometimes  associated  with  a  more  or  less  rigid  state 
of  the  abdominal  muscles  of  that  side.  The  duration  of  the  pain  is  that  of  the 
lodgment  of  the  stone,  and  it  may  be  from  a  few  hours  to  weeks,  ceasing 
rather  suddenly  when  the  stone  is  discharged  into  the  bowel.  There  may, 
however,  be  remissions.  Nausea  and  vomiting  are  almost  invariable  symp- 
toms of  biliary  colic.  They  often  bring  temporary  relief  through  the  result- 
ing relaxation.  Fever  is  soon  added  to  the  pain,  while  a  chill  is  not  infre- 
quent. The  temperature  is  usually  102°  F.  to  103°  F.  (38.8°  C.  to  39.5°  C). 
It  may  be  intermittent,  but  such  intermission  is  more  apt  to  be  associated 
with  prolonged  obstruction,  constituting  with  a  chiU  a  part  of  the  symptoms 
of  so-called  hepatic  fever,  to  be  next  considered.  Gall-stone  crepitus  may 
sometimes  be  detected  when  the  gall-bladder  is  packed  with  calculi.  Jaun- 
dice occurs  when  the  stone  is  in  the  common  and  hepatic  duct ;  rarely  occurs 
when  the  stones  are  in  the  gall-bladder.  Hence,  jaundice  is  not  a  neces- 
sary symptom  of  gall-stones.     Indeed,  it  frequently  is  absent. 

If  the  stone  is  lilcely  to  be  in  the  common  duct,  ha\'ing  probably  started 
in  the  cystic  duct.  Three  or  four  days  may  elapse  between  the  beginning 
of  obstruction  and  the  super\'ention  of  jaundice,  the  degree  of  which  in- 
creases with  the  completeness  and  duration  of  obstruction.  The  entrance 
of  the  stone  into  the  common  duct  may  be  attended  by  one  of  the  remissions 
aUuded  to,  though  the  jaundice  grows  even  deeper  on  account  of  the  more 
thorough  obstruction  to  the  descent  of  the  bile. 

David  Riesman  has  called  attention  to  a  cardiac  systolic  murmxir 
sometimes  developed  in  the  course  of  an  attack  of  biliar\^  colic.  He  ascribes 
it  to  a  dilatation  of  the  heart  and  relative  insufficiency-  of  the  mitral  valve, 
caused  by  pain,  anemia  or  cachexia. 

The  liver  is  sometimes  slightly  enlarged,  as  determined  by  percussion. 
A  rare  symptom  is  collapse  with  fatal  syncope,  due  to  perforation  at  the  seat 
of  lodgment,  with  consequent  peritonitis  and  shock. 

Diagnosis. — This  is  commonly  easy.  While  the  pain  may  be  more  or 
less  diffuse,  it  is  for  the  most  part  localized  in  the  right  lower  thoracic  and 
upper  abdominal  regions,  and  the  tenderness  is  always  there,  while,  if  jatm- 
dice  and  biliary  urine  are  present,  all  doubt  is  removed.  Nephritic  colic  and 
biliary  colic  are  confounded  with  surprising  and  unjustified  frequency.  In 
the  former  condition  the  pain  starts  in  the  lumbar  region  and  radiates  down 
ward  into  the  groin,  the  testicle,  and  the  inside  of  the  thigh.  Such  error  is 
fortified  by  the  fact  that  bilious  urine  is  too  often  confounded  with  bloody 
urine.     It  should  be  necessary  only  to  mention  this  to  guard  against  error. 


442  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Examination  of  the  urine  will  show  blood  and  leucocytes  in  nephritic  colic 
which  are  absent  in  hepatic  colic. 

Cholelithiasis  has  been  mistaken  for  acute  pleurisy  in  the  vicinity  of  the. 
gall-bladder  and  the  reverse  mistake  has  been  made.  The  friction  rale  of 
pleurisy  should  preclude  an  error,  but  the  friction  rale  may  not  be  present 
at  the  particular  stage. 

Our  growing  knowledge  of  appendicitis  has  led  to  the  discovery  that  the 
pain  characteristic  of  this  disease  is  sometimes  localized  in  the  right  hypo- 
chondrium,  where,  indeed,  the  appendix  has  been  found  at  operation. 
Jaundice  and  bile-stained  vuine  do  not,  however,  attend  appendicitis. 
Gastralgia  has  been  confounded  with  biliary  colic,  but  attention  to  the  symp- 
toms described  when  treating  that  affection  should  prevent  mistake.  The 
term  hepatic  neuralgia  has  been  applied  to  an  apparently  causeless  pain, 
sometimes  felt  in  the  neighborhood  of  the  liver,  but  it  is  less  severe  than 
biliary  colic  and  unaccompanied  by  any  of  the  other  symptoms.  This  is 
allied  to  pseudo-biliary  colic  which  is  to  be  remembered  as  a  possible  event  in 
nervous  women.  Both  are  characterized  by  the  absence  of  jaundice. 
The  pain  of  ulcer  of  the  stomach  resembles  gall-stone  colic  to  a  certain  degree. 
It  is,  however,  rarely  severe,  and  usually  is  attended  by  relief  by  taking  food. 

It  is  very  important,  immediately  after  an  attack  of  supposed  biliary 
colic,  to  search  for  a  stone  in  the  fecal  discharges.  For  this  purpose  the  fecal 
mass  should  be  placed  on  a  sieve,  and  water  passed  over  it  until  all  soluble 
parts  are  run  out.  Such  examination  should  be  kept  up  for  several  days 
after  the  attack,  for  the  stone  is  not  always  passed  immediately. 

Prognosis. — The  termination  of  an  ordinary  attack  of  biliary  colic  is,  in 
the  vast  majority  of  instances,  favorable.  It  is  only  in  the  rare  cases,  where 
perforation  takes  place,  that  a  fatal  ending  follows.  Surgery  of  the  gall- 
bladder has  come  to  be  an  important  division  of  surgery,  and  many  lives 
have  been  saved  by  operations.  The  surgeon  should,  therefore,  be  promptly 
sent  for  if  the  symptoms  persist. 

Chronic  Impacted  Gall-stone. 

Symptoms. — These  vary  somewhat  with  the  seat  of  the  impaction  and 
its  duration.     From  this  standpoint  they  may  be  divided  into  certain  groups : 

1.  Symptoms  Due  to  Stones  Retained  in  the  Gall-bladder. — There  are 
practically  always  the  direct  result  of  infection.  For  without  acute  in- 
fections stones  in  the  gall-bladder  are  frequently  without  symptoms.  There 
is  pain,  tenderness  over  the  gall-bladder,  fever,  and  often  leucocytosis. 
If  the  cystic  duct  is  obstructed  there  is  usually  distention  of  the  gall-bladder. 
On  the  other  hand  the  gall-bladder  may  be  atrophied  and  drawn  tightly  about 
the  stones. 

2.  Symptoms  Due  to  Chronic  Calculous  Obstruction  of  the  Cystic  Duct. — 
In  addition  to  more  or  less  of  the  symptoms  detailed  under  acute  impaction, 
the  immediate  result  of  such  obstruction  is  dilatation  of  the  gall-bladder,  or 
hydrops  vesica:  felleas,  already  referred  to.  Dilatation  of  the  gall-bladder  is 
more  frequently  caused  by  obstruction  of  the  cystic,  than  of  the  common  duct. 
The  source  of  the  accumulation  is  not,  however,  the  bile,  which,  as  might  be 
expected,  cannot  get  into  the  gall-bladder  through  the  obstructed  duct  any 


GALL-STONES  443 

more  than  it  can  get  out  of  it.  It  is  the  products  of  inflammation  of  the 
mucosa,  added  to  the  bile  previously  present,  which  cause  the  dilatation. 
The  occasional  enormous  dilatation  has  more  than  once  been  mistaken  for 
ovarian  disease,  an  error  the  more  excusable  when  we  remember  that 
jaundice  is  usually  absent.  More  frequently  the  dilatation  is  moderate,  and 
can  be  felt  below  the  edge  of  the  liver  as  a  round  or  ovoid  elastic  tumor,  in 
which  fluctuation  may  sometimes  be  obtained. 

3 .  Symptoms  Due  to  Chronic  Calculous  Obstruction  of  the  Common  Duct. — 
If  the  common  duct  is  obstructed  by  a  calculus,  dilatation  of  the  gall-bladder 
is  generally  absent,  and  if  it  does  occur,  the  dilatation  is  moderate;  whereas 
in  obstruction  of  this  duct  by  new  growth  the  gall-bladder  forms  a  palpable 
tumor,  although  not  invariably.  This  is  Courvoisier's  law.  Such  obstruc- 
tion is  commonly  associated  with  cholangitis,  catarrhal  or  suppurative, 
(a)  In  simple  chronic  catarrhal  cholangitis  the  common  duct  is  dilated; 
at  times  also  the  branches  of  the  hepatic  duct  extending  into  the  liver. 
This  condition  has  been  especially  studied  by  Charcot  and  Murchison 
abroad  and  William  Osier  in  this  country.  It  may  be  intermittent 
or  remittent.  Very  interesting  among  the  causes  of  intermittent  obstruc- 
tion is  the  movable  or  ball-valve  stone  in  the  diverticulum  of  Vater. 
A  stone  in  this  position  is  characterized,  in  addition  to  the  persistent 
jaundice  and  paroxysmal  pain,  by  ague-like  attacks,  consisting  of  chills,  fever, 
and  sweats.  These  occur  at  surprisingly  regular  intervals,  resembling  in 
this  respect  the  quotidian,  tertian,  or  quartan  spells  of  intermittent  fever, 
with  which  the  condition  has  been  confounded.  They  may  occur  for  weeks 
at  a  time  and  then  remit.  Pain  is  commonly  associated  with  the  ague-like 
spells,  but  is  not  always  present.  The  chills  may  be  extremely  severe,  the 
sweats  also,  and  the  fever  correspondingly  high,  the  temperature  sometimes 
reaching  105°  F.  (40.5°  C).  The  jaundice  usually  deepens  after  an  attack. 
There  may  be  nausea  and  vomiting.  The  duration  may  be  indefinite  from  a 
few  months  to  years,  and  the  patient  may  yet  recover;  or  he  may  perish, 
although  the  exhaustion  is  extremely  slow  and  the  effect  on  the  general 
health  barely  appreciable  from  week  to  week.  The  fever  is  probably  irri- 
tative, although  it  has  been  ascribed  to  the  omnipresent  organism — bac- 
terium coli  commune.  There  is  no  sign  of  suppuration  in  these  cases.  There 
is  sometimes  slight  enlargement  of  the  liver,  appreciable  to  physical  exami- 
nation, and  in  long-protracted  cases  some  fibroid  induration  may  be  expected 
to  take  place.  The  stools  are  sometimes  bile-stained,  at  others  not.  There 
is  occasionally  enlargement  of  the  spleen. 

The  following  are  Naunyn's  distinguishing  signs  of  stone  in  the  common 
duct:  "  (i)  The  continuous  or  occasional  absence  of  bile  from  the  feces;  (2) 
distinct  variations  in  the  intensity  of  the  jaundice;  (3)  normal  size  or  only 
slight  enlargement  of  the  liver;  (4)  absence  of  distention  of  the  gall-bladder; 
(5)  enlargement  of  the  spleen;  (6)  absence  of  ascites;  (7)  presence  of  febrile 
disturbance,  and  (8)  duration  of  the  jaundice  for  more  than  a  year." 

Thus,  Ecldin  found  that  of  172  cases  of  obstruction  of  the  common  duct 
by  calculus,  the  gall-bladder  was  contracted  in  1 10,  normal  in  34,  and  dilated 
in  28.  Of  139  cases  of  occlusion  of  the  common  duct  from  other  causes  the 
gall-bladder  was  contracted  in  9,  normal  in  9,  and  dilated  in  121. 

(b)  Suppurative  cholangitis  is  marked  symptomatically  by  a  fever  which 


444  DISEASES  OE  THE  DIGESTIVE  SYSTEM 

is  more  of  the  septic  type,  with  remissions  rather  than  intermissions.  The 
jaundice  is  less  marked,  the  Hver  is  tender  and  enlarged,  the  duration  of  the 
disease  shorter,  and  termination  fatal.  The  inflammation  involves  more  or 
less  the  ducts  of  the  liver,  whence  it  may  extend  into  the  liver  substance  or 
gall-bladder,  causing  abscess  of  the  liver  and  empyema  of  the  gall-bladder. 

Other  Remote  Results  of  Gall-stone  Impaction. — Rarer  terminations  of 
impacted  gall-stones  are  the  various  forms  and  situations  of  biliary  fistulae, 
mentioned  when  treating  of  the  morbid  anatomy.  Some  more  detailed 
reference  to  these  fistulae  should  be  made.  Much  has  been  added  to  our 
knowledge  of  the  subject  by  the  industry  of  Prof.  L.  G.  Coun.^oisier,  of  Basle.' 
Courvoisier  collected  499  cases  of  ulcerative  perforation  of  the  biliary  pas- 
sages of  which  70  occurred  directly  into  the  peritoneum,  while  in  49  cases 
there  was  encapsulated  abscess,  and  in  three  there  was  retro-peritoneal 
perforation.  Between  the  biliary  passages  themselves  were  eight  cases; 
this  perforation  was  found  directly  from  the  gall-bladder  into  the  substance 
of  the  liver  (four  cases) ;  into  the  hepatic  duct  (two  cases) ,  into  a  diverticu- 
lum of  the  common  duct  (one  case),  or  between  the  intestinal  and  hepatic 
parts  of  the  common  duct  (one  case).  Perforation  between  the  biliarj' 
passages  and  portal  vein  was  found  in  five  cases.  Openings  between  the 
biliary  passages  and  gastro-intestinal  canal  are  not  uncommon  (137  cases); 
most  frequently  between  the  bile  passages  and  duodenum,  of  which  there 
were  83  cases,  of  which  73  were  between  the  gall-bladder  and  the  duodenum, 
while  ten  were  between  the  common  duct  and  duodenimi.  From  the 
biliary  passages  into  the  stomach  there  were  13  perforations;  into  the  jeju- 
nvun  one,  ileum  one,  colon  39.  As  might  be  expected,  perforation  takes 
place  most  frequently  from  the  intestinal  part  of  the  duct,  the  stone  first 
lodging  in  the  diverticulum  of  Vater.  Perforation  into  the  urinary  passages 
was  found  in  seven  cases  and  into  the  pleura  and  lungs  in  24  cases.  To 
these  last  J.  E.  Graham^  added  ten  cases  of  broncho-biliarv'  fistula.  Finally, 
there  may  be  fistulous  communication  between  the  biliary  passages  and 
the  external  integument,  Courvoisier  having  collected  196  cases,  in  49  of 
which  the  communication  was  in  the  right  hypochondrium,  36  at  the  border 
of  the  ribs,  49  at  the  navel  or  in  its  vicinity,  17  in  the  right  meso-gastrium., 
ten  in  the  right  iliac  region,  and  six  in  the  epigastrium.  Very  interesting  in 
this  connection  is  the  fact  that  out  of  169  cases  in  which  the  sex  was  noted, 
126  were  women  and  43  men.  Among  other  remote  results  are  septic  chole- 
cystitis, associated  with  high  fever,  intense  prostration,  and  death  from  fatal 
peritonitis;  empyema  of  the  gall-bladder,  already  alluded  to  as  a  result  of 
suppurative  cholangitis ;  the  latter  is  commonly  associated  with  gall-stones. 
Calcification  of  the  gall-bladder  is  a  frequent  termination  of  purulent  in- 
flammation. It  is  present  in  two  forms :  first,  as  a  simple  incrustation  of  the 
mucosa  with  lime  salts,  and,  second,  as  a  true  infiltration  of  the  whole  thick- 
ness of  the  wall. 

Atrophy  of  the  gall-bladder  is  not  iiofrequent  and  may  succeed  on 
hydrops  vesiccs  fellecB.  Many  gaU-bladders  do  not  hold  more  than  a  dram 
(4  c.c.)  or  two  of  bile,  and  sometimes  there  is  a  mere  remnant  left  in  the 
shape  of  a  fibroid  mass;  at  other  times  the  shrunken  bladder  closely  em- 

1  Casuistisch-Statistische  BeitrSge  zur  Pathologie  und  Chirurgie  der  Gallenwege,  Leipzig,  1890. 
^  Transactions  of  the  Association  of  American  Physicians,  vol.  xii.,  1897. 


GALL-STONES  445 

braces  a  gall-stone  of  large  size.  Gall-stones  are  occasionally  found  in 
diverticula  of  the  gall-bladder.  Suppurative  phlebitis  and  abscess  of  the 
liver  may  also  be  due  to  gall-stone,  causing  a  puriform  thrombus  in  an 
adjacent  branch  of  the  portal  vein. 

In  other  instances  the  gall-stone  is  of  such  size  as  to  obstruct  the  bowel 
when  discharged  into  it,  although  it  may  have  passed  through  the  natural 
channel,  as  evidenced  by  dilatation  of  the  common  duct.  But  for  the 
most  part  such  discharge  is  by  ulceration  into  the  intestinal  tract.  This 
subject  has  been  sufficientlj^  considered  when  treating  of  obstruction  of  the 
bowels. 

Diagnosis  and  Prognosis. — Chronic  impaction  of  gall-stone  must  be  diag- 
nosed from  obstruction  due  to  other  causes.  Dilatation  of  the  gall-bladder 
when  accompanied  by  jaundice  is  usually  due  to  pressure  from  a  new  gro^\'th 
in  the  common  duct.  Extremely  large  gall-bladders  are  usually  due  to  ob- 
struction of  cystic  duct  from  adhesions,  stone  or  new  gro^i;h.  The  jaimdice 
accompanying  obstniction  of  the  common  duct  by  a  stone  is  usually  accom- 
panied by  intermittent  pain  and  fever  without  emaciation  which  occurs  in 
carcinoma.  The  perforations  which  may  occur  are  usualh^  preceded  by  a 
history  of  gall-stones.  There  may  be  some  difficult3^  at  first  in  the  diagno- 
sis of  hepatic  fever,  but  the  persistent  jaundice,  the  ague-like  paroxysms  of 
chUls,  fever,  sweats,  and  pain  are  a  combination  of  sj'mptoms  belonging 
to  no  other  condition  than  that  of  a  ball-valve  stone.  A  cancer  of  the  gall- 
bladder, which  will  form  a  tumor  in  the  same  locality,  is  much  more  tender;  it 
is  harder  and  more  uneven,  and  jaundice  is  frequently  associated  with  it, 
while  the  patient  is  much  more  seriously  ill  and  declines  more  rapidly. 
There  should  be  no  confusion  with  a  movable  kidney,  which  furnishes  a 
different  physical  condition.  The  suppurative  form  of  cholangitis  or  chole- 
cystitis is  characterized  by  the  more  continuous  fever  and  the  more  serious 
aspect  of  the  septic  state,  its  shorter  course,  and  its  loltimate  fatal  termination. 
The  catarrhal  form  is  less  serious  and  quite  often  terminates  favorably. 

Treatment  of  Impacted  Gall-stone  and  its  Complications. — The  first 
indication  in  an  acute  attack  is  the  relief  of  pain.  This  is  best  accomplished 
by  the  hypodermic  injection  of  morphin,  the  action  of  which  is  favored  by 
combination  with  atropin.  Scarcely  less  than  1/4  grain  (0.0165  gm-)  with 
1/150  grain  (0.0005  gm-)  of  atropin  suffices,  and  this  must  often  be  repeated. 
The  use  of  anodynes  must  be  kept  up  as  long  as  needed.  The  atropin  favors 
the  relaxation  needed  to  release  the  calculus.  The  severest  cases  may 
require  the  inhalation  of  a  few  drops  of  chloroform  pending  the  action  of 
the  morphin. 

Whether  anything  else  can  be  done  toward  releasing  the  stone  is  not 
established.  The  nausea  and  vomiting,  which  are  so  often  symptoms, 
sometimes  relieve  the  pain  by  the  relaxation  they  produce,  such  relaxation 
being  at  times  sufficient  to  favor  the  onward  movement  of  the  stone.  Anes- 
thesia by  ether  or  chloroform  may  act  similarly,  and  the  inhalation  above 
suggested  while  waiting  for  the  morphin  to  act  favors  such  relaxation. 
Hot  baths  or  fomentations  applied  to  the  region  of  the  liver  may  also  be 
similarly  effective. 

Some  solvent  for  the  stone  is  constantly  inquired  after.  No  known  sol- 
vent for  a  gall-stone  in  the  living  human  being  is  known. 


446  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

The  free  use  of  alkaline  mineral  waters  does  seem  to  favor  the  dislodg- 
ment  of  the  stone,  especially  if  the  authorities  at  Carlsbad  are  to  be  relied  on, 
who  claim  the  discharge  of  immense  numbers  of  biliary  calculi  under  the  use 
of  Carlsbad  water.  Certainly  no  harm  can  attend  its  use,  and  when  within 
the  power  of  the  patient  to  get  it,  it  may  be  freely  taken.  The  same  is 
claimed  by  the  physicians  at  Vichy  for  the  Vichy  waters — true  alkaline 
waters.  In  this  country,  however,  the  Saratoga  waters  may  be  used  instead. 
These  waters  are  saline  and  not  alkaline  waters,  but  they  seem  to  fulfill 
much  the  same  indications.  Those  containing  the  largest  proportion  of 
alkaline  carbonate  are  to  be  preferred.  The  waters  of  Vals — also  true 
alkaline  waters — are  recommended  for  the  same  purpose. 

To  relieve  the  itching  caused  by  the  deposit  of  pigment  in  the  skin, 
which  is  sometimes  very  annoj'ing  in  chronic  cases,  the  hot  pack  on  alternate 
days  or  even  every  day  is  serviceable.  A  very  efficient  local  application  for 
this  purpose  is  a  mixture  of  7  1/2  minims  (0.5  gm.)  of  carbolic  acid,  2 
fiuidrams  (8  c.c.)  of  glycerin,  and  6  fluidrams  (24  c.c.)  of  water.  It  should 
be  applied  with  a  sponge  and  allowed  to  dry  on  the  skin. 

Surgical  Treatment. — In  acute  suppurative  cholangitis  and  cholecystitis 
immediate  drainage  of  the  gall-bladder  and  ducts  should  be  performed. 
In  acute  attacks  of  gall-stone  colic,  where  the  condition  lasts  for  days, 
and  perforation  of  the  bladder  or  ducts  is  threatened,  operation  should  be 
performed.  Chronic  cholelithiasis  is  a  siu-gical  condition.  Ail  of  the  s^^mp- 
toms  described  above  will  be  relieved  and  the  patient  cured  by  a  skillful 
operator.  The  patient  will  suffer  and  perhaps  become  mortally  ill  by  long- 
continued  treatment  by  drugs  and  hygiene. 

The  preventive  treatment  is  important.  To  this  end  diet  is  important. 
The  patient  should  eat  sparinglj^  of  hydrocarbons  and  carbohydrates, 
omitting  every  form  of  fat,  alcohol,  sugar,  and  starch.  IMeat,  cheese,  and 
glutens,  on  the  other  hand,  are  allowable. 

The  alkaline  and  saline  mineral  waters  are  more  especially  indicated  be- 
tween the  attacks  than  during  them,  and  their  more  or  less  continued  use 
is  advisable,  especially  in  the  morning,  when  their  efficiency  is  also  increased 
by  their  being  taken  hot.  The  sodium  salts  have  considerable  reputation 
for  their  efficiency  in  preventing  the  concentration  of  bile  and  formation  of 
gall-stones,  having  been  long  ago  recommended  by  Prout.  The  phosphate 
is  the  modem  favorite,  in  dram  doses  in  the  morning,  or  more  frequently, 
but  the  sulphate  is  more  constant  and  more  potent  in  its  results,  and  Uttle, 
if  any,  more  unpleasant.  The  sodium  salicylate  has  a  similar  reputation, 
and  may  be  used  when  no  effect  on  the  bowels  is  desired.  By  either  of  the 
former  or  by  the  aperient  mineral  waters  a  daily  action  of  the  bowels  should 
be  secured,  while  a  proper  hygiene  of  the  bodj',  in  which  daUy  exercise, 
bathing,  and  friction  plaj'  a  conspicuous  part,  is  to  be  constantly  maintained. 

Salicylic  acid  in  some  form,  in  ten  grain  (0.12)  doses  every  four  hours, 
or  one  of  the  soda  salts,  succinate  in  5  grains  (0.30),  or  hexamethylenamin 
in  the  same  dose. 


ACUTE  CHOLECYSTITIS  447 

ACUTE  INFECTIOUS  CHOLECYSTITIS. 
Synonym. — Acute  inflammation  of  the  gall-bladder. 

Definition. — Inflammation  of  the  gall-bladder  due  to  infection  by 
pathogenic  bacteria. 

Etiology. — The  most  frequent  predisposing  condition  which  leads  to 
infection  of  the  gall-bladder  is  probably  biliary  calculus,  the  stone  being 
lodged  either  in  the  gall-bladder  or  some  one  of  the  biliary  ducts,  the  vvdner- 
abUity  of  the  mucous  membrane  of  the  gall-bladder  being  thus  increased. 
But  any  obstructive  cause,  such  as  inflammatory  adhesion,  or  even  inflam- 
matory swelling  of  the  mucous  membrane  of  the  cj'stic  duct,  may  be  such 
cause — facilitating  bacterial  infection.  Adhesive  inflammation  between 
the  gall-bladder  and  intestines,  however  induced,  is  a  rare  cause,  the  process 
extending  inward  through  the  peritoneum.  Lithiasis  is  not,  however, 
necessary  to  produce  infection.  Pathogenic  bacUli  may  act  independently 
of  predisposing  cause.  Indeed,  gaU-stones  themselves  are  a  res\alt  of  bac- 
terial invasion.  The  infecting  bacterium  may  be  any  one  of  the  pathogenic 
bacteria  infesting  the  small  intestine,  but  recent  observations  have  shown 
the  bacillus  of  typhoid  fever  and  the  colon  bacillus  to  be  probably  the  most 
frequent,  although  the  pneumococcus,  staphylococcus,  and  streptococcus 
have  also  been  found  to  be  the  infecting  agents. 

Morbid  Anatomy. — This  varies  with  the  virulence  of  the  inflammation. 
In  the  severer  cases  there  is  distention  of  the  gall-bladder  with  mucus, 
muco-pus,  or  pus ;  at  tim.es  the  contents  may  be  hemorrhagic.  Perforation 
and  gangrene  have  been  the  first  indications  of  the  presence  of  the  disease. 
There  ma^'  be  adhesions  between  the  gall-bladder  and  colon  or  omentum. 

Symptoms. — The  most  invariable  symptom  is  pain,  which  is  commonly 
sudden  and  sometimes  paroxysmal.  It  is  sittiated  to  the  right  of  the  median 
line  at  the  border  of  the  thorax;  is  attended  hy  fever,  sometimes  preceded  by 
chills  and  followed  by  sweats.  So  many  abdominal  conditions,  however, 
cause  pain  that  it  alone  is  not  distinctive.  A  chill  is  often  the  first  symptom. 
Tenderness,  less  circumscribed  than  might  be  expected,  is  invariably  pres- 
ent. Jaundice  is  not  a  frequent  symptom,  never  unless  the  infection  involves 
the  hepatic  duct  or  common  duct.  Vomiting,  on  the  other  hand,  is  very  com- 
mon and  often  severe.  It,  too,  may  be  paroxysmal.  Certain  cases  are 
fulminating,  and  it  may  be  impossible  to  get  the  surgeon  soon  enough  to 
avert  perforation  and  a  fatal  termination.  On  the  other  hand,  many 
mild  cases  occur,  like  one  seen  with  Thomas  Potter,  of  Germantown,  suc- 
ceeding a  relapse  of  typhoid  fever  after  a  normal  temperattu-e  had  been 
maintained  for  several  days.  After  recovery  from  this  relapse,  there 
occurred  suddenly  a  chill,  sharp  pain  in  the  region  of  the  gall-bladder,  and 
rise  of  temperature.  These  symptoms  subsided  in  four  or  five  daj's,  to  be 
followed  by  another  attack  in  which,  instead  of  a  chill,  there  was  simply 
chilliness  with  pain  and  fever  less  marked;  again,  after  a  couple  of  days, 
a  return  of  pain  with  sudden  rise  of  temperature,  but  no  chill,  again  dis- 
appearing in  a  few  days.  The  distended  gall-bladder  may  sometimes  be  felt. 
The  pulse  is  sometimes  very  slow,  as  in  a  case  reported  by  Frederick  A. 
Packard,  where  the  rate  fell  to  48,  and  another  seen  with  Markley,  of  Cam- 


448  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

den,  N.  J.,  in  wliich  it  fell  to  40.  It  is  seldom  over  100.  In  Packard's 
case  there  was  no  fever,  in  that  of  Markley  the  temperature  rose  to  103°  F. 
(39-4°C.). 

Symptoms  may  arise  from  adhesions  with  adjacent  organs,  chiefly  pain, 
but  sometimes  also  a  dragging  sensation.  These  are  commonly  part  of  a 
chronic  condition.  Constipation  is  also  a  symptom  to  be  expected.  In  fact, 
some  cases  have  been  treated  for  obstruction  of  the  bowel,  for  appendicitis, 
and  more  rarely  for  pancreatitis. 

Diagnosis. — Since  attention  has  been  directed  to  the  subject,  the  diag- 
nosis in  many  cases  has  become  easy.  In  others  it  still  remains  difficult  or 
impossible.  Given  a  case  of  typhoid  fever  in  which,  especially  during  con- 
valescence, a  chill,  fever,  and  sweat  make  their  appearance  and  there  is  pain 
in  the  region  of  the  gall-bladder,  we  may  infer  reasonably  the  presence  of 
cholecystitis.  The  same  inference  ma}^  be  made  if  these  symptoms  occur 
in  a  case  of  chronic  cholelithiasis.  The  presence  of  an  actual  tumor  at  the 
seat  of  the  gaU-bladder  is  even  more  confirmatory.  Circumscribed  tender- 
ness is  more  frequent.  The  severity  of  the  attack  cannot  always  be  inferred 
from  the  early  symptoms,  but  as  there  are  a  good  many  mild  cases,  a  diag- 
nosis of  cholecystitis  need  not  necessarily  cause  alarm.  It  should  be  re- 
membered that  jaundice  is  not  a  frequent  sj^mptom,  indeed,  it  is  a  rare 
symptom. 

As  to  differential  diagnosis,  the  conditions  with  which  it  has  been  con- 
founded are  appendicitis,  pancreatitis,  localized  peritonitis,  pyonephrosis  and 
inflammatory  thickening  about  the  pyloric  orifice  of  the  stomach  and  the 
duodenum.  In  the  absence  of  the  predisposing  conditions  referred  to,  these 
lesions  are  sometimes  difficult  to  differentiate.  Disease  of  the  head  of  the 
pancreas  is  much  more  frequently  associated  with  jaundice  than  is  chole- 
cystitis. If  a  tumor  is  present  in  pancreatitis,  it  is  fixed  and  immovable. 
It  is  not  usually  movable  in  cholecystitis.  An  exploratory  operation  should 
not  be  long  delayed  as  perforation  of  the  gall-bladder  may  precipitate  a  fatal 
issue.  In  cases  like  three  narrated  by  Maurice  H.  Richardson,*  in  none  of 
which  was  there  history  suggesting  gall-stones  and  where  the  symptoms,  in- 
cluding pain,  vomiting,  fever,  and  tenderness  over  the  appendix,  were  so 
suggestive  that  an  incision  was  made  in  that  quarter,  a  diagnosis  of  chole- 
cystitis is  impossible.  It  is  difficult  to  see  how  an>-thing  but  appendicitis 
could  be  expected  in  such  cases. 

Prognosis. — This  depends,  of  course,  upon  the  severity  of  the  case  and 
the  promptness  of  operative  interference.  There  appear  to  be  a  good  many 
mild  cases  which  seemingly  do  not  go  beyond  catarrhal  inflammation. 

Treatment. — There  is  really  no  medical  treatment  except  the  symp- 
tomatic, and  the  patient  recovers  through  inherent  tendencies,  or  his  life  is 
saved  by  operation  and  drainage.  In  gangrenous  cases  even  operation  fails 
to  save  some,  but  all  cases  demanding  operation  have  the  chances  of  recovery 
increased  by  promptness.  Richardson  says  that  acute  cholecystitis  de- 
mands interference  even  more  strongly  than  appendicitis.  If  an  operation 
is  denied,  or  the  condition  of  the  patient  will  not  allow  of  an  operation,  an 
ice-bag  or  mustard  or  hot  fomentations  may  be  applied  to  the  region  of 
the  gall-bladder  to  relieve  pain.     Nausea  and  vomiting  are  among  the  most 

'  "Acute  Inflammation  of  the  GaU-bladder,"  "Am.  Jour.  Med.  Set.."  June.  1898. 


CANCER  OF  GALL-BLADDER  449 

difficult  symptoms  to  relieve.  It  is  a  reflected  nausea  like  that  of  appendi- 
citis. Local  applications  of  ice,  or  at  times  the  opposite  treatment  by  heat, 
pieces  of  ice  swallowed,  champagne,  cold  effervescing  waters  may  all  be 
tried.  Calomel  in  hourly  doses  of  i/io  gr.  (0.0066  gm.)  to  1/5  gr.  (0.0132 
gm.),  applied  dry  on  the  tongue,  should  be  given  in  connection  with  other 
remedies.     None  of  these  remedies  should  be  used  except  as  palliatives. 

CANCER  OF  THE  GALL-BLADDER. 

Etiology  and  Morbid  Anatomy. — John  H.  Musser,  in  a  study  of  100 
cases,  found  it  three  times  as  frequent  in  women  as  in  men. 

When  primary,  it  commonly  begins  in  the  fundus.  It  may  occur  by 
contiguous  invasion,  either  from  the  liver  or  adjacent  abdominal  organs. 
Cancer  may  also  extend  from  the  gall-bladder  to  adjacent  parts.  The 
primary  form  is  associated  in  at  least  87  per  cent,  of  all  cases  with  biliary 
calculi,  and  there  has  been  much  discussion  as  to  which  is  primary,  the 
gall-stone  or  the  cancer.  Zenker  and  others  regard  the  cancer  as  secondary, 
starting  in  the  ulcerative  and  cicatricial  tissue  caused  by  the  stones,  as  is 
thought  to  be  the  case  in  some  instances  of  cancer  of  the  stomach. 
This,  too,  may  account  for  the  greater  frequency  of  the  disease  in  women, 
if  such  is  the  case,  since  women  are  much  more  commonly  the  subjects  of 
gall-stone.  More  recent  experience  proves  that  gall-stones  are  often  the 
exciting  cause  of  carcinoma. 

A  more  or  less  hard,  solid,  irregular,  and  fixed  mass  is  the  form  assiimed 
by  the  cancer. 

Symptoms. — Jaundice  is  absent  so  long  as  the  disease  is  limited  to 
the  gall-bladder,  but  as  soon  as  the  biliary  duct  or  the  common  duct  is 
involved  it  ensues,  so  that  jatmdice  is  present  in  69  per  cent.,  gradualh' 
increasing  in  intensity.  There  is  great  tenderness,  with  pain;  vomiting, 
sometimes  of  blood,  bloody  stools,  and  dropsy,  at  times  succeeded  by  the 
cancerous  cachexia.  But  none  of  these  is  distinctive,  being  found  in  cancer 
of  the  pylorus,  duodenum,  and  transverse  colon.  The  presence  of  a  hard, 
uneven,  and  tender  tumor  in  the  neighborhood  of  the  gall-bladder,  which 
moves  with  the  liver  in  respiration,  confirms  the  suspicion.  This  has,  in 
fact,  been  found  in  about  69  per  cent.  If  the  disease  is  seated  in  the  cystic 
duct,  the  enlargement  of  the  gall-bladder  is  comparable  to  that  due  to 
obstruction  in  that  duct  from  other  causes,  and  may  be  marked. 

Diagnosis. — This  is  difficult.  Pain  and  tenderness  are  more  marked 
than  in  most  other  affections  of  the  liver,  except  cholecystitis.  Fever  and 
rigors  are  exceptional  and  point  rather  to  infectious  disease  of  the  gall- 
bladder or  ducts. 

Treatment. — All  recognized  gall-stones  should  be  removed  before  they 
give  serious  symptoms.  The  treatment  can  only  be  palliative  after  the 
carcinoma  has  developed. 

Carcinoma  of  the  Biliary  Passages. 

Cancer  of  the  bUe-ducts  may  be  primary  or  secondary.  In  either  event 
the  first  symptom  is  usually  jaundice,  which  grows  deeper  and  deeper  imtil 
the  skin  may  assume  an  almost  bronze-like  hue.     A  cachexia  rapidly  de- 


450  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

velops.  There  are  pain  and  tenderness  and  moderate  enlargement  of  the 
gall-bladder.  Enlargement  of  the  gall-bladder  is  characteristic  of  cancer 
of  the  common  bile-duct  as  contrasted  with  obstruction  of  the  common 
duct  by  gall-stones,  according  to  Courvoisier's  law.  Moreover  the  jaundice 
keeps  progressivelj^  increasing  and  never  grows  better,  while  in  calculous 
obstruction  it  may  not  be  very  deep  or  progressive.  The  disease  often 
escapes  recognition  tmtil  an  autopsy  reveals  it.  Cancer  may  invade  the 
bile-ducts  from  the  gall-bladder  and  possibly  from  primary  or  secondary 
cancers  in  the  parenchyma  of  the  organ. 

The  relation  of  the  morbid  growth  to  gall-stones  in  its  vicinity  is 
governed  by  the  same  laws  as  that  between  gall-stones  and  cancer  of  the 
gall-bladder. 

Stenosis  of  the  Biliary  Ducts. 

Stenosis,  or  more  or  less  incomplete  occlusion  of  the  common  duct,  may 
be  due  to  inflammatory  adhesion  or  to  compression  from  without.  Some- 
times it  follows  the  ulceration  attending  the  passage  of  a  gall-stone.  Exter- 
nal pressure  may  be  produced  by  morbid  growths  and  other  causes  alluded 
to  on  p.  434.     Notably,  cancer  of  the  pancreas  is  one. 

Cicatricial  contraction  the  result  of  perihepatitis,  syphilitic  disease,  per- 
forating duodenal  ulcer,  and  cholelithiasis  should  also  be  mentioned  as  a 
cause  of  external  compression  of  biliary  passages,  to  be  recognized,  if  at  all, 
by  aid  of  the  associated  symptoms  of  the  disease  causing  it.  In  the  first 
there  may  be  a  peritoneal  friction  in  the  neighborhood  of  the  liver,  audible 
and  palpable. 

Parasites. 

Parasites  may  enter  the  larger  biliary  passages  and  produce  obstruction. 
Such  are  ecliinococci  which  may  enter  the  ducts  primarily  in  the  larval 
state  and  develop  there  the  hydatid  cyst  with  resulting  obstruction;  or, 
as  is  more  frequent,  the  sac  perforates  or  compresses  a  duct  in  the  course 
of  its  growth.  The  other  symptoms  of  echinococcus  disease  are  added  to 
those  of  obstruction  thus  produced,  or  the  cysts  may  appear  in  the  stools, 
vomited  matter,  or  expectoration.  Cases  are  reported  in  which  the  distoma 
hepaticum  has  been  found  lodged  in  the  hepatic  duct,  and  round  worms 
in  the  common  and  hepatic  ducts.  A  remarkable  specimen,  containing  a 
number  of  limibricoids  lodged  in  these  ducts,  is  in  the  Wistar  and  Homer 
Museum  of  the  University  of  Pennsylvania.  The  symptoms  of  these  last 
conditions  wotdd  be  undistingtushable  from  hepatic  obstruction  from  other 
causes. 

DISEASES  OF  THE  BLOOD-VESSELS  OF  THE  LIVER. 

Hyperemia. 

Passive  Hyperemia — Red  Atrophy. 

The  hyperemia  of  the  liver  which  is  of  chief  clinical  importance  is 
passive  hyperemia. 

Etiology. — It  is  always  due  to  obstruction  to  the  movement  of  the 


HYPEREMIA  OF  LIVER  451 

blood  toward  or  through  the  heart.  Valvular  heart  disease  is  the  most 
frequent  cause,  though  diseases  of  the  lungs,  such  as  emphysema  or  cirrho- 
sis, intrathoracic  growths,  diseases  of  the  pleura,  compression  of  the  vena 
cava,  or  other  cause  resisting  the  movement  of  the  blood  through  the  organ 
and  thus  cardiac  decompensation  are  all  competent  to  produce  passive 
hyperemia  of  the  liver. 

Morbid  Anatomy. — The  appearances  of  the  organ  after  death  are  deter- 
mined by  the  duration  of  the  congestion.  If  it  has  been  of  short  dtiration, 
the  liver  rapidly  assumes  its  natural  size  and  appearance  after  death.  Even 
in  long-continued  passive  congestion  the  liver  after  death  becomes  verj- 
much  smaller  than  during  life,  by  reason  of  the  emptying  of  the  blood-vessels 
which  rapidly  succeeds  death.  In  other  respects,  however,  after  prolonged 
hyperemia  it  presents  decided  changes.  It  is  dark  in  color,  and  the  vessels 
still  contain  an  excess  of  blood,  but  the  •intralobular  vein — i.  e.,  the  central 
vein  of  each  lobule — and  its  adjacent  capillaries  contain  most  blood,  con- 
trasting strongly  with  the  peripheral  or  wiedobular  vessel  and  its  adjacent 
capillaries.  There  is  thus  produced  in  one  way  that  alternation  of  dark  and 
light  tint  which  constitutes  the  nutmeg  liver  and  which  is  particularly  con- 
spicuous on  section.  It  becomes  even  more  marked  at  a  later  stage,  when 
the  organ,  in  its  ultimate  atrophy,  becomes  reduced  in  size,  constituting  the 
so-called  red  or  cyanotic  atrophy  of  the  liver — the  atrophied  nutmeg  liver — 
the  histology  of  which  exhibits  a  destruction  of  the  cells  and  capillaries  in 
the  center  of  each  lobule  and  a  deposit  of  dark  pigment  in  their  places.  In 
the  liver  thus  atrophied  the  blood-vessels  also  share  in  the  destruction,  and 
short  cuts  are  established  between  the  branches  of  the  portal  vein  and  he- 
patic vein,  while  the  latter  may  also  become  dilated.  The  exterior  of  the 
liver  is  smooth,  and  the  organ  differs  in  this  respect  from  the  cirrhotic 
liver,  though  there  is  sometimes  a  slight  overgrowth  of  the  interlobular 
connective  tissue. 

Symptoms. — The  liver  at  first  is  enlarged  and  tender.  The  lower 
border,  as  determined  by  palpation,  may  be  as  low  as  the  iimbilicus  and 
even  lower.  It  may  be  the  seat  of  expansile  pulsation,  due  to  regurgita- 
tion of  blood  into  it  from  the  right  heart.  This  pulsation  is  to  be  dis- 
tinguished from  a  motion  communicated  to  the  liver  by  the  action  of  the 
heart.  In  the  true  pulsation  the  whole  liver  seems  to  dilate,  and  does 
dilate  as  the  blood  flows  back  into  it,  as  contrasted  with  the  downward 
movement  communicated  by  the  heart.  Very  characteristic  of  this  enlarge- 
ment is  the  changing  size  of  the  organ  pari  passu  with  the  degree  of  conges- 
tion, whether  spontaneous  or  the  result  of  treatment. 

Ascites  is  also  a  symptom.  It  does  not  occur,  however,  until  a  marked 
degree  of  passive  hyperemia  or  secondary  contraction  is  attained.  The 
ascites  is  partly  the  result  of  the  general  stagnation  always  present,  and 
partly  of  the  congestion  of  the  portal  system  due  to  the  backing  of  the 
blood  of  the  hepatic  vein  into  it.  Jaundice  occurs.  It  is  due  to  the  com- 
pression exerted  on  the  fine  interlobular  gall-ducts  by  the  overdistended 
interlobular  capillaries,  thus  producing  an  obstructive  jaundice. 

Scanty  urine  of  high  specific  gravity  is  also  a  symptom,  while  hypere- 
mia with  ^enlargement  of  the  spleen  and  hyperemia  of  the  mucous  mem- 
brane of  the  stomach  are  constant,  as  a  result  of  the  same  cause. 


452  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

All  of  these  symptoms  must  be  accompanied  by  a  failing  heart  to  make 
I  he  diagnosis. 

Treatment. — The  treatment  of  passive  hyperemia  is  the  treatment  of 
the  condition  causing  it.  Rest  is  most  important  because  it  gives  the  heart 
an  opportunity  to  regain  its  tone.  All  the  treatment  which  is  described 
in  that  of  failing  cardiac  compensation  must  be  used.  Simultaneoush- 
the  urine  is  increased,  and  the  general  dropsy,  ascites,  and  hydrothorax 
disappear.  Such  treatment  is  aided  also  by  depletion  from  the  portal 
side  by  purgatives.  Blue  mass  is  the  type  of  these,  but  colocynth,  elate- 
rium,  and  compound  jalap  powder,  or  the  simple  salts,  are  also  efficient. 
It  sometimes  happens  that  the  general  dropsy  in  these  cases  is  dispersed 
by  treatment,  but  the  ascites  remains,  in  which  event  we  must  suppose 
the  simple  passive  congestion  to  be  combined  with  some  degree  of  atrophy, 
when  the  dropsy  is  more  likely  to  remain.  Treatment  should  now  be 
supplemented  by  hydragogue  cathartics,  or,  still  better  by  tapping,  fol- 
lowed by  dr^'  diet  and  the  hydragogues.  A  dram  (4  gm.)  or  more  of  com- 
]D0und  jalap  powder  may  be  given  each  morning  fasting,  or  elaterium,  1/6 
grain  (o.oi  gm.)  ever}^  three  hours,  until  the  bowels  are  moved. 

Active  Hyperemia. 

Definition. — This  is  a  much  less  important  condition  than  passive 
hypereniia,  and,  indeed,  is  rarely  recognized.  A  physiological  hyperemia 
of  the  liver  takes  place  after  each  meal,  which  may  be  exaggerated  and 
even  continuous  in  those  who  overeat  and  overdrink  habitually.  Such 
hyperemia  may  lead  to  structural  change,  consisting  ultimately  in  inter- 
stitial growth.  Like  this,  also,  is  the  hyperemia  which  is  associated  with 
diabetes  mellitus,  and  which  is  the  associated  condition  of  many  glycosurias, 
whether  experimental  or  the  result  of  disease  affecting  the  diabetic  center. 
Such  is  a  vicarious  hyperemia  said  to  take  place  during  suppressed  men- 
struation and  after  cutting  oft"  a  hemorrhoidal  flux. 

Active  hyperemia  does  not,  however,  present  any  symptoms  referable 
to  it,  unless  it  be  that  the  dull  ache  and  full  feeling  sometimes  felt  in  the 
right  hypochondrium  be  caused  by  such  condition. 

Treatment. — The  treatment  must  consist  of  measures  which  tend  to 
diminish  this,  mainly  the  substitution  of  a  scanty  for  an  overabundant 
diet,  simple  and  easily  digested  foods,  dilute  milk,  and  thin  broths,  and 
the  avoidance  of  fats,  alcohol,  and  sugar. 

Thro.mbosis  and  Embolism. 

The  portal  vein  is  the  seat  of  thrombosis  and  of  inflammation,  consti- 
tuting pylethrombosis  and  pylephlebitis.  The  hepatic  artery  also  becomes 
rarely  the  seat   of  aneurysms. 

Pylethrombosis. 

Thrombosis  takes  place  in  the  smaller  branches  of  the  portal  vein,  which 
are  constantly  being  obliterated  in  the  course  of  cirrhosis  of  the  liver. 


PYLEPHLEBITIS  453 

Larger  branches  are  sometimes  invaded  by  cancer,  or  a  gall-stone  may  be 
admitted  into  one  of  them  by  ulceration,  or  the  lodgment  of  a  parasite  may 
be  the  focus  about  which  a  coagulum  may  form,  while  thrombosis  may  also 
be  favored  by  the  pressure  incident  to  the  encroachment  of  a  neighboring 
tumor.  Rarely  a  thrombus  may  extend  into  the  portal  vein  from  one  of 
its  branches  in  the  intestine'or  mesentery. 

Symptoms. — These  include  those  to  be  detailed  when  treating  of  cir- 
rhosis— viz.,  ascites,  hyperemia  in  the  parts  behind  the  obstructed  vessel, 
with  this  difference,  that  the  symptoms  appear  more  or  less  suddenly  and 
severely.  It  is  mainly  by  the  suddenness  and  intensity  of  the  sj^mptoms 
that  we  are  led  to  suspect  thrombosis,  especially  if  it  be  associated  with 
any  of  the  previously  named  conditions  capable  of  producing  it.  In  such 
an  event  the  symptoms  would  come  about  in  the  course  of  a  few  days, 
instead  of  weeks  and  months.  A  caput  meduscB  thus  rapidly  produced 
would  mean  that  the  thrombus  had  formed,  not  in  the  portal  vein  itself, 
but  more  peripherally,  causing  the  para-umbilical  veins  to  be  filled  from 
the  peripheral  branches.  These  come  off  the  portal  vein  in  the  suspensory 
ligament,  and  pass  out  to  the  neighborhood  of  the  umbilicus  by  two  branches 
communicating  with  the  epigastric  and  internal  mam.mary  vein. 

When  pylethrombosis  occurs,  it  sometimes  happens  that  a  complete 
collateral  circulation  is  established,  the  thrombus  undergoing  the  usual 
changes,  while  the  portal  vein  may  be  ultimately  converted  into  a  fibrous 
cord.  Osier  reports  such  a  case,  in  which  compensation  finally  failed,  and 
the  usual  symptoms,  including  hematemesis,  supervened,  and  the  patient 
died. 

Pylephlebitis. 

Mild  grades  of  pylephlebitis  probably  succeed  the  thrombosis  referred 
to,  but  they  are  of  no  consequence  unless  the  thrombus  is  septic.  Hemor- 
rhagic infarct  does  not  usually  succeed  the  lodgment  of  an  embolus  in  a 
branch  of  the  portal  vein,  because  of  the  free  anastomosis  of  its  branches 
with  those  of  the  hepatic  artery,  by  which  the  lobular  capillaries  are  sup- 
plied. It  does,  however,  sometimes  occur.  Here  again  the  results  are  not 
serious,  so  long  as  the  embolus  is  not  septic.  Much  more  serious  is  suppura- 
tive phlebitis,  the  resrdt  of  septic  embolism,  or  septic  thrombosis  arising 
from  an  inflammatory  focus  somewhere  in  the  portal  area,  as  in  the  case  of 
the  bowel,  dysentery  or  in  the  territory  of  the  umbilical  vein  of  the  new- 
bom  child  or  in  suppurative  appendicitis.  Pylephlebitis  is  one  of  the  causes 
of  abscess  of  the  liver.  It  is  associated  with  the  usual  signs  of  septic  in- 
fection— viz.,  chills,  remittent  fever,  and  sweats,  while  the  symptoms  which 
point  to  the  liver  are  pain  in  that  neighborhood,  jaundice  in  most  cases, 
and  the  signs  of  portal  vein  obstruction  more  or  less  pronounced.  Suppura- 
tive peritonitis  is  also  sometimes  added.  Such  phlebitis  does  not  always 
proceed  to  the  degree  of  abscess  formation  before  death  supervenes.  The 
symptoms  of  abscess  will  be  considered,  when  treating  of  that  subject, 
when,  too,  attention  will  be  called  to  the  diagnosis  between  it  and  suppura- 
tive phlebitis,  so  far  as  it  can  be  made  out. 


454  DISEASES  OF  THE  DIGESTIVE  SYSTE'M 

Other  Changes  in  the  Hepatic  Artery  and  Vein. 

The  artery  is  sometimes  dilated  in  cirrhosis  of  the  liver;  it  may  be  the 
seat  of  endarteritis  and  sclerosis.  Aneurysm  of  the  artery  is  a  rare  condi- 
tion. The  symptom  is  a  pulsating  tumor,  which  may  be  the  seat  of  a  mur- 
mur. In  the  cases  reported  there  have  beenhematemesis,  bloody  stools, 
jaundice  from  compression  of  the  biliary  ducts,  and  pain  in  the  neighborhood 
of  the  liver  due  to  compression  of  adjacent  nerves. 

The  hepatic  vein  is  subject  to  dilatation,  alluded  to  in  treating  of  pas- 
sive hyperemia;  to  stenosis,  and  to  thrombosis  extending  backward  from 
the  right  auricle. 

FATTY  LIVER. 

Definition. — The  term  fatty  liver  is  applied  to  a  condition  in  which  the 
cells  of  the  liver  are  more  or  less  completely  converted  into  fat.  This  is 
accomplished,  however,  by  two  distinct  processes.  In  one  there  is  an  in- 
filtration of  the  liver  cells  with  fat  drops,  which  simply  push  aside  the 
protoplasm  and  cause  its  tdtimate  disappearance  by  interfering  with  its 
nutrition.  In  the  other  there  is  a  disintegration  or  metamorphosis  of  the 
protoplasm  of  the  cell  into  various  products,  of  which  one  is  oU.  In  the 
former,  fatty  infiltration,  the  cell  maintains  its  integrity,  being  simply 
fiUed  with  the  fat  drops,  in  the  latter  the  cell  disintegrates  and  leaves  a 
residue  of  which  fat  is  the  chief  representative.  It  shotdd  be  mentioned 
that  some  use  the  term  "fatty  liver"  as  synonymous  with  "fatty 
metamorphosis. " 

Fatty  Infiltration. 

Etiology. — Abnormal  fatty  infiltration  occurs  in  two  ways: 

1.  In  case  of  overingestion  of  fat-producing  substances,  resulting  in 
obesity,  of  which  it  is  a  part,  and  as  the  result  of  which  the  liver  becomes 
a  storehouse  for  fat.  Excessive  consumption  of  alcohol  is  attended  by 
fatty  infiltration,  because  more  carbohydrate  is  introduced  than  can  be 
burned  up.     It  is,  therefore,  stored  in  the  liver  cells. 

2.  In  a  series  of  cachectic  states,  in  which  oxidation  is  interfered  with 
and  the  fat  which  is  ingested  is  not  oxidized,  but  accimiulates  in  the  liver. 
Such  a  condition  is  pulmonary  tuberculosis,  which  is  the  most  common 
cause  of  fat-infiltrated  liver,  except    alcoholism. 

Morbid  Anatomy. — The  liver  of  fatty  infiltration  is  uniformly  large, 
soft,  and  smooth.  Its  appearance  varies  somewhat  at  different  stages. 
Since  the  infiltration  begins  at  the  periphery  of  the  lobule,  we  have,  in  the 
first  stage,  a  simple  distinctness  of  the  line  of  demarcation  between  the 
adjacent  acini.  In  the  second  stage  this  has  become  more  marked,  con- 
trasting strongly  with  the  darker  color  of  the  center  of  the  lobule,  and  pro- 
ducing one  form  of  nutmeg  liver — as  contrasted  with  the  liver  of  red  atrophy, 
already  described  in  treating  of  passive  congestion.  In  the  third  stage  the 
entire  acinus  is  infiltrated,  and  the  whole  organ  assumes  a  uniform  yellow 
or  brownish-yellow  appearance,  from  complete  fatty  infiltration  of  the  cells. 
The  organ  is  also  anemic.     In  this  last  stage  it  is  that  we  have  the  macro- 


FATTY  LIVER  455 

scopic  changes  complete — the  softness,  the  broadened  edges,  and  increase 
in  size,  with,  however,  a  decided  reduction  in  specific  gravity. 

Symptoms. — Outside  the  physical  condition,  determined  by  palpation 
and  percussion,  and  the  causing  disease  or  state,  there  are  no  distinctive 
symptoms.  There  is  no  jaundice,  and  the  bile-forming  function  of  the 
liver  seems  little  interfered  with,  though  the  stools  are  pale.  There  is  no 
obstruction  to  the  portal  circulation,  and,  therefore,  no  abdominal  dropsy. 
Percussion  recognizes  enlargement  of  the  liver,  which  is,  however,  moderate 
compared  with  that  of  amyloid  liver  and  cancer,  extending,  as  it  does,  but 
a  short  distance  below  the  normal  site,  where  its  edge  can  be  felt  even 
through  abdominal  walls  of  some  thickness.  There  is  no  enlargement  of 
the  spleen. 

Diagnosis. — It  becomes  necessary  to  differentiate  the  enlarged  fatty 
liver  from  the  amyloid  liver,  which  is  harder  and  larger  and  associated  with 
enlarged  spleen  and  albuminuria.  With  the  hyperemic  enlargement  of  the 
first  stage  of  cirrhosis  it  is  not  likeh''  to  be  confounded.  Such  enlargement 
would  be  trifling,  accompanied  by  tenderness,  and  sooner  or  later  succeeded 
by  contraction,  while  the  fatty  liver  continues  to  enlarge.  From  the  en- 
largement due  to  the  cloudy  swelling  characteristic  of  the  infectious  dis- 
eases, typhoi(J  and  typhus,  it  is  distinguished  bj'  the  absence  of  fever  and 
other  symptoms  of  these  diseases. 

Prognosis. — This  depends  upon  that  of  the  causing  disease. 

Treatment. — The  treatment  is  that  of  the  disease  causing  it. 


Fatty  Metamorphosis. 

Definition. — This  is  a  much  more  serious  condition,  in  which  the  cell 
protoplasm  is  directlj^  converted  into  fat,  or  rather,  perhaps,  into  a  number 
of  products  of  which  fat  is  one,  while  the  cell  undergoes  disintegration.  It 
is  the  effect  of  some  poison,  which  has  its  type  in  phosphorus-poisoning  and 
in  the  cause,  whatever  it  may  be,  of  acute  yellow  atrophy  of  the  liver. 

Morbid  Anatomy. — The  liver,  instead  of  enlarging,  undergoes  rapid 
reduction  in  size,  or  at  least,  if  there  is  enlargement,  it  is  of  such  short  dura- 
tion that  it  is  never  recognized.  The  appearance  and  condition  of  the  liver, 
to  be  described  luider  acute  yeUow  atrophy,  are  those  of  the  liver  which  is 
the  seat  of  rapidly  progressing  fatty  metamorphosis. 

Symptoms. — They  are  those  of  the  diseases  causing  it,  and  will  be 
described  under  Acute  Yellow  Atrophy. 

The  prognosis  is  fatal  and  treatment  is  unavailing. 


THE  AMYLOID  LIVER. 


Synonyms. — Lardaceous  Liver;  Waxy  Liver;  Albuminoid  Liver. 

Definition. — In  the  amyloid  liver  there  is  an  iiofiltration,  in  various 
degrees,  of  aU  the  tissues  of  the  organ  by  the  so-called  amyloid  substance. 
The  blood-vessel  walls  are  the  first  affected,  and  by  preference  those  of  the 


456  DISEASES  OF  THE  DIGESTIVE  SYSJ-EM 

intermediate  area  of  the  lobule — i.  e.,  that  suppHcd  Vjy  the  hepatic  artery, 
then  the  central  or  hepatic  vein  zone,  and  finally  the  peripheral  or  portal 
zone.  The  infiltration  begins  in  the  smaller  arteries,  then  invades  the  cells 
and  capillaries,  and  in  extreme  cases  pervades  all  the  liver  tissue,  includ- 
ing connective  tissue. 

Etiology. — The  most  usual  cause  of  amyloid  liver  is  prolonged  suppura- 
tion, especially  in  connection  with  tubercular  disease  of  the  bones.  Hence 
it  is  found  in  children  who  have  had  hip  disease.  For  the  same  reason  it 
is  found  associated,  though  less  frequently  than  might  be  expected,  with 
prolonged  tuberculosis  of  the  lungs.  Syphilis  is  one  of  the  recognized 
causes,  whence  it  may  arise  as  a  tertiary  manifestation  or  as  the  result  of 
bone  disease  incident  to  it.  Rickets  likewise  produces  some  cases,  and  it 
is  also  associated,  though  rarely,  with  leukemia,  the  cancerous  cachexia 
and  the  infectious  diseases. 

Morbid  Anatomy. — The  liver  is  much  enlarged,  reaching  sometimes 
enormous  dimensions,  scarcely  exceeded  by  the  largest  cancers.  Its  ap- 
pearance is  waxy  or  resembles  bacon,  especially  in  thin  sections.  This 
appearance  is  partly  due  to  the  anemic  state.  The  amyloid  parts  strike 
a  mahogany-red  color  with  weak  solutions  of  iodin.  In  addition  to  the 
change  in  size  and  translucency,  the  amyloid  liver  is  hard  and  smooth, 
its  border  usually,  though  not  always,  rounded,  and  its  fissure  exaggerated. 
In  certain  syphilitic  forms  its  surface  is  beset  with  nodules.  Instead  of 
being  general,  the  amjdoid  change  is  sometimes  circumscribed,  when 
it  may  be  associated  mth  red  atrophy.  It  is  occasionally  combined  with 
fatty  infiltration. 

Symptoms. — Beyond  the  enlargement,  which  is  usually  manifest,  the 
organ  extending  sometimes  as  low  as  the  umbilicus,  and,  in  addition  to  the 
symptoms  of  its  causing  state,  there  are  none  peculiar  to  the  amyloid  liver. 
There  is  no  pain,  unless  it  be  the  result  of  an  associated  syphilitic  hepatitis, 
but  there  may  be  a  dragging  sensation,  induced  b}*  the  weight  of  the  organ. 
There  is  no  jaundice,  though  the  stools  may  be  light-hued,  because  the 
secretion  of  bile  is  diminished.  There  is  no  ascites,  except  in  extreme  cases, 
when  it  is  a  consequence  of  the  general  hydremia,  and  not  of  obstruction 
in  the  portal  circulation.  It  is  usually  associated  with  amyloid  spleen, 
which  is  enlarged,  and  with  the  amyloid  kidney,  which  secretes  albuminous 
urine. 

Diagnosis. — This  is  usually  easy.  The  large,  smooth,  hard  organ,  the 
history  of  the  presence  of  the  primary  disease,  the  absence  of  jaimdice  and 
of  dropsy,  the  association  of  enlarged  spleen  and  albuminuria,  admit  of 
scarcely  any  other  interpretation.  It  is  to  be  remembered,  however,  that 
amyloid  spleen  is  not  invariably  present,  and,  when  present,  may  be  over- 
shadowed and  compressed  by  the  large  liver.  The  enlarged  liver  of  leuke- 
mia, the  result  of  lymphoid  infiltration,  may  at  once  be  distinguished  by 
the  blood  examination. 

Prognosis  and  Treatment. — They  are  those  of  the  primary  disease. 
We  have  never  seen  an  amyloid  liver  reduced  to  the  normal  size,  yet  the 
absence  of  symptoms  growing  out  of  moderate  degrees  of  it  makes  practical 
recovery  not  impossible. 


PORTAL  CIRRHOSIS  457 

THE  CIRRHOSES  OF  THE  LIVER. 

Synonyms. — Chronic  Interstitial  Hepatitis;  Gin  Liver,  Granular  Liver;  Hob- 
nail Liver. 

Definition. — Cirrhosis  of  the  liver  is  a  disease  characterized  by  an  over- 
growth of  connective  tissue  with  more  or  less  destruction  of  the  paren- 
chyma of  the  organ,  commonly  attended  by  a  harder  consistence,  sometimes 
by  a  reduction  of  size,  at  others  by  enlargement,  and  at  others  by  no  changes 
in  size.  Too  much  stress  has  been  laid  in  the  past  on  shrinking  of  the 
organ  as  a  necessary  feature  of  the  disease.  Hypertrophic  and  atrophic 
as  applied  to  cirrhosis  should  be  abolished.  As  Adami  remarks,  they  are 
only  relative. 

There  are  various  types  of  cirrhosis  which  are  found  affecting  the 
liver.  The  capsular  cirrhosis,  where  the  whole  organ  is  enveloped  in  a 
thick  fibrous  membrane;  the  cirrhosis  due  to  cardiac  disease  which  has 
been  described,  syphilitic  cirrhosis,  which  will  be  considered;  and  small 
cirrhotic  patches  due  to  various  causes.  Besides  these  there  are  two  forms 
of  diffuse  cirrhosis  which  especially  concern  the  clinician:  portal  cirrhosis 
(atrophic),  and  biliary  cirrhosis  (hypertrophic). 

PORTAL  CIRRHOSIS 

Laennec's  Cirrhosis.     Atrophic  Cirrhosis. 

This  form  is  popularly  known  as  atrophic  cirrhosis,  but  as  stated  before 
this  term  applies  only  to  the  terminal  stages  of  the  disease. 

Etiology. — In  many  cases  it  follows  the  overuse  of  alcohol,  but  over- 
eating, especially  of  highly  seasoned  food  is  also  a  well-recognized  cause; 
syphilis,  tuberculosis,  and  malaria  have  been  given  as  causes.  It  occurs 
in  men  twice  as  frequently  as  in  women.  It  has  been  reported  in  children 
frequently.     Alcohol  and  syphilis  seem  to  be  the  causes  here. 

Pathology. — The  liver  varies  much  in  size.  There  is,  however,  always 
an  overgrowth  of  the  connective  tissue.  It  can  be  very  small,  one  of  our 
cases  it  weighed  a  little  over  one  pound.  This  is  the  true  atrophic  cirrhosis, 
the  hob-nailed  liver — small,  deformed,  rough,  the  surface  being  covered 
with  small  prominent  areas,  whence  the  name  hob-nailed.  In  the  earty 
stages  the  liver  is  enlarged,  the  surface  is  slightly  granular. 

A  third  form  is  the  fatty,  cirrhotic  liver. 

In  all  these  forms  there  is  increase  in  the  connective  tissue.  There  is 
hyperplasia  and  hypertrophy  of  the  liver  cells. 

In  the  atrophic  form  the  hyperplasia  of  the  liver  cells  is  most  marked. 
Here  great  islands  of  hyperplastic  cells  are  cut  off  from  other  parts  of  the 
liver,  causing  the  yellow-tawny  appearance  of  the  cut  surface  of  the  liver. 
The  depressions  on  the  surface  are  found  to  correspond  to  fibrous  bands 
which  are  of  a  pinkish  color.  Histologically  the  fibrous  bands  are  found 
to  surround  several  lobules  or  around  single  lobules. 

Finally  the  liver  cells  are  destroyed  and  replaced  by  the  contracting 
connective  tissue. 

In  the  fatty  cirrhosis  there  is  more  or  less  fatty  infiltration  in  addition 
to  the^usual  changes. 


458  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Symptoms. — (a)  Of  Portal  Cirrhosis. — Clinicians  have  sought  with 
increased  effort  for  symptoms  caused  by  cirrhosis  of  the  liver  in  its  early 
stages.  None  are  distinctive,  but  given  an  enlarged  liver  otherw'ise  inex- 
plicable in  an  alcoholic  subject,  the  presence  of  chronic  gastric  catarrh 
manifested  by  anorexia,  nausea  and  sense  of  distention;  a  tendency  to 
gastro-intestinal  hemorrhage,  recturing  slight  jaundice,  high  colored  urine 
and  growing  anemia,  a  strong  suspicion  of  the  presence  of  a  first  stage  is 
justified.  The  same  symtpoms  continue  as  the  result  of  more  advanced 
degrees.  The  gastric  catarrh  is  the  consequence  of  chronic  passive  hyper- 
emia, due  to  obstructed  movement  of  the  portal  blood.  As  a  resvilt  of 
the  hyperemia  the  mucous  membrane  of  the  stomach  is  more  or  less  con- 
stantly covered  with  mucus,  which  excites  nausea  and  interferes  with  secre- 
tion of  .'gastric  juice.  A  similar  condition  exists  in  the  small  intestine, 
causing  constipation,  which  is  increased  by  the  deficient  biliary  secretion. 
This  is  ftirther  shown  by  the  paleness  of  the  stools.  The  well-known 
comforting  effect  of  the  early  morning  "dram"  upon  the  inebriate  may  be 
due  to  some  action  of  the  alcohol  upon  this  mucus.  The  disease  is  usually 
afebrile.  Occasionally  there  is  slight  fever  with  temperature  of  ioo°  to 
102°  F.  (37.7°  to  38.8°  C.j. 

The  late  symptoms  are  mainly  the  result  of  the  Hgature-like  effect  of  the 
connective  tissue  on  the  portal  vessels.  Nasal  hemorrhage,  often  very 
obstinate,  is  one  of  these.  So  are  gastric,  intestinal  and  esophageal  hemor- 
rhages, these  hemorrhages  being  often  enormous  and  alarming,  but  reaUy 
beneficial,  by  removing  the  gastro-intestinal  congestion.  Either  one 
of  these  forms  of  hemmorrhage  may  be  the  very  first  symptom  to  attract 
attention.  Uterine  flooding  also  sometimes  occurs,  and  even  hematuria. 
Similarly  caused  is  the  abdominal  dropsy,  which  is  often  enormous.  Four 
gallons  (15  liters)  and  more  are  not  infrequently  removed  at  one  tapping, 
and  sometimes  the  fluid,  from  its  weight,  bursts  through  the  feeble  barrier 
at  the  abdominal  ring,  distending  the  tunica  vaginalis.  The  navel  is  often 
pushed  out  by  the  enormous  distention. 

The  surface  of  the  upper  abdomen  and  lower  thorax,  anteriorly,  is 
marked  by  overdistended  veins.  This  is  directly  due  to  the  backing  of  the 
blood  into  these  veins,  rendered  possible  by  the  anastomotic  communi- 
cation between  the  portal  and  caval  circulations.  Such  anastomosis 
between  the  rudimentary  veins  in  the  round  ligament  (branches  of  the 
portal  vein)  and  the  epigastric  and  mammary  veins  leads  to  enlargement 
of  the  superficial  branches  of  these  veins,  and  in  extreme  cases  to  the  for- 
mation of  a  caput  medusce  about  the  navel.  Communication  between  the 
superior  hemorrhoidal  vein  (a  branch  of  the  portal  vein)  and  the  middle 
and  inferior  hemorrhoidal,  and  through  them  -with  the  hypogastric  veins 
and  vena  cava,  produces  hemorrhoids,  a  characteristic  symptom  of  cirrhosis. 
Anastomosis  between  the  superior  gastric  vein  (a  branch  of  the  portal)  and 
the  inferior  esophageal,  whose  blood  goes  to  the  cava  through  the  azygos 
and  hemi-azygos,  causes  a  varicose  condition  of  the  veins  of  the  lower  end 
of  the  esophagus  which  has  resulted  in  fatal  hemorrhage.  The  overfilling 
of  the  esophageal  and  azygos  veins  may  also  obstruct  the  movement  of  the 
blood  through  the  intercostal  and  pleural  vessels  of  the  right  side,  causing 
rightsided  hydrothorax.     These  dilatations,  which  have  been  characterized 


PORTAL  CIRRHOSIS  459 

as  "attempts  at  compensation,"  are  to  be  distinguished  from  the  m.ore 
diffuse  dilatation  of  the  abdominal  veins  seen  in  the  flanks,  which  are  due 
to  the  pressure  on  the  cava  by  extreme  abdominal  dropsy,  preventing  the 
return  of  the  blood  of  the  lower  extremities  by  the  cava  and  causing  the 
effort  to  return  through  the  more  superficial  vessels.  Edema  of  the  legs 
may  occur  but  is  much  more  uncommon  than  abdominal  dropsy,  and,  when 
present,  depends  upon  the  further  pressure  exercised  by  the  enormous 
accumulation  of  fluid  in  the  abdominal  sac  upon  the  returning  blood  of  the 
lower  extremities. 

Jaundice  is  slight  in  atrophic  cirrhosis,  and  less  frequent  than  might  be 
expected.  It  may  be  because  comparatively  little  bile  is  secreted.  A  sallow- 
ness  of  complexion  is  also  sometimes  present,  while  a  ruddiness  of  face  is 
not  uncommon. 

Physical  examination  by  palpation  and  percussion  discovers  a  dimin- 
ished area  of  hepatic  dullness  when  the  liver  is  atrophic  or  increase  in  dullness 
when  the  liver  is  enlarged.  Occasionally  an  atrophied  liver  will  tUt  on  its 
axis  and  appear  in  the  examination  as  an  enlarged  liver.  On  the  other  hand, 
splenic  dullness  is  often  enlarged,  the  latter  because  of  resisted  return  of 
blood  from  the  spleen  through  the  liver,  through  the  spleen  may  be  enlarged 
simultaneously  through  other  causes.  According  to  Frerichs,  the  spleen 
is  enlarged  in  about  one-half  of  the  cases;  some  even  say  in  three-fourths. 
In  alcoholic  cirrhosis  especially  enlarged  spleen  is  considered  evidence  of 
an  advanced  stage  of  the  disease.  It  is  often  impossible  to  outline  either 
liver  or  spleen  because  of  the  extreme  abdominal  distention,  and  tapping 
must  first  be  resorted  to  before  physical  exploration  is  satisfactory. 

The  urine  in  atrophic  ciiThosis  of  the  liver  is  generally  scanty,  of  high 
specific  gravity,  highly  colored,  and  often  loaded  with  urates,  which  subside 
on  standing,  forming  a  bulky  sediment.  The  proportion  of  urea  is  often 
diminished,  a  natural  result  of  the  deranged  fimction  of  the  liver,  to  which 
modem  physiology  assigns  an  important  rloe  in  urea  formation.  The  urine 
also  contains  at  times  bile  pigment,  but  less  frequently  than  in  hypertrophic 
cirrhosis.     Blood  is  also  sometimes  found  in  the  urine. 

In  atrophic  cirrhosis  the  feces  are  often  wanting  in  bile  and  consequently 
are  gray  or  the  color  of  pipe  clay. 

Drowsiness  and  coma  and  even  delirium  are  sometimes  terminal  symp- 
toms, especially  in  cases  where  there  is  jaundice,  but  also  where  there  is 
ascites  without  jaundice.     They  have  been  ascribed  to  cholesteremia. 

Diagnosis. — The  diagnosis  of  cirrhosis  of  the  liver  is  not  usually  difficult 
in  advanced  stage.  If  one  is  satisfied  that  there  is  a  reduction  or  enlarge- 
ment of  the  organ,  and  there  are  associated  with  this  no  sj^mptoms  of 
acute  disease  and  no  history  of  starvation,  if  enlarged  spleen,  acsites  and 
hemorrhages  from  the  stomach  are  present,  we  may  infer  scarcely  any- 
thing else  but  cirrhosis. 

Tuberculous  peritonitis,  with  its  Uquid  effusion,  has  been  mistaken  for 
cirrhosis,  and  the  wasting  which  attends  advanced  stages  of  the  former 
affection  closely  resembles  that  in  the  latter,  but  the  abdominal  tenderness 
in  peritonitis  is  characteristic,  there  is  fever,  and  the  effusion  is  never  very 
large.     The  effusion  of  the  two  conditions  differs. 


460  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

BILIARY  CIRRHOSIS. 

Hanoi's  Cirrhosis.     Hypertrophic  Cirrhosis. 

The  French  cUnicians,  headed  by  Requin  (1846)  and  Hanot  (1875), 
have  studied  this  form  most  thoroughly.  The  subjects  are  young,  more 
frequently  males.  The  liver  is  enlarged,  weighs  from  four  to  eight  pounds 
(2  to  4  kilograms). 

The  surface  of  the  liver  is  smooth,  the  cut  surface  is  smooth  of  green 
or  greenish-3'ellow  color  due  to  stains  ^\^th  bile,  the  connective  tissue  invades 
the  lobules  and  divides  off  small  groups  of  liver  cells. 

The  disease  apparently  begins  as  a  catarrh  of  the  fine  biliary  capillaries, 
the  portal  system  remaining  free.     The  spleen  is  enlarged. 

(b)  Symptoms. — The  symptoms  which  distinguish  this  form  from  the 
atrophic  variety  are: 

1 .  The  jaundice,  which  begins  with  the  first  vague  symptoms  of  the  dis- 
ease and  gradually  deepens  as  the  disease  progresses. 

2.  The  absence  of  hyperemia  of  the  stomach  and  bowels,  of  hemor- 
rhoids, enlargement  of  the  spleen,  and  preeminently  of  ascites;  or  the  pres- 
ence at  least  of  only  mUd  degrees  of  these  symptoms. 

3.  The  presence  of  tenderness  in  the  liver,  in  addition  to  its  evident 
enlargement  and  smoothness. 

4.  Certain  differences  in  the  urine  in  the  two  forms. 

It  is  a  well  recognized  fact  that  when  there  is  jaundice  the  urine  is  also 
colored.  In  portal  cirrhosis  jaundice  is  more  infrequent,  and  when  present, 
say  in  about  one-fourth  the  cases,  it  is  very  slight.  The  same  is  true  to 
a  less  degree  of  the  urine,  for  while  the  latter  is  scantj^  and  highly  colored, 
it  less  frequently  contains  bile  pigment.  In  biliary  cirrhosis,  on  the  other 
hand,  bile-stained  urine  is  more  common.  Blood  is  never  found  in  the 
urine  of  biliary  cirrhosis,  while  in  atrophic  cirrhosis  it  sometimes  is  in  ad- 
vanced stages,  as  is  also  albumen.  In  portal  cirrhosis  the  urea  is  diminished ; 
in  biliary,  it  is  normal  in  quantity.  In  biliary  cirrhosis  the  feces  are  some- 
times devoid  of  bile;  at  others  bUe  is  present. 

Rosenstein  has  made  a  study  of  the  blood  in  hj'pertrophic  cirrhosis,  and 
has  found  the  red  corpuscles  diminished  one-half  and  the  leukocytes  rela- 
tively increased.  He  also  found  it  associated  in  certain  cases  with  the 
hemorrhagic  diathesis.     The  disease  is  of  unknown  toxic  origin. 

The  course  of  hypertrophic  cirrhosis  is  of  usually  chronic  course.  It 
may  be  put  down  at  two  to  six  years,  3'et  in  some  cases  it  is  shorter.  Osier 
mentions  a  case  which  proved  fatal  in  ten  days;  another  in  three  weeks. 
It  may  be  questioned  whether  these  very  short  cases  were  not  cases  of  acute 
exacerbations.  All  cases  terminate  more  or  less  acutely.  Delirium  sets 
in,  the  tongue  becomes  drj^  the  pulse  rapid,  and  the  temperature  rises 
from  102°  to  104°  F.  (38.9°  to  40°  C). 

(6)  Diagnosis. — Hypertrophic  cirrhosis  is  to  be  distinguished  from 
cancer  of  the  liver,  amyloid  liver,  multilocular  echinococcus  disease,  and 
the  Hver  of  obstructive  jaundice.  In  cancer  there  is  no  splenic  enlargement, 
ascites  is  more  frequent,  the  liver  is  more  uneven,  and  the  patient  is  older, 
while  in  hypertrophic  cirrhosis  we  may  have  the  history  of  alcoholism. 


BILIARY  CIRRHOSIS  461 

In  amyloid  liver  there  is  also  splenic  enlargement,  but  there  is  no  pain, 
no  jaundice,  and  we  have  the  etiological  history  peculiar  to  amyloid  disease. 

Multilocular  hydatid  disease  in  the  liver  may  present  almost  identical 
symptoms,  including  jaundice  and  splenic  tumor,  but  in  addition  there  are 
the  nodules  on  its  surface  which  soften  with  time. 

The  liver  which  is  associated  with  chronic  biliary  obstruction  and  sec- 
ondary cirrhosis,  while  somewhat  enlarged,  is  not  nearly  so  much  so  as  in 
hypertrophic  cirrhosis.  Hepatic  colic  has  been  present  at  some  time  in  the 
course  of  the  disease.  The  liver  is  also  hard,  and  the  condition  is  accom- 
panied by  marked  jaundice  and  other  evidence  of  hepatic  obstruction.  Its 
course,  while  slow,  is  more  rapid  as  a  rule  than  that  of  hypertrophic 
cirrhosis,  while  the  liver  also  after  a  time  diminishes  in  size. 

The  prognosis  and  treatment  of  the  two  forms  will  be  considered 
together. 

Prognosis. — The  prognosis  of  cirrhosis  of  the  liver  is  unfavorable  if 
restoration  of  the  normal  organ  be  the  object.  A  liver  once  the  seat  of  inter- 
stitial hepatitis  can  probably  never  resume  its  normal  histology.  Yet  the 
liver  has  a  good  deal  of  elasticity  of  function,  and  if  the  cause  of  the  condi- 
tion, supposing  it  to  be  alcoholism,  is  removed  and  the  contraction  be  not 
too  far  advanced,  the  patient  may  be  restored  to  comparative  health. 
Generally,  however,  the  course  of  cirrhosis  is  from  bad  to  worse,  although 
it  may  be  a  slow  course,  and  the  patient  finally  dies  of  exhaustion  and 
cholesteremia. 

It  only  rarely  happens  that  death  is  caused  by  the  copious  hemorrhages 
from  the  esophagus  which  sometimes  occur.  We  have  already  referred  to 
two  cases  in  our  practice.  On  the  other  hand,  they  frequently  relieve  the 
portal  congestion,  thus  giving  to  the  patient  a  new  lease  of  life.  The 
patient  may  live  many  years  in  comparative  comfort. 

Treatment. — The  treatment  of  cirrhosis  of  the  liver  resolves  itself  into 
two  parts — first,  prophylaxis;  second,  the  relief  of  the  symptoms,  and,  third, 
the  restoration  of  the  organ  to  its  normal  state. 

Prophylaxis. — Overindulgence  in  alcohol,  syphilis,  and  overeating  are 
fertile  sources  of  cirrhosis  of  the  portal  type.     They  should  be  avoided. 

Toward  the  relief  of  symptoms  the  removal  of  the  cause  is  indispensable. 
The  alcoholic  must  stop  drinking.  This,  after  some  temporary  inconveni- 
ence, of  itself  brings  alleviation.  But  the  effect  of  gastric  congestion  remains 
in  part,  and  sufficiently  to  cause  want  of  appetite,  nausea,  unpleasant  taste 
in  the  mouth,  and  a  general  disgust  of  one's  self  and  everyone  else.  The 
mucous  membrane  of  the  stomach  is  swollen,  and  probably  bathed  with 
mucus.  The  latter  can  be  removed  by  free  drinking  of  alkaline  mineral 
waters  before  meals,  such  as  those  of  Vichy,  Vals,  and  Carlsbad,  the  effect 
of  all  of  which  is  increased  when  hot.  Here,  too,  as  in  gastric  catarrh — it  is 
really  gastric  catarrh  we  are  treating — the  hot-water  treatment  is  often 
highly  useful  by  ridding  the  stomach  of  mucus.  A  tumblerful,  as  hot  as  it 
can  be  borne,  is  taken  slowly  before  breakfast,  or  before  each  meal.  Its 
effect  is  often  highly  beneficial.  We  know  no  additional  explanation  of  its 
action  unless  it  be  that  it  may  likewise  stimulate  the  secretion  of  gastric 
juice.     Lavage  also  relieves  this  condition  and  its  consequent  symptoms. 

The  congestion  which  is  responsible  for  this  secretion  must  be  removed. 


462  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

This  is  best  done  by  the  saline  and  mercurial  purgatives.  Five  to  lo  grains 
of  blue  mass  at  bedtime,  followed  by  a  dose  of  sulphate  of  magnesium  in  the 
morning  or  of  Hunyadi  or  Fricdrichshalle  water,  will  deplete  the  engorged 
veins  and  relieve  the  symptoms  for  the  time  being.  The  mineral  waters  of 
Saratoga,  in  this  country,  some  of  which  are  also  purgative,  are  very  useful 
for  the  same  purpose.  A  course  at  Saratoga  is  greatly  appreciated  by  the 
confirmed  free  drinker,  and  he  is  alwaj's  better  for  some  time  after  it.  The 
hot  saline  and  sulphur  waters  at  Greenwood,  Colo.,  are  similar  in  their 
effects. 

Finally,  foods  which  make  the  least  demand  upon  the  stomach  are  to 
be  used.  Fatty  matters  are  especially  contraindicated.  In  advanced 
stages  milk  and  Vichy,  peptonized  milk,  and  buttermilk  may  be  assimi- 
lated when  other  foods  cannot  be  managed  by  the  feeble  digestion,  but  even 
these  are  absorbed  with  difficulty  as  long  as  the  mucous  membrane  of  the 
bowels  is  much  congested. 

The  abdominal  effusion  is  combated  by  the  purgatives  alluded  to,  and 
diuretics  may  be  added;  of  these  the  acetate  of  potassium  seems  more  ef- 
ficient than  the  bicarbonates  and  citrates  where  dropsy  is  due  to  hepatic 
derangements.  Perhaps  this  is  because  in  large  doses  it  has  also  some 
laxative  effect.  Theobromin  is  often  an  efficient  diuretic  in  these  cases, 
especially  when  the  heart  is  in  good  condition.  When  the  abdominal  ef- 
fusion becomes  large,  it  must  be  removed  by  tapping,  although  the 
reaccumulation  may  be  very  rapid  and  it  may  have  to  be  repeated 
many  times.  Recently  operation  has  been  suggested  for  permanent  cure 
of  abdominal  efiusion  due  to  this  cause.  It  consists,  in  a  word,  in  the 
production  of  vascular  adhesions  between  the  parietal  peritoneum  of  the 
abdominal  walls  and  the  omentum,  providing  a  short  cut  for  part  of  the 
blood  which  must  otherwise  pass  through  the  liver,  the  so-called  Talma 
operation  to  be  of  value  it  must  be  done  early. 

Nothing  can  be  done  to  remove  the  growth  of  the  connective  tissue. 

General  tonic  treatment  must  be  instituted.  Stychnine  and  iron  are 
the  drugs  to  use. 

SUPPURATIVE  HEPATITIS. 

Synonym. — Abscess  of  the  Liver. 

Etiology. — Abscess  of  the  liver  is  traceable  to  causes  which,  in  one  wa>- 
or  another,  are  associated  with  microbic  origin.  Even  traimiatic  abscess, 
which  it  is  admitted  may  occur,  is  ascribed  to  an  associated  infectious 
agent,  although  the  possibility  of  abscess  excited  by  simple  chemical,  as 
contrasted  -Rath  bacterial  cause  should  at  least  be  mentioned.  Abscess  of 
the  Uver  may  be  solitarj^  or  multiple.  The  solitary  or  tropical  abscess  is 
due  to  a  preexisting  amoebic  dysenter}-.  Amoebae  coli  have  been  found  in 
the  pus  of  the  abscess  and  in  the  abscess  walls. 

The  multiple  or  pyemic  or  thrombotic  abscesses  are  caused  bj'  infectious 
thrombus,  which,  starting  in  the  venule?  of  an  area  drained  by  the  portal 
vein,  extends  thence  to  the  branches  of  the  portal  vein  in  the  Uver,  where 
it  gives  rise  to  a  suppurative  pylephlebitis.  This  area  may  be  the  colon, 
rectum,  the  neck  of  the  bladder  or  the  appendiceal  region. 


ABSCESS  OF  THE  LIVER  463 

Abscesses  of  the  liver  may  also  be  caused  by  infectious  emboli  arising  in 
the  left  heart,  the  pulmonic  or  systemic  circulation,  reaching  the  liver  via  the 
hepatic  artery.  Even  a  noninfectious  embolus  may  excite  an  abscess  if 
brought  into  association  with  pyogenic  organisms  entering  the  hver  in 
another  way.  Such  organisms  may  enter  the  liver  through  the  common 
duct  from  the  alimentary  canal.  This  is  probably  the  route  of  the  organism 
causing  suppurative  cholangitis,  and  of  that  causing  the  abscess  often 
associated  with  hydatid  cyst  of  the  liver.. 

Morbid  Anatomy.  Multiple  Abscess.^ — The  right  lobe  of  the  liver  in  its 
thickest  part  is  the  most  frequent  seat  of  abscess — in  two-thirds  of  all  cases. 
In  the  multiple,  the  abscess  varies  in  size  from  that  of  a  mere  point  to  that 
of  a  child's  head,  the  whole  right  lobe  being  sometimes  converted  into  one 
abscess  cavity.  It  may  be  single  or  multiple.  Rarely,  the  abscesses  inter- 
communicate. The  liver  is,  of  course,  correspondingly  enlarged.  Not- 
withstanding this,  the  external  appearance  of  the  organ  maj^  not  be 
changed.  On  the  other  hand,  if  the  abscess  is  near  the  surface,  there 
may  be  a  prominence  under  which  fluctuation  may  be  recognized,  or  the 
liver  may  become  adherent  to  the  abdominal  wall  or  adjacent  viscera. 
The  abscess  cavity,  if  of  any  size,  is  usually  ragged,  and  not  sharply  defined 
from  the  surrounding  hyperemic  liver  tissue.  Such  hyperemia  may  in- 
volve two  or  three  rows  of  acini. 

The  contents  of  the  abscess  may  be  pus,  or  a  purifonn  fluid  consisting 
of  the  granular  debris  of  cells,  oil  drops,  a  few  leukocytes,  cholesterin  and 
other  fat  crystals,  and  niunerous  crystals  of  bilirubin.  Should  the  abscess 
accompany  hydatid  disease,  echinococcus  booklets  may  be  found.  The 
contents  of  such  abscesses  is  generally  a  true  pus.  Any  form  of  abscess 
may  perforate  the  diaphragm  and  lung,  producing  abscess  or  empj^ema; 
or  the  pus  with  echinococcus  booklets  may  be  expectorated;  or  the  abscess 
may  burrow  into  the  peritoneiom,  setting  up  fatal  peritonitis,  or  into  the 
pericardium,  causing  fatal  pericarditis;  into  any  adjacent  hollow  organs  or 
into  the  abdominal  wall,  discharging  externally  by  fistulous  openings. 

The  thrombotic  and  embolic  forms  of  abscess  alwaj^s  begin  as  a  phlebitis, 
which  rapidly  invades  the  adjacent  tissue.  Contrary  to  what  is  usual  in 
embolism  elsewhere,  the  lodgment  of  an  embolus  in  the  liver  is  not  followed 
by  hemorrhagic  infarct. 

Symptoms.  Multiple  or  Pyemic  Abscess. — Abscess  of  the  liver  is  gen- 
erally associated  with  pain  in  the  hepatic  region,  with  fever,  very  often  with 
chills,  sweats,  and  sometimes  with  jaundice.  The  pain  is  almost  invariably 
accompanied  with  tenderness.  It  may  be  deep  or  superficial,  and  in  the 
latter  event  it  may  be  sharp  and  cutting,  because  involving  the  peritoneum. 
The  characteristic  shoulder  pain  of  hepatic  disease  may  also  be  present. 

Fever  is,  perhaps,  the  most  invariable  symptom,  and  in  no  other  affec- 
tion of  the  liver  does  it  rise  so  high.  Indeed,  except  acute  yellow  atrophy 
and  the  so-called  hepatic  fever,  there  are  no  other  diseases  of  the  liver  as- 
sociated with  fever.  In  the  former  it  is  of  comparatively  short  duration, 
and  in  the  latter  it  is  moderate.  The  temperature  reached  in  abscess  is 
very  high — 104°  to  105°  F.  (40°  to  40.5°  C.) — and  may  be  preceded  by  chills 
of  corresponding  severity,  while  the  fever,  in  turn,  is  succeeded  by  sweats, 
profuse  and  exhausting.     Jaundice  is  present,  but  varies  in  degree. 


464  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Solitary  Abscess. — The  case  is  one  of  pyemic  symptoms  with  jaundice, 
solitary,  or  amoebic  abscess.  Fever,  pain  and  septic  symptoms  are  the 
symptoms  found  in  this  form  also.  There  is  often  cough,  sometimes 
accompanied  by  expectoration  of  pus  due  to  rupture  of  the  abscess  into  the 
bronchus.  Amoebae  coli  may  be  found  in  the  expectoration.  The  liver 
is  enlarged  upward  mostly  in  the  right  lobe.  The  enlargement  is  sharply 
upward  in  the  nipple  line.     The  face  is  sallow,  pale  and  possibly  jaundiced. 

Diagnosis. — This  may  be  difficult  at  first,  but  as  time  passes  doubts 
clear  up.  Intermittent  fever  very  naturally  is  first  thought  of  in  many  in- 
stances, but  it  will  not  be  long  before  this  disease  can  be  eliminated.  There 
is  no  enlargement  of  the  spleen,  no  history  of  malarial  exposure,  no  malarial 
organism  is  found  in  the  blood,  and,  above  all,  antiperiodic  therapeutics, 
so  efficient  in  malarial  disease,  fails  of  its  purpose.  In  the  absence  of  ma- 
laria and  in  the  presence  of  the  causes  usually  responsible  for  abscess  of  the 
liver  there  is  little  else  left  to  mistake  for  it.  A  pleuritic  effusion  on  the 
right  side  gives  dullness  on  percussion  in  the  same  locality,  but  along  with 
this  are  the  diminished  fremitus  and  diminished  vocal  resonance  character- 
istic of  fluid  in  the  pleural  sac,  while  there  may  also  be  the  bronchial  breath- 
ing brought  on  by  compressed  lung.  A  suppurating  echinococcus  cyst  may 
give  rise  to  similar  symptoms,  but  in  view  of  its  rarity  in  this  country,  is 
scarcely  likely  to  be  recognized  until  aspiration  discovers  the  elements  char- 
acteristic of  it.  The  needle  should  be  tried  early  if  abscess  be  suspected, 
vet  it  is  evident  that  in  so  large  an  organ  an  abscess  of  moderate  size  may 
easily  elude  it. 

Hepatic  intermittent  fever,  due  to  chronically  impacted  calculus,  re- 
sembles abscess  by  its  fever,  chiUs,  and  sweats,  and  by  tenderness  over  the 
liver,  but  the  history  of  hepatic  colic  is  present,  jaundice  is  more  marked' 
and  obstinate. 

Prognosis  is  fairly  good  when  the  abscess  is  of  the  solitary  type  due 
to  amoeba  coli.  Here  operation  is  of  value.  In  the  multiple  abscess  prog- 
nosis is  fatal. 

Treatment. — This  is  palliative  and  supporting,  except  in  those  cases 
where  surgical  interference  is  possible.  The  usual  measures  to  relieve  pain, 
nourishing  and  easily  assimilable  food,  quinin,  iron,  and  stimulants  are 
indicated.     Surgical  interference  in  the  suppurative  type  will  save  many. 

PERIHEPATITIS. 

Definition. — An  inflammation  of  the  peritoneal  covering  of  the  liver. 

Etiology. — Perihepatitis  occurs  in  a  circumscribed  area — (i)  as  the 
result  of  extension  by  continuity  from  some  one  of  the  various  diseases  of 
the  liver,  such  as  abscess  or  hydatid  cyst;  (2)  as  a  part  of  a  general  peri- 
tonitis, and  (3)  rarely  by  the  spread  of  a  pleurisy  through  the  diaphragm; 
(4)  it  may  be  also  caused  by  direct  violence,  as  by  a  blow;  (5)  it  may  be  the 
result  of  a  perforating  ulcer  of  the  stomach,  duodenum  or  gall-bladder. 
^  Morbid  Anatomy. — In  the  more  acute  forms  there  is  a  fibrinous  or 
purifonn  product  wdth  more  or  less  adhesion.  These  adhesions  may  lace 
ofE  areas  between  the  liver  and  the  diaphragm  which  may  be  filled  with  pus, 
sometimes  large  quantities,  constituting  subphrenic  abscess,  or  if  there  be 


PERIHEPATITIS  465 

perforation  of  the  diaphragm,  subphrenic  pyopneumothorax,  more  common 
over  the  right  lobe.  In  the  more  chronic  form  the  capsule  of  the  liver  is 
thickened,  especially  near  the  portal  fissure,  and  adhesions  may  take  place 
with  adjacent  organs,  as  the  diaphragm,  stomach,  colon,  or  abdominal  wall. 
The  organ  may  be  shrunken  and  lobidated,  and  the  portal  or  hepatic  vein 
and  bile-ducts  may  be  stenosed.  The  capsule  of  the  liver  is  often  found 
thickened  at  autopsies  when  no  symptoms  were  present  during  life  to 
indicate  it. 

Symptoms. — The  pain  and  tenderness  which,  naturally,  are  attached  to 
this  condition,  while  often  exceedingly  severe,  like  those  of  peritonitis  from 
other  cause,  are  not  distinctive  of  it.  Nor  is  the  jaundice  resulting  from 
compression  of  the  bile-ducts;  nor  the  symptoms  of  portal  engorgement  due 
to  compression  of  the  portal  vein  by  the  inflammatory  products.  Physical 
examination  sometimes  gives  more  definite  results.  Thus,  a  friction  rub 
may  sometimes  be  heard  in  the  mammillary  line  from  the  seventh  rib  down- 
ward, and  in  the  axillary  line  from  the  ninth  rib  downward;  also  sometimes 
in  the  epigastrium.  It  is,  however,  of  short  duration.  If  there  is  a  purulent 
collection,  fever  is  likely  to  be  present,  while  the  right  hypochondrium  may 
be  distended  and  the  intercostal  spaces  motionless.  The  dullness  on  percus- 
sion may  extend  as  high  as  the  angle  of  the  scapula,  and  all  the  signs  of  a 
pleuritic  effusion  may  be  present.  On  the  other  hand,  the  lower  border  of 
the  liver  may  be  much  lowered — as  far  down  as  the  navel. 

The  course  of  perihepatitis  may  be  acute,  or  it  may  be  much  prolonged, 
when  all  the  symptoms  of  chronic  suppurative  processes  are  added — fever, 
high  temperature,  sweats,  fistulous  communications  with  other  organs,  in- 
cluding the  lungs,  intestines,  and  abdominal  wall. 

Diagnosis. — This  lies  chiefly  between  that  form  of  the  condition  under 
consideration,  attended  with  pus  accumulation  between  the  liver  and  dia- 
phragm, and  an  empyema  or  pneumothorax.  The  physical  signs  and  later 
symptoms  are  very  similar,  and  it  is  chiefly  in  the  initial  symptoms  that 
the  two  conditions  differ,  the  one  beginning  with  cough  and  pleuritic  pain 
associated  with  cardiac  displacement;  the  other  with  sjTiiptoms  more  ab- 
dominal in  situation.  The  liver  in  pleuritic  effusion  and  empyema  is  never 
so  much  pushed  down  as  in  the  peri  hepatic  disease.  Aspiration  may  also 
be  availed  of  in  diagnosis,  but  will  not  differentate  it  for  a  pleural  collec- 
tion.    X-ray  examination  will  often  make  a  diagnosis  possible. 

Prognosis. — This  is  grave  in  the  severer  forms  terminating  in  suppura- 
tion. A  protracted  illness,  with  gradual  exhaustion  of  the  patient's  strength, 
is  prone  to  occur,  which  skillful  surgical  measures  may  nevertheless  turn  to 
recovery.     Milder  attacks  terminate  favorably  in  a  few  days. 

Treatment. — Treatment  in  the  early  stage  must  consist  of  measures 
to  relieve  pain,  local  and  general.  Counterirritation  by  cupping  operates 
to  check  the  disease  and  also  shorten  the  attack.  Sinapisms  and  fomenta- 
tions contribute  in  a  less  degree  to  the  same  end.  If  suppuration  occur, 
the  counsel  and  aid  of  a  surgeon  should  be  early  sought,  as  it  is  by  his 
efforts  that  a  cure  becomes  possible. 

Glissonian  Cirrhosis. — This  is  a  term  applied  to  a  form  of  peri- 
hepatitis in  which  the  capsule  is  thickened,  assuming  a  semicartilaginous 


466  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

a]Dpearance.  It  is  associated  with  reduction  in  size  and  some  degree  of 
interstitial  overgrowth  and  distortion.  The  capsule  may  attain  a  thickness 
of  from  4/10  to  6/10  of  an  inch  (i  to  1.5  cm.)- 


ACUTE  YELLOW  ATROPHY  OF  THE  LIVER. 

Synonyms. — Icterus   gravis;   Acute   Parenchymatous   Hepatitis;   Malignant 

Jaundice. 

Definition. — A  rapidly  destructive  disease  of  the  liver,  resulting  in  fatty 
degeneration  and  atrophy  of  the  organ,  associated  with  toxic  s^^mptoms  and 
death. 

Etiology. — This  remarkable  and  fortunateh'  rare  disease  is  probably 
due  to  the  action  of  some  vinilent  poison,  autogenetic  perhaps,  but  the 
nature  of  which  is  as  yet  undiscovered.  Pregnancy  is  one  of  the  conditions 
acknowledged  to  produce  it,  and  more  cases  occur  among  women  than  men. 
It  occurs  in  the  sesond  half  of  pregnancy.  It  has  occurred  in  the  course  of 
the  infectious  diseases,  and  the  usual  microbic  origin  has  been  held  respons- 
ible for  it,  as  have  been  alcoholism  and  mental  excitement.  It  is  also  found 
in  phosphorus-poisoning  and  also  in  chloroform  poisoning.  Bacteria  have 
been  found  in  the  organ  after  death.  Autodigestive  processes  have  been 
suggested.     Beyond  this  we  know  nothing  of  its  cause. 

Pathology  and  Morbid  Anatomy. — The  destructive  process  in  the  liver 
is  almost  identical  with  that  of  phosphorus-poisoning,  and  consists  essen- 
tially in  a  very  rapid  destruction  of  the  liver  cells.  Opinions  are  divided  as 
to  whether  this  is  the  result  of  an  acute  irrflammatory  process,  or  whether 
the  cells  are  destroyed  by  some  solvent  or  digestive  action. 

The  liver  at  necropsy  is  found  very  much  reduced  in  size,  often  to  half 
and  even  quarter  its  normal  volimie.  This  may  take  place  in  three  or  four 
days,  and  even  less.  A  stage  of  primary  enlargement  is  said  to  be  sometimes 
present,  but  is  never  seen  at  autopsy.  The  organ  is  flattened,  flabby,  and 
can  be  folded  over  on  itself,  and  the  usual  lobular  markings  are  either  very 
indistinct  or  altogether  absent.  The  capsule  is  loose  and  wrinkled,  and  the 
organ  is  of  a  dirty  yellow  color. 

On  section,  the  surface  is  either  uniformly  yellow  or  it  exhibits  an 
alternation  of  yellow  and  red.  The  yellow  appears,  for  the  most  part,  in 
islets,  which  are  surrounded  by  the  red.  The  yellow  represents  an  earlier 
stage  of  the  disease.  It  is  soft  and  spongy,  and  rises  cushion-like  above  the 
surface.  The  red  is  tougher,  more  leathery,  and  sinks  below  the  level  of  the 
cut  surface.  When  the  organ  is  uniformly  yellow,  this  later  stage,  repre- 
sented by  the  red,  has  not  been  reached  before  death. 

Histologically,  the  yellow  areas  exhibit  softening  and  apparent  solution 
of  the  cell  network,  very  few  liver  cells  remaining  which  retain  their  own  con- 
tour. Instead  are  found  disintegrating  ceUs  with  fat  drops  of  all  sizes,  the 
cells  being  in  places  still  united  by  their  connecting  substance  so  as  to  main- 
tain the  original  network.  Sometimes  crystals  of  bilirubin,  leucin,  and 
t>-rosin  are  met  with.  The  red  areas  consist  of  a  network  of  capillaries 
whose  meshes  contain  fat  drops  and  biliary  coloring-matter,  representing  the 
softened  liver  parenchyma  bereft  of  its  cells.     In  places  there  may  be  seen  a 


YELLOW  ATROPHY  OF  THE  LIVER  467 

slight  degree  of  cell  infiltration  of  the  interstitial  tissue,  in  others  irregular 
branching  bands  and  apparently  blind-ending  tubes  of  cells  resembling 
bUiary  epithelitun.  The  atrophy  usually  takes  place  more  rapidly  in  the 
left  lobe. 

The  skin  and  organs  are  generally  intensely  bile-stained.  There  may 
be  small  extravasations  of  blood  in  various  parts.  The  spleen  is  enlarged 
and  hyperplastic,  the  renal  epithelium  and  heart  muscles  are  fatty,  while 
the  serous  cavities  contain  more  than  the  normal  amount  of  fluid. 

Symptoms. — There  are  no  symptoms  distinctive  of  the  beginning  of 
acute  yellow  atrophy.  For  several  days  there  may  be  signs  of  gastro-intes- 
tinal  catarrh,  promptly  followed  by  jaundice.  The  former  include  headache, 
malaise,  loss  of  appetite,  nausea,  vomiting,  eructations,  and  epigastric  discom- 
fort. Then  there  suddenly  supervene  serious  symptoms — delirium,  abdom- 
inal pain,  convulsions,  local  or  general  drowsiness,  and  coma.  Sometimes  the 
symptoms  of  this  stage  are  delayed — in  extreme  cases  as  long  as  three  weeks. 

The  liver  rapidly  diminishes  in  size.  Three  or  four  days  may  see  its 
disappearance  to  percussion  and  palpation,  favored  by  further  obscuration 
by  distended  air-holding  viscera.  W.  von  Leube  calls  attention  to  a  symp- 
tom elicited  by  palpation  which  he  thinks  may  be  of  diagnostic  value — a 
more  or  less  permanent  "pitting"  to  pressure  in  the  epigastric  region.  He 
ascribes  this  to  an  impression  made  upon  the  relaxed  liver,  to  which  the 
abdominal  wall  fits  itself.  The  spleen,  on  the  other  hand,  is  enlarged,  the 
jaundice  is  intense,  the  vomiting  obstinate,  while  there  may  be  epistaxis, 
hematemesis,  hematuria,  menorrhagia,  and  hemorrhagic  extravasations, 
while  the  stools  are  devoid  of  bUe.  The  pregnant  woman  aborts.  There 
is  little  fever,  and  in  the  worst  stage  there  is  but  moderate  rise  of  tempera- 
ture— rarely  above  ioi°  F.  (38.2°  C).  The  pulse,  a  first  infrequent,  in- 
creases toward  the  end  to  120  or  more. 

The  changes  in  the  urine  are  very  characteristic  and  have  been  thor- 
oughly studied.  It  is  deeply  bile-stained,  is  concentrated,  the  specific 
gravity  often  reaching  1030.  It  is  slightly  albiuninous,  and  may  contain 
the  bUe  acids,  bile-stained  fatty  casts,  and  bUe-stained  renal  epithelium. 
The  quantity  of  urea  is  diminished,  even  totally  absent.  The  characteristic 
feature  is  the  presence  of  leucin  spheres  and  tyrosin  needles  in  most  cases. 
These  crystals  may  appear  without  treatment  of  the  urine  or  they  may  come 
down  after  slight  concentration.  In  addition  are  found  also  aromatic 
oxyacids,  especially  oxymandelic  acid,  all  representing  products  of  albumin 
disintegration. 

Diagnosis. — The  symptoms  of  acute  yellow  atrophy  in  the  first  stage 
do  not  admit  of  a  diagnosis.  This  is  the  more  true  because  there  is  no 
symptom,  even  atrophy,  which  may  not  be  wanting.  Thus,  cases  have 
perished  from  hemorrhage  before  the  disease  was  recognized  or  before 
jaundice  appeared  in  the  rapidly  terminating  cases.  In  the  second  stage, 
on  the  other  hand,  the  symptoms  are  so  distinctive  that  it  seems  almost 
impossible  for  one  familiar  with  them  to  fail  to  recognize  them.  It  is, 
however,  so  rare  a  disease  in  this  country  that  the  opportunity  does  not 
often  present  itself;  hence  it  is  sometimes  overlooked  because  not  sus- 
pected, the  more  excusably  because  grave  nervous  symptoms  may  occur 
even  in  catarrhal  jaundice  and  in  the  infectious  diseases — as,  for  example, 


468  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

in  pneumonia,  where  jaundice  is  sometimes  a  symptom.  A  case  of  pneu- 
mococcicaemia  with  rapid  hemolysis  came  under  our  care  with  all  the 
symptoms  of  acute  yellow  atrophy  of  the  liver.  Acute  phosphorus- 
poisoning  so  closely  resembles  acute  yellow  atrophy  that  the  diagnosis 
depends  largely  upon  the  possible  recognition  of  the  cause.  There  are, 
however,  some  differences.  The  reduction  in  size  of  the  liver  is  not  so 
rapid,  the  nervous  symptoms  are  not  so  grave,  and  leucin  and  tyrosin  are 
not  usually  found  in  the  urine  of  phosphorus-poisoning.  Hypertrophic 
cirrhosis  also  sometimes  resembles  acute  yellow  atrophj'  clinically,  but 
the  enlarged  liver  is  the  distinctive  feature  of  the  former. 

Prognosis. — This  is  so  unfavorable  that  recovery'  may  be  said  to  imply 
an  error  of  diagnosis. 

Treatment. — There  is  no  ciirative  treatment.  Symptoms  should  be 
relieved  by  the  usual  palliatives.  Headache  should  be  relieved  b}-  phenace- 
tin  and  acetanilid,  rather  than  morphin.  An  ice-bag  may  give  great 
relief. 

MORBID  GROWTHS  OF  THE  LIVER. 

The  only  morbid  growths  of  the  liver  which  are  of  clinical  importance 
are  cancer  and  sarcoma.  An  angioma  is  an  interesting  new  formation  of 
small  size,  which  presents  no  recognizable  symptoms  before  death.  It  is 
composed  of  vascular  tissue  and  is  distinctly  capsulated.  The  large  sizes 
may  be  as  big  as  a  walnut,  more  rarely  still  larger.  Some  pathologists 
describe  an  adenoma,  which  others  class  among  the  cancers  as  a  trabecular 
variety.  Myoma  is  another  form  of  histioid  timaor  rarely  found  in  the  liver. 
Cysts,  represented  by  the  dilatation  cj'st  and  the  hydatid  cyst,  are  of  occa- 
sional occurrence. 

Carcinoma  of  the  Liver. 

Etiology. — Cancer  of  the  liver  is  a  comparatively  common  disease; 
it  is  next  in  frequency  to  that  of  the  uterus  and  stomach.  It  is,  more- 
over, in  the  vast  majority  of  cases  secondarj^ — in  full  three-fourths  of  cases, 
and  of  these  two-thirds  are  secondary  to  primary  cancer  of  the  portal 
area,  one-third  to  primary  cancer  elsewhere.  The  stomach  is,  the  most 
frequent  primary  focus.  Cancer  of  the  liver  is  most  common  in  male 
adults  between  the  40th  and  60th  year. 

Morbid  Anatomy.-.— There  are  two  chief  forms  in  which  cancer  of  the 
liver  presents  itself — the  nodular  and  the  massive.  Rare  forms  are  radiating, 
colloid,  and  cancer  with  cirrhosis. 

I .  In  the  nodtdar  form  nodules  of  various  sizes  are  scattered  throughout 
the  organ.  The  nodules  vary  in  diameter  from  one-fifth  of  an  inch  to 
two  inches  (0.5  cm.  to  s  cm.)  or  more.  They  are  usuall3'  opaque,  white, 
or  yellowish-white,  and  may  be  very  numerous.  The  superficial  nodules  pro- 
ject above  the  surface,  and  may  even  be  felt  through  the  abdominal  wall  in 
the  emaciated  subject,  giving  rise  to  the  oft-described  "bosselated"  feel. 
These  superficial  nodules  are  often  umbilicated,  because  of  the  disintegration 
and  absorption  of  the  older  central  cells,  leaving  a  residue  of  connective 


CARCINOMA  OF  LIVER  469 

tissue  and  partially  obliterated  blood-vessels.  The  umbilication  is  confined 
to  the  superficial  nodules,  which  also  received  the  name  of  Farre's  tubercles. 
This  variety  of  nodiilar  cancer  may  be  both  primary  and  secondar}^  The 
nodules  usually  reach  a  large  size  in  the  secondary,  and  are  apt  to  be  more 
numerous. 

2 .  The  massive  form,  in  which  there  is  one  large  cancerous  mass,  greatly 
increasing  the  bulk  of  the  organ.  It  is  grayish-white  in  color,  and  may 
reach  four  or  six  inches  (lo  or  15  cm.)  in  diameter.     This  form  is  primary. 

3.  The  radiating  form,  usually  pigmented,  in  which  the  nodules  may 
also  be  multiple,  but  smaller  and  less  niunerous  than  in  the  nodular  form. 
It  is  a  form  of  secondary  cancer. 

4.  A  colloid  form,  rare  and  only  secondary. 

S-  A  rare  form  is  cancer  with  cirrhosis,  in  which  the  liver  is  but  slightly 
enlarged,  weighing  4.5  to  6.5  pounds  {circa  2  or  3  kilograms),  and  presents  a 
greenish  yellow  appearance,  studded  over  with  small  white  nodides  not  un- 
like those  of  the  hob-nail  liver,  the  same  appearing  in  large  numbers  when 
the  organ  is  cut. 

All  varieties  of  cancer  are  subject  to  degeneration,  but  the  secondary 
.  forms  degenerate  more  rapidly.     The  change  is  a  fatty  metamorphosis  of  the 
cells,  associated  sometimes  with  rupture  of  blood-vessels  and  large  extravasa- 
tions of  blood,  which  may  even  burst  into  the  peritoneum  and  gaU  bladder. 
There  may  be  occasional  suppuration  around  the  nodule. 

As  to  the  histological  origin  of  cancer,  the  primary  forms  start  in  the 
liver  cells;  they  are  true  epitheliomata,  the  capillary  network  forming  the 
primary  stroma,  to  which  an  independent  growth  of  stroma  is  subsequently 
added.  The  secondary  forms  are  embolic  in  origin,  chiefly  through  the 
branches  of  the  portal  vein,  but  possibly  hy  the  hepatic  artery,  with  or 
without  intermediate  involvement  of  the  lung,  the  first  new  cancer  cell  in 
this  form  being  an  infected  cell  of  the  capillary  wall,  whence  the  parenchymal 
liver  cells  are  in  turn  affected.  The  stamp  of  the  pigmented  radiating  cancer 
is,  perhaps,  thus  derived,  and  illustrates  this  mode  of  invasion.  The  second- 
ary forms  repeat  the  type  of  the  primary  varieties.  The  cells  are  mainly 
epithelioid,  but  may  be  polygonal  and  even  cylindrical.  They  exhibit 
various  grades  of  fatty  degeneration. 

The  liver  is  variously  enlarged  by  these  different  forms  of  cancer,  the 
maximum  product  being  the  largest  produced  by  any  disease  of  the  liver 
(see  Fig.  103). 

Sarcoma. — Of  the  remaining  morbid  growths  of  the  liver,  sarcoma  alone 
demands  a  few  words.  It  is  almost  invariably  secondary,  very  few  cases 
of  primary  sarcoma  of  the  liver  having  ever  been  found.  Secondary 
sarcoma  of  the  liver  includes  melanosarcoma,  lymphosarcoma,  and  myxo- 
sarcoma. The  melanosarcoma  is  the  most  frequent  and  interesting.  It  is  ■ 
always  secondary  and  usually  multiple,  though  a  diffusely  infiltrated  variety 
exists,  giving  the  liver  on  section  a  granitic  appearance.  Melanotic  sarcoma 
of  the  orbit  often  precedes  it,  and  it  is  sometimes  a  part  of  a  general  melan- 
otic distribution  over  the  body,  including  the  skin.  Sarcoma  of  the  liver  is 
said  to  be  never  associated  with  ascites. 

Symptoms. — Very  rarely  cancer  of  the  liver  may  be  latent,  except  as  to 
a  vague  ill  health  explained  by  the  findings  of  the  autopsy.     In  most  in- 


470 


DISEASE.S  OF  THE  DIGESTIVE  SYSTEM 


stances  such  ill  health  grows  worse  more  or  less  rapidly,  and  examination  of 
the  liver  shows  enlargement,  to  which  may  or  may  not  be  added  recog- 
nizable nodules.  The  enlargement  may  extend  beyond  the  umbilicus, 
but  it  is  not  usually  so  great,  and  in  some  cases  there  is  none  whatever. 
To  inspection  the  enlargement  is  first  seen  in  the  upper  zone  of  the  abdo- 
men, and  produces  a  change  of  configuration  which  involves  commonly 
the  whole  upper  abdomen.  Rarely,  the  nodules  may  be  seen.  The 
superficial  veins  are  enlarged. 


Fig.  103. — Showing  Appropriate  Enlargement  of  the  Liver  Corresponding  to  the  Dififerent 
Diseases  Described  in  the  Text — {afler  Rindfleisch). 
I.  Position  of  the  diaphragm  to  the  maximum  enlargement  (carcinoma  and  in  abscess). 
//.  //.  Normal  situation  of  the  diaphragm.  II,  III.  Relative  dullness.  IV.  Border 
of  the  Uver  in  cirrhosis.  V.  Border  in  health.  \  I.  Lower  border  of  the  fatty  hver.  VII. 
Of  the  amvloid  Hver.     VIII.  Of  cancer,  leukemia,  and  adenoma. 


•  The  Other  signs  of  ill  health  alluded  to,  apart  from  those  of  a  primary 
cancer  elsewhere,  are  loss  0}  appetite,  nausea,  a  sense  0}  epigastric  fullness, 
pain  in  the  epigastric  or  hypochondriac  region  or  in  both  simultaneously. 
The  pain  may  be  lancinating  and  extend  to  the  right  shoulder.  To  this 
tenderness  is  sooner  or  later  added.  Indeed,  perhaps  tenderness  precedes. 
Emaciation  may  have  preceded  the  more  striking  degree  of  these  symptoms 
and  increase  rapidly,  wliile  the  characteristic  cachexia  develops  pari  passu. 
An  examination  of  the  blood  shows  a  reduction  of  hemoglobin  and  corpuscles, 
and  as  the  blood  degenerates,  edema  develops.  In  some  cases  there  is 
fever,  especially  toward  the  end,  ^vith  a  temperature  of  100°  to  102°  F. 


CARCINOMA  OF  LIVER  471 

(37.8°  to  38.9°  C),  more  or  less  intermittent,  but  rarely  associated  with 
rigors. 

Obstructive  jaundice  is  a  frequent  symptom  in  carcinoma  hepatis — it 
may  be  said  in  fully  half  the  cases.  It  is  due  to  compression  of  the  smaller 
billiary  passages,  and  does  not  usually  reach  a  high  degree.  Nor  are  the 
feces  usually  devoid  of  bile.  If  the  latter  event  occurs,  and  the  jaundice 
is  intense,  it  means  that  some  of  the  larger  ducts  are  obstructed,  while  in- 
volvement of  the  gall-bladder  or  the  portal  lymphatics  ma}'  be  suspected. 
Jaundiced  urine  is  about  as  constant  as  jaundice  itself.  The  presence  of 
melanin  is  said  to  point  especially  to  the  presence  of  the  pigmented  varieties 
of  cancer.     Albuminuria  is,  on  the  other  hand,  unusual. 

Ascites  is  a  rather  infrequent  symptom,  and  can  only  occur  when  the 
portal  vein  or  branches  become  involved  either  by  compression  or  invasion. 
This  is  common  in  carcinoma  with  cirrhosis.  Should,  however,  a  bloody 
fluid  be  obtained  by  tapping,  and  a  tumor  of  the  liver  be  present,  the  in- 
dications are  that  the  trunor  is  cancer.  Enlargement  of  the  spleen  is  rarely 
present  in  cancer  of  the  liver. 

The  duration  of  the  disease  ranges  from  three  to  15  months. 

Diagnosis. — This  is  not  always  easy,  even  if  there  is  enlargement.  It 
is  simplified  if  the  nodules  can  be  felt,  or  if  there  is  recognized  primary 
cancer  elsewhere. 

The  smooth,  enlarged  liver  of  cancer  is  distinguished  from  that  of  the 
more  benignant  conditions  of  fatty  liver  and  amyloid  liver  by  the  absence 
in  these  two  of  grave  sjmiptoms  and  of  jaundice.  The  fatty  liver  is  softer 
than  the  liver  of  cancer,  the  amyloid  is  harder,  more  often  smoother,  while 
its  rounded  border  can  sometimes  be  felt.  It  is  also  accompanied  by  en- 
larged spleen.  In  abscess  of  the  liver  the  organ  may  be  soft  or  doughy  in 
consistence,  and  the  same  may  be  true  of  the  abdominal  walls  over  it. 
There  are  also  the  causes  of  abscess  of  the  liver,  and  among  symptoms  the 
characteristic  chills,  high  fever,  and  sweats. 

Multiple  echinococcus  cysts  may  furnish  similar  local  signs,  even  the 
"bosselated"  feel,  but  hydatid  disease  is  rare  in  temperate  climates;  the 
nodules  are  softer,  the  disease  is  of  longer  duration,  and  is  less  rapidly  fol- 
lowed by  wasting.  Enlargement  of  the  spleen  is  quite  common  in  hydatid 
disease,  present,  it  is  said,  in  nine-tenths  of  all  cases.  It  is  rarely  present  in 
cancer.  Jaundice  is  even  more  frequent  in  this  disease  than  in  cancer — 
in  four-fifths,  as  contrasted  with  a  little  more  than  one-half.  Aspiration 
may  aid  in  the  solution.  Of  other  affections  attended  by  uneven  surface  of 
the  liver  the  amyloid  organ  beset  with  nodules  offers  difficulties,  but  the' 
lesser  gravity,  the  longer  duration,  and,  especially,  the  syphilitic  history 
solve  the  question.  Cancer,  as  a  rule,  is  not  associated  with  enlarged  spleen, 
but  the  rapid  enlargement  of  the  liver  in  amyloid  disease  sometimes  ob- 
scures the  enlarged  spleen  and  even  interferes  with  its  development. 

Doubt  sometimes  arises  in  the  presence  of  certain  stubborn  forms  of 
jaundice  as  to  whether  cancer  may  not  be  the  cause,  especially  as  in  some 
of  .these  there  is  rapid  loss  of  weight.  If  there  is  enlargement  of  the  liver, 
the  solution  is  less  difficult,  because  in  simple  jaundice  there  is  no  enlarge- 
ment; but  in  its  absence  time  alone  can  settle  the  question;  for  stubborn 
as  these  rare  cases  of  jaundice  are,  they  are  less  so  than  cancer,  while  even 


472  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

if  they  are  not  followed  by  ixltimate  recovery,  their  course  is  much  longer 
than  that  of  cancer.  Should  ascites  arise,  the  question  is  settled  in  favor 
of  cancer.  It  may  sometimes  be  difficvilt  to  decide  between  cancer  and 
hypertrophic  cirrhosis,  which  also  furnishes  an  enlarged,  hard,  more  rarely 
nodular  liver,  with  jaundice.  Carcinoma  occurs  in  persons  over  40  years 
of  age,  hypertrophic  cirrhosis  in  those  younger.  Carcinoma  produces  cach- 
exia, hypertrophic  cirrhosis  does  not.  Carcinoma  produces  marked  tender- 
ness, hypertrophic  cirrhosis  but  slight.  A  possible  cause  in  either  case  must 
be  sought,  primary  cancer  elsewhere  pointing  to  cancer,  and  the  alcoholic 
habit  to  cirrhosis,  to  which  also  the  enlarged  spleen  and  the  absence  of 
cachexia  point.  A  family  history  of  cancer,  if  present,  adds  weight  to  other 
signs  of  cancer  of  the  liver.  Many  cases  of  syphilis  of  the  liver  are  mistaken 
for  carcinoma.  Therefore  in  every  doubtful  case  of  enlargement  of  the 
liver,  a  Wassermann,  reaction  should  be  done,  and  inunctions  of  mercury 
shoiild  be  given. 

There  is  no  special  reason  why  cancer  of  the  liver  should  be  distin- 
guished from  sarcoma  or  adenoma,  as  the  clinical  significance  of  the  various 
conditions  is  about  the  same.  But  if,  along  with  a  primary  sarcoma  else- 
where, as  in  the  orbit,  there  appears  enlargement  of  the  liver,  then  the 
inference  is  reasonable  that  a  secondary  sarcoma  is  there  established. 
Melanosarcoma  is  more  likely  to  invade  other  organs,  as  the  lungs,  kidneys, 
spleen,  and  even  the  skin. 

There  is  no  sign  by  which  secondary  cancer  can  be  distinguished  from 
primary,  except  by  the  presence  of  primary  cancer  elsewhere,  notably  in 
the  stomach,  breast,  large  intestine,  uterus  and  appendages,  and  the  pre- 
sumption based  on  the  fact  that  the  majority  of  all  cases  of  cancer  of  the 
liver  are  secondary.  Careful  search  should,  however,  be  made  for  cancer 
in  all  organs  in  which  primary  cancer  is  likely  to  occur.  The  gastric  secre- 
tion should  be  investigated  chemically,  the  rectum  explored  by  the  finger 
and  speculum,  the  uterus  by  the  finger,  speculum,  and  sound.  Such  inves- 
tigation is  further  useful  in  the  settlement  of  the  diagnosis  of  cancer  of  the 
liver,  for  a  doubtful  case  becomes  confirmed  if  a  primary  focus  can  be  found. 

Prognosis. — This  disease  is  invariably  fatal — usuall}^  in  from  three  to 
1 5  months. 

Treatment. — This  must  consist  in  attempts  to  relieve  the  discomfort  and 
l^rolong  the  life  of  the  patient. 

SYPHILIS  OF  THE  LIVER. 

Definition. — Syphilis  of  the  liver  includes  several  morbid  conditions 
due  to  this  specific  poison,  which  are  best  considered  under  a  single  title. 

Etiology. — Syphilis  of  the  liver  may  be  the  result  of  acquired  or  inherited 
syphilis. 

Morbid  Anatomy. — i.  The  product  in  the  liver  of  inherited  syphilis 
isjalways  a  cellular  infiltrate,  which  may  be  diffuse  or  localized,  (i)  The 
diffuse  infiltrate  produces  an  enlargement  and  hardening  of  the  organ,  which 
gives  place  to  a  reduction  in  size  and  unevenness  due  to  contraction  of  the 
newly  formed  connective  tissue.  (2)  The  circumscribed  product,  more  rare 
as  the  result  of  inherited  syphilis,  is  the  gumma.     The  gumma  is  rather  a 


SYPHILIS  OF  THE  LIVER  473 

product  of  acquired  syphilis,  but  rarely  also  it  is  found  in  connection  with 
hereditary  syphilis. 

2.  The  changes  in  the  liver  due  to  acquired  syphilis  are  regarded  as 
one  of  its  tertiary  manifestations,  and  do  not  show  themselves  until  some 
time  after  the  primary  infection — it  may  not  be  for  several  years.  They  are 
represented  by  an  interstitial  hepatitis,  by  the  syphilitic  gumma  or  syphi- 
loma, by  amyloid  disease,  and  occasionally  by  endarteritis.  Diffuse  inter- 
stitial hepatitis  does  not  differ  essentially  from  the  tnore  usual  forms 
of  nonspecific  cirrhosis.  The  ultimate  product  is  sometimes  very  irregu- 
lar, and  the  lobules  preserve  a  palpable  distinctness.  The  gimima  is  the 
most  characteristic  lesion  of  tertiary  syphilis.  It  is  a  nodular  growth, 
which  may  be  as  small  as  a  pea  or  smaller,  or  as  large  as  an  orange — from 
1/5  to  four  inches  (five  millimeters  to  ten  centimeters)  in  diameter.  A 
favorite  seat  is  the  convexity  of  the  organ  near  the  suspensory  ligament; 
another,  on  the  under,  surface  in  the  connective  tissue  embracing  the  portal 
vessels;  while  it  is  also  found  in  the  substance  of  the  organ.  The  tendency 
is  to  cheesy  change  in  the  center  of  the  nodule,  and  to  contraction,  which 
distorts  the  liver  and  reduces  its  size,  with  the  formation  of  cicatricial  mark- 
ings and  furrows.  These  cicatrix-like  puckerings  and  fibrous  bands  are 
found  also  on  section  of  the  syphilitic  liver.  Endarteritis  sometimes 
invades  the  smaller,  and  even  the  larger,  branches  of  the  hepatic  artery 
and  portal  vein. 

Symptoms. — Syphilitic  changes  in  the  liver  are  often  first  discovered  at 
autopsy.  When  symptoms  are  produced  during  life,  they  are  commonly 
those  due  to  portal  obstruction,  as  already  detailed  in  treating  ordinary 
cirrhosis.  Jaundice  may  be  thus  caused.  It  is  not  a  frequent  symptom, 
yet  it  was  early  made  a  matter  of  record,  A.  D.  1493-1541.  Gubler  col- 
lected seven  cases  in  which  jaundice  followed  syphilitic  infection.  It  ac- 
companied a  syphilitic  exanthem,  and  was  also  preceded  by  digestive 
disorders,  loss  of  appetite,  nausea,  diarrhea,  bitter  taste  in  the  mouth,  and  pain 
in  the  epigastrium.  There  has  been  under  observation  one  case  precisely 
fulfilling  these  conditions  pointed  out  by  Gubler.  The  jaundice  may  be 
slight,  moderate,  or  severe.  It  rapidly  attains  its  maximum  intensit}^ 
lasting  a  variable  time,  seldom  more  than  a  fortnight.  Though  the  expla- 
nation may  not  be  immediately  easy,  Gubler  gives  sufficient  reasons  for 
justifying  a  relation  of  cause  and  effect.  It  is  possible  that  the  poison 
may  act  like  certain  other  poisons  which  produce  grave  icterus,  as  phos- 
phorus. On  the  other  hand,  it  is  quite  as  likely  that  it  may  arise  from  a 
duodenal  and  bUiary  catarrh,  the  result  of  the  general  disturbance,  espe- 
cially as  it  is  so  often  associated  with  other  symptoms  of  this  condition — 
viz.,  loss  of  appetite  and  nausea.  Or  it  may  be  the  result  of  biliary  obstruc- 
tion by  the  contracting  processes  of  the  syphilitic  liver  as  already  stated. 

Enlargement  oj  the  spleen  is  an  associated  symptom  when  there  is  amyloid 
disease,  to  which  ascites  may  also  be  added.  Sometimes  the  larger  nodules 
of  gummy  growth  can  be  felt  through  the  abdominal  walls,  when  the 
diagnosis  must  be  made  between  syphilis  of  the  liver  and  carcinoma,  a 
differentiation  greatly  aided  by  the  history  of  the  case. 

Diagnosis. — This  depends  most  largely  upon  the  history  of  the  case, 
which  must  be  careftdly  sought.     Nor  should  the  physician  be  satisfied  with 


474  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

a  negative  history,  in  view  of  the  fact  that  it  is  so  common  for  syphihtic  sub- 
jects to  deny  infection,  even  though  they  know  it  is  to  their  interest  to  tell 
the  truth.  Careful  examination  should,  therefore,  be  made  for  secondary 
symptoms,  such  as  glandular  enlargement  or  cicatrics  and  markings  left  by 
syphilids.  A  Wassermann  reaction  should  be  made  in  every  suspicious  case. 
Prognosis  and  Treatment. — Patients  should  be  subjected  to  the  usual 
syphilitic  treatment  by  iodid  of  potassiiun  and  inunctions  of  mercury  as  soon 
as  the  diagnosis  is  established,  and  even  when  it  is  doubtful.  For  while 
early  treatment  may  be  efficient  in  preventing  new  growths,  it  is  less  certain 
that  when  present  they  can  be  removed  by  antisyphilitic  treatment.  Cer- 
tain cases  clear  up  in  a  remarkable  manner.  We  have  seen  a  tumor  of  the 
liver  as  large  as  a  grapefruit  presenting  in  the  epigastrium,  which  disappeared 
in  one  week  under  mercurial  inunctions. 


PARASITES  OF  THE  LIVER. 

EcHiNOCOCcus  Disease,  or  Hydatid  Cyst  of  the  Liver. 

Etiology  and  Pathogenesis. — The  most  important  and  interesting  of  the 
parasitic  diseases  of  the  liver  is  the  echinococcus  or  hydatid  cyst,  caused  by 
the  embryo  or  larva  of  the  tcenia  echinococcus,  a  minute  tape-worm,  consist- 
ing of  three  or  four  links,  and  about  i/s  inch  (four  to  five  mm.)  long.  Its 
natural  habitat  is  the  upper  part  of  the  intestine  of  the  dog,  the  wolf  and 
jackal.  The  worm  is  not  often  found  in  this  coimtry,  (see  Fig.  104)  and 
can  be  easily  overlooked,  appearing  as  minute,  thread-like  body,  adher- 
ing to  the  viUi  of  the  intestine  of  the  dog.  Hydatid  disease,  though  not 
very  common,  is  still,  nevertheless,  more  so  than  would  be  expected  from 
the  seeming  rarity  of  this  worm.  In  Australia  and  Iceland,  where  the  in- 
tercourse between  men  and  dogs  is  more  intimate,  hydatid  disease  is  com- 
paratively frequent.  In  the  latter  country  28  per  cent,  of  all  dogs  are  said 
to  be  infected;  in  Copenhagen,  four  per  cent.;  in  Zurich,  3.9  per  cent.; 
in  Lyons,  7 .  i  per  cent. ;  in  Berlin,  one  per  cent. ;  and  in  Leipzig,  none,  as 
far  as  investigated. 

The  ovum  of  this  tape-worm,  entering  the  hvunan  intestine  with  food  or 
drink,  has  its  shell  dissolved  by  the  digestive  fluids;  the  larva  is  liberated, 
and  bores  its  way  by  its  stilettos  and  hooklets  into  a  branch  of  the  portal 
vein,  through  which  it  is  carried  to  the  liver.  Lodging  there,  the  hooklets 
disappear,  and  the  embryo  becomes  a  small  cyst,  called  the  proscolex, 
possessed  of  two  layers — an  external  cuticle  of  laminated  structure,  the 
ectocyst,  and  an  internal  parenchymatous  or  germinal  layer,  the  endocyst. 
Within  the  cyst  is  a  clear  fluid.  Surrounding  the  cyst  is  gradually  developed 
a  capsule  of  connective  tissue,  due  to  reactive  inflammation. 

At  the  earliest  stage  at  which  these  bladders  or  resting  embryos  have 
been  with  certainty  observed — by  Leuckart  in  the  pig  four  weeks  after  feed- 
ing with  ripe  proglottides — they  form  solid,  spherical  bodies,  25/100  to 
3S/ioo  of  a  millimeter  in  diameter,  and  are  called  proscolices.  At  this  stage 
they  resemble  a  mammalian  egg,  and  are  subsequently  difterentiated  into 
the  bladders. 

Development  from  Proscolex. — When  from  15  to  20  millimeters  in  diameter 


HYDATID  OF  LIVER 


475 


i 


this  proscolex,  or  bladder-worm,  proceeds  to  development  of  numerous 
heads  or  scolices.  It  may  give  rise,  first,  to  a  single  head,  arising  from  the 
germinal  layer  producing  a  cysticercus;  second,  to  many  heads,  each  of  which 
is  termed  a  cenurus;  third,  to  numerous  heads  produced,  not  directly  from 
the  germinal  layer,  but  indirectly  from  special  delicate  sacs  called  brood 
capsules,  which  arise  as  minute  elevations  from  the  cells  of  the  germinal 
layer.  In  these  elevations  a  small  spheroidal  cavity  appears,  gradually 
increases  in  size,  and  becomes  lined  internally  with  a  delicate  cuticular 
membrane,  outside  of  which  is  a  la^'er  of  cellular  structure.  Thus,  the  wall 
of  the  brood  capsule  consists  of  two  laj^ers  like  those  of 
the  mother  bladder,  but  inverted  as  to  relative  position, 
as  if  the  brood  capsule  were  an  invagination  of  the 
mother  bladder.  These  brood  capsules  exhibit  active 
movements.!  From  the  internal  wall  of  the  brood 
capsule  arises  the  head,  first  as  a  discoidal  thickening, 
growing  into  an  externally  situated  club-shaped  process, 
perforated  longitudinally  by  a  tube-like  continuation 
of  the  cavity.  While  an  external  protrusion  of  the 
brood  capsule,  it  may  be  temporarily  inverted.  At  the 
distal  end  of  this  protrusion,  furthest  from  the  point 
of  attachment,  the  suckers  and  hooks  of  the  head  or 
scolex  are  formed.  The  hooklets  appear  as  a  thick 
fringe  of  prickles,  all  of  which,  except  the  foremost  rows, 
subsequently  drop  off.  Thus,  in  different  stages  of 
development,  heads  to  the  number  of  lo,  15  or  20  may 
live  within  one  capsule,  and  in  large  bladders  the  in- 
cluded capsules  may  number  thousands.  From  these, 
shoiild  they  reach  the  intestine  of  a  suitable  host,  the 
proglottides  of  the  strobile,  or  sexual  worm,  are  formed 
by  lengthening  and  transverse  segmentation.  The 
period  of  development  from  the  scolex  condition  to 
that  of  the  adult  worm  varies  from  four  to  eight  weeks. 

In  the  liver  the  hydatid  bladder  thus  described 
consists  of  a  single  sac,  which  may  attain  an  enormous 
size,  bearing  on  its  surface  brood  capsules  containing 
scolices  in  varying  munber  and  stages  of  development.     This  is  the  form 
of  cyst  known  as  echinococcus  veterinorum,  because  common  in  the  domestic 
animals,  though  frequently  also  found  in  man.^ 

Development  by  Daughter  Cysts. — In  another  method  of  development 
secondary  and  completeh^  separated  bladders  may  be  formed,  either  in- 
side or  outside  the  primary  or  mother  cyst,  constituting  daughter  cysts. 
The  former,  or  endogenous  type,  is  that  usually  met  in  man — echinococcus 
hydatidosus  of  Leuckart,  echinococcus  endogenus  of  Kuhn — and  arises  either 
by  vesicular  transformation  of  the  scolices  of  the  brood  capsules,  or  by  in- 


F I G .  104.  — Tsenia 
Echinococcus,  from  the 
Dog — {ajler  Heller). 

At  a,  natural  size;  at 
h,  magnified. 


1  They  are  easfly  ruptured  and  may  escape  observation  altogether,  whence  it  has  been  inferred  that 
connection  between  the  heads  and  brood  capsules  is  temporary,  and  that,  after  separation,  the  living  sco- 
lices float  tree  in  the  fluid  of  the  mother  bladder.  According  to  Leuckart,  however,  all  parts  of  the  echino- 
coccus— mother  bladder,  brood  capsules,  and  heads — are  throughout  life  in  direct  continuity  with  one 
another.  According  to  Verco  and  Stirling,  it  may  be  that  the  scolices  are  also  formed  directly  from  the 
germinal  membrane,  in  evidence  of  which  they  state  that  they  have  examined  a  specimen  which  shows 
lour  heads  sprouting  directly  from  the  germinal  membrane  of  an  exogenously  developed  daughter  cyst 

2  J.  C.  Verco  and  E.  C.  Stirling  in  Allbutt's  "System  of  Medicine,"  vol.  ii.,  1897,  p.  mo 


476 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


foldings  of  the  .parenchymal  layer.  The  daughter  cysts  thus  formed  and 
lying  within  the  parent  cyst,  with  which  they  correspond  in  structure  and 
behavior,  also  give  rise  to  brood  capsules  and  scolices.  These  daughter 
bladders  ma}-  also  bud  endogenously  and  exogenously,  and  produce  a  third 
or  fourth  generation  within  or  without  themselves,  the  whole  brood  being 
contained  within  the  mother  bladder. 

The  exogenous  type — echinococcus  exogenus  of  Kuhn — is  less  common 
in  man,  but  is  frequently  met  in  domestic  animals,  especially  the  pig.  In 
this  form  the  secondary  bladders  arise  from  small  granular  masses  in  the 
deeper  layer  of  the  cuticle  of  the  mother  cyst,  probably  ultimately  derived 
from  the  parenchymal  layer.  They  assume  a  special  cuticular  covering, 
and  their  central  parts  clear  up  and  liquefy.     As  the  centripetal  formation 


Fig.  105. — Section  through  an  Echinococcus  Cyst  with  Blood  Capsules — {from  Braun,  aflcr 

Wax  Model). 


of  new  layers  in  the  cuticle  of  the  mother  bladder  goes  on,  with  rupture  of 
the  outer  layers,  the  new  formations  make  their  way  externally  as  separate 
sacs,  and  undergo  subsequent  development  outside  of  the  mother  bladder, 
usually  close  to  it,  though  at  times,  as  in  hydatids  of  bone,  the  indi\H[duals 
of  the  restilting  broods  may  lie  at  some  distance  from  one  another  and  from 
their  common  parent.  It  is  to  a  special  variety  of  this  latter  that  Virchow 
has  given  the  name  echinococcus  muUilocularis ,  wherein  the  cysts,  becom- 
ing surrounded  and  joined  together  by  thick  capsules  of  connective  tissue, 
form  a  hard  tumor  composed  of  vesicles  the  size  of  a  pea,  often  resembling, 
en  masse,  colloid  cancer.  In  the  spaces  are  found  remnants  of  the  echino- 
coccus C3'st,  at  times  hooklets  or  scolices,  by  the  discovery  of  wliich  their 
true  nature  is  determined.  At  other  times  they  are  barren.  Most  cases 
of  this  form  of  disease  have  been  met  in  Bavaria  and  Switzerland,  but  one 
case  being  reported  in  this  country — by  Delafield  and  Prudden,  in  their 
"Pathological  Anatomj', "  third  edition,  page  372.  The  subject  was,  how- 
ever, a  German,  who  had  been  in  the  country  five  years. 

The  fluid  contents  of  the  young  cyst  are  clear  and  limpid,  have  a  specific 
gravity  of  1005  to  1009,  are  nonalbuminous,  but  contain  a  small  quantity 
of  chlorid  of  sodium,  occasionally  a  trace  of  sugar,  succinic  acid,  or  hema- 
toidin.  Scolices  and  booklets  are  almost  always  present,  and  are  of  great 
diagnostic  value. 

The  hydatid  cyst  ranges  in  size  from  that  of  a  pin's  head  to  a  child's 
head.  It  grows  very  slowly,  and  may  be  in  the  liver  for  many  years — 
some  say  as  many  as  20.  Ultimateh-  it  dies,  the  walls  contract,  their  con- 
tents become  inspissated  and  walls  themselves  calcified.     Sometimes  they 


HYDATID  OF  LIVER  477 

suppurate,  the  cysts  forming  large  abscesses;  or  they  may  rupture  in  various 
directions  with  corresponding  mischief,  including  sudden  death  from  col- 
lapse.    The  bile  passages  and  inferior  cava  have  been  seats  of  rupture. 

Symptoms. — Small  cysts  may  occasion  no  symptoms,  being  often  un- 
expectedly found  at  necropsy,  and  under  any  circumstances  the  failure  of 
health  is  very  gradual  at  first.  As  cysts  become  large  they  produce  a  sense 
of  weight  or  dragging  in  the  region  of  the  liver,  and  other  symptoms,  de- 
pending on  their  size  and  situation;  jaundice,  if  they  cause  obstruction  of 
the  biliary  passages;  dyspnea  and  cardiac  disturbance,  if  they  encroach  on 
the  lungs  or  heart;  pyemic  symptoms — that  is,  fever,  sweat,  and  sometimes 
chills,  with  rapid  exhaustion — if  they  suppurate.  The  Uver  may  become 
very  much  enlarged,  demonstrable  by  inspection,  palpation,  and  percus- 
sion. If  there  is  a  single  superficial  cyst,  either  in  the  right  or  left  lobe,  it 
may  be  felt  as  an  elastic  or  even  fluctuating  tumor ;  or  there  ma}'  be  the  distinct 
feel  of  a  nodular  growth  over  the  liver.  If  posterior  in  the  right  lobe,  it 
may  encroach  on  the  inferior  part  of  the  lung  and  pleural  space,  causing 
dullness  on  percussion  posteriorly  and  postero-lateraUy,  and  other  signs 
of  pleuritic  effusion.  Hydatid  thrill  or  fremitus  is  always  to  be  sought  for. 
It  may  be  found,  if  the  cyst  is  superficial,  by  placing  one  hand  over  the 
tumor  and  tapping  lightly  with  the  fingers  of  the  other.  The  result  is  a 
vibrating  or  trembling  movement  felt  for  a  short  time.  It  is  not  often  ob- 
tainable, and  is  possible  only  with  superficial  cysts.  It  has  been  ascribed 
by  Briancon  to  the  collision  of  the  daughter  cysts. 

If  rupture  occurs,  other  symptoms  are  added.  The  pleural  cavity  is 
often  invaded,  or  the  lungs,  as  evidenced  by  the  expectoration  of  cysts  and 
booklets;  the  bile  passages,  by  the  production  of  jaundice  or  increased 
jaundice;  and  the  subsequent  appearance  of  booklets  and  cysts  in  the  fecal 
discharges.  Rupture  into  the  stomach  is  manifested  by  vomiting  of  hook- 
lets  and  cysts ;  into  the  vena  cava,  by  embarrassment  of  right  cardiac  action 
and  pulmonary  thrombosis  from  lodgment  of  cysts;  into  the  pericardium, 
by  fatal  pericarditis;  into  the  peritoneum,  by  fatal  peritonitis;  and  into  the 
abdominal  wall,  by  outward  discharge. 

The  spleen  is  commonly  enlarged. 

Diagnosis. — The  differential  diagnosis  depends  on  the  recognition  of 
hydatid  fremitus  or  on  some  of  the  pathognomonic  features  just  mentioned, 
and  the  history  of  the  case  in  connection  with  the  slowness  of  development 
of  the  symptoms.  The  resemblance  to  cancer  is  sometimes  very  close,  in 
consequence  of  the  presence  of  nodular  swellings  over  the  liver,  and  to 
syphilis  of  the  liver  for  the  same  reason.  In  cancer  the  health  fails  very 
much  more  rapidly,  but  in  syphilis  scarcely  more  so,  and  the  history  and 
blood  examination  must  here  again  come"  to  our  assistance.  When  sup- 
puration takes  place,  we  have  the  symptoms  of  abscess  of  the  liver.  The 
recognition  of  sugar  in  the  fluid  obtained  by  tapping  is  presumptive  evidence 
of  its  hydatid  nature. 

Prognosis. — When  the  disease  develops  sufficiently  to  manifest  symp- 
toms, the  chance  of  spontaneous  recovery  is  very  slight.  It  is  possible  when 
external  rupture  takes  place,  but  this  should  be  anticipated  by  operative 
interference,  which  is  often  successful. 

Treatment. — No  medicinal  treatment  avails,  while  spontaneous  cure  is 


478  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

not  infrequent,  by  reason  of  the  death  of  the  parasite  before  the  develop- 
ment of  the  disease  to  a  recognizable  degree.  A  surgeon  should  be  con- 
sulted as  soon  as  the  diagnosis  is  made.  A  preliminary  tapping  is  justi- 
fied under  strict  antiseptic  precautions,  and,  in  fact,  has  been  succeeded  by 
permanent  recovery.  Avistralian  surgeons  have  had  the  largest  experience, 
and  it  appears  of  justify  the  bolder  course  of  incision  and  evacuation  of  the 
cysts  rather  than  the  more  conseryative  method  of  first  securing  adhesion 
of  the  sac  to  the  abdominal  walls  and  then  laj'ing  open  the  cyst  and  evacu- 
ating the  contents.  The  former  practice  of  injecting  the  sac  with  iodin  has 
also  been  discontinued.  Should  suppuration  take  place,  the  treatment  be- 
comes that  of  abscess  of  the  liver. 

Other  Parasites  of  the  Liver. 

The  remaining  parasites  of  the  liver  are  of  pathological  rather  than  of 
clinical  interest. 

The  arthropoda  are  presented  by  the  pentastomes,  of  which  the  pen- 
tastomum  denticulatum — larval  form  of  the  pentastomum  or  lingiiatula 
tcBfiioides — -has  been  found  in  the  liver.  The  adult  worm  is  lancet-shaped 
and  marked  with  numerous  rings.  The  female  is  from  three  to  five  inches 
(8  to  13  cm.)  long,  the  male  little  less  than  one  inch  (1.8  to  2.5  cm.).  The 
adult  worm  has  been  found  in  the  nostril  of  man. 

The  cystercus  celluloscB  and  psorosperma  are  rare  parasites.  Of  the 
latter,  the  coccidium  oviforme,  which  is  very  common  in  the  liver  of  the 
rabbit,  produces  whitish  nodules,  as  in  other  organs,  ranging  in  size  from 
that  of  a  pin  to  that  of  a  split  pea,  and  even  larger.  They  may  produce 
fever  of  an  intermittent  type,  diarrhea,  nausea,  and  tenderness  over  the 
liver  or  other  organ  invaded  with  enlargement. 

In  examining  a  case  of  suspected  hepatic  disease  the  following  questions 
should  be  raised  with  a  \'iew  to  eliciting  important  facts  which  bear  upon  the 
diagnosis:  First,  whether  there  has  been  or  is  syphilis;  second,  suppura- 
tive disease  or  rickets;  third,  alcoholism;  fourth,  enlargement  of  the  spleen; 
fifth,  elevation  of  temperature;  sixth,  jaundice;  seventh,  what  has  been 
the  duration  of  the  symptoms  ? 

DISEASES  OF  THE  PANCREAS. 

Almost  the  only  diseases  of  the  pancreas  which  possess  much  clinical 
interest  are  cancer  and  pancreatitis.  Reginald  H.  Fitz  has  invested  the 
subject  of  pancreatitis  with  increased  interest  by  his  masterly  IMiddleton 
Goldsmith  lecture,  and  more  are  now  recognized  antemortem  than  previous 
to  its  publication.  The  remaining  diseases  are,  however,  of  great  patho- 
logical interest. 

ACUTE  PANCREATITIS. 

Definition. — Acute  pancreatitis  is  an  acute  inflammation,  aflecting 
primarily  the  fibrous  and  fatty  interstitial  tissue  of  the  organ.     It  is  a  rare 


ACUTE  PANCREATITIS  479 

affection.  Fitz  divides  it  into  hemorrhagic,  suppurative  and  gangrenous, 
but  as  suppuration  and  gangrene  are  terminations  rather  than  initial  fea- 
tures, and  hemorrhage  is  at  least  a  very  frequent  primary  etiological  feature, 
It  will  be  treated  under  the  single  heading  of  acute  pancreatitis. 

Etiology. — It  may  begin  with  hemorrhage,  which  may  be  traumatic. 
Most  subjects  are  between  26  and  70  years  old.  The  majority  are  rnen._ 
A  few  are  alcoholics.  James  M.  Anders^  collected  40  cases  of  pancreatic 
hemorrhage,  in  34  of  whom  the  sex  was  given.  Twenty-five  of  these  were 
males  and  nine  females.  The  ages  of  30  were  stated,  of  whom  13,  or  43.3 
per  cent.,  were  over  45.  Many  had  been  previously  subject  to  gastric  and 
gastro-intestinal  derangements,  often  inflammatory.  The  causative  gas- 
tro-duodenitis  extends  probably  from  the  bowel  to  the  pancreatic  duct. 
Pathogenic  organisms  play  an  undoubled  role. 

Morbid  Anatomy. — This  varies  with  the  stages  or  varieties,  which,  as 
seen  at  necropsy,  are  hemorrhagic,  gangrenous ,  and  suppurative.  In  the 
hemorrhagic  stage  the  pancreas  is  enlarged  throughout  or  at  its  head,  and 
is  infiltrated  with  blood,  which  imparts  its  color  in  different  shades  and 
may  invade  the  pancreatic  duct.  The  hemorrhagic  foci  may  alternate  with 
white  spots  oi  fat-necrosis .  The  hemorrhage  may  extend  into  the  peripan- 
creatic  tissue  or  the  mesentery,  mesocolon,  omentum,  and  beyond  to  the 
brim  of  the  pelvis.  On  minute  examination  round  cells  and  red  blood  disks 
are  found  in  the  ducts  and  acini.  Many  lobules  are  in  a  state  of  coagula- 
tion-necrosis, while  bacteria  are  present  in  large  numbers. 

If  the  patient  survive  the  first  few  days — say  the  fourth  day — the  con- 
dition passes  on  either  to  gangrene  or  suppuration.  If  to  gangrene,  the  tip 
or  the  entire  gland  may  be  converted  into  an  offensive,  dark,  slate-colored 
mass,  which  softens  and  becomes  shreddy.  Gangrene  may  set  in  almost 
simultaneously  with  hemorrhage.  The  organ  may  become  completely 
sequestrated  in  the  smaller  omental  cavity,  attached  only  by  a  few  shreds. 
The  adjacent  parts  exhibit  the  appearance  of  peritonitis,  with  dirty,  puru- 
lent extravasate.  Disseminated  fat-necrosis  may  be  present.  The  spleen 
may  be  enlarged  and  its  veins  thrombosed,  as  may  be  also  the  portal  vein. 

In  the  suppurative  termination  the  organ  is  enlarged,  and  contains 
numerous  small  abscesses,  intervening  parts  being  hyperemic.  There 
may  be  peritonitis  of  adjacent  areas  of  the  peritoneum.  There  may  be 
diffuse  suppuration  or  small  abscesses  disseminated  throughout  the  organ. 
In  the  chronic  form  there  may  be  a  solitary  abscess  as  large  as  a  hen's  egg, 
with  cheesy  contents.  The  lesser  omental  cavity  and  peripancreatic  tissue 
may  be  invaded;  rarely,  also,  the  liver.  Fat  necrosis  in  this  form  is  a  rare 
condition,  while  thrombosis  of  the  splenic  and  portal  veins  may  still  occur. 

Symptoms. — The  disease  begins  suddenly  with  abdominal  pain,  some- 
times succeeding  attacks  of  indigestion.  It  is  severe  and  in  the  upper  left 
quadrant  of  the  abdomen  and  in  the  course  of  the  pancreas,  but  it  may  ex- 
tend throughout  the  abdomen.  It  is  ascribed  to  stretching  of  the  celiac 
plexus  of  nerves.  There  is  also  tenderness.  The  pain  is  usually  followed 
by  vomiting,  rarely  by  nausea  alone.  The  vomited  matter  may  be  bilious  or 
black.  There  may  be  diarrhea.  The  upper  abdomen  becomes  swollen 
and  tympanitic,  or  the  tympany  may  be  general.     The  temperature  is  sub- 

^  "Pancreatic  Hemorrhage,"  "Journal  of  the  American  Med.  Assoc, "^December  2,  1899. 


480  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

normal  or  slightly  elevated.  Death  occurs  in  untreated  cases  usually  within 
three  days,  but  may  be  delayed  a  week.  If  the  patient  lives  longer,  the 
case  becomes  one  of  gangrenous,  or  suppurative  pancreatitis.  Recovery 
may  occur,  though  rarely. 

If  the  gangrenous  or  suppurating  termination  succeeds,  chills,  fever, 
abdominal  swelling,  tympanites,  tenderness,  jaundice,  collapse,  and  death 
ensue. 

If  suppuration  occurs,  life  may  be  prolonged  for  three  or  four  weeks, 
and  there  may  be  added  high  temperature  and  irregular  chills,  with  exacer- 
bations and  remissions  and  signs  of  deep-seated  peritonitis  in  the  epigastric 
region. 

Diagnosis. — This  is  based  upon  the  foregoing  symptoms  and  their  sud- 
denness, especially  the  circumscribed  tympany.  The  disease  is  to  be  dif- 
ferentiated from  the  effects  of  irritant  poison,  perforation  of  the  stomach  or 
biliary  tract,  and  acute  intestinal  obstruction.  The  history  eliminates  cor- 
rosive poison.  Perforation  of  the  stomach  is  preceded  by  symptoms  of 
ulcer,  and  of  the  biliary  passages  by  sjrmptoms  of  gall-stones.  There  is  no 
tenderness  localized  in  the  region  of  the  pancreas  in  intestinal  obstruction, 
■which  is  rare  in  the  upper  part  of  the  small  intestine.  Obstruction  in  the 
large  intestine  must  be  eliminated  by  measures  calculated  to  determine  the 
patulousness  of  the  bowel.  Laparotomy  has  been  done  for  intestinal  ob- 
struction, and  pancreatitis  was  found. 

Prognosis  and  Treatment. — The  former  is  almost  always  unfavorable. 
If  recovery  takes  place,  it  is  accidental  rather  than  the  result  of  medical 
treatment,  which,  in  the  main,  can  only  be  palliative,  and  such  as  is  de- 
manded by  peritonitis.  Surgical  treatment  is  of  great  value.  A  surgeon 
should  at  once  be  consulted  in  all  suspected  cases  and  operation  should  be 
done  early. 

Chronic  Pancreatitis. — This  consists  of  an  interstitial  overgrowth, 
by  which  the  organ  is  hardened  and  slightly  enlarged.  The  secreting 
structure  is  compressed  and  degenerated.  It  has  frequently  been  found  in 
diabetes.  There  may  be  pigmentary  deposits,  and  pancreatic  calculi  ma\' 
be  found  in  the  ducts. 

Symptoms. — There  are  those  above  mentioned,  in  a  milder  form.  Fat 
find  sugar  digestion  are  poor  and  large  quantities  of  undigested  matter 
especially  sugar  and  fat  are  found  in  the  feces.  Jaundice  may  be  especially 
present  in  this  form  where  the  pancreatitis  is  due  to  an  extension  of  an  in- 
fection from  the  duodenum.  The  relation  of  chronic  pancreatitis  has  been 
])ointed  out  of  late  particularly  by  Deaver.  The  only  available  treatment 
is  surgical. 

CANCER  OF  THE  PANCREAS. 

Morbid  Anatomy. — Though  a  rare  disease,  it  is  not  infrequently  cor- 
recth-  diagnosed.  It  is  usually  primary  and  situated  in  the  head  of  the 
organ.  It  is  commonly  scirrhous,  but  it  may  also  be  colloid.  It  may  arise 
by  contiguity  from  cancer  of  the  stomach  or  intestines.  It  occurs  in  those 
past  middle  life.  It  is  especially  apt  to  invade  adjacent  parts  andmore 
distant  ones  by  metastasis,  especially  the  liver  and  lymph  glands. 


CYSTS  OF  THE  PANCREAS  481 

Symptoms. — These  are  not  distinctive.  The  most  valuable  sj'mptom 
is  jaundice,  which  occurs  when  the  head  of  the  organ  is  involved.  It  is 
caused  by  obstrtiction  of  the  common  bile-duct.  A  fixed  tumor  may  be 
felt  in  the  pancreatic  region,  and  if  it  be  associated  with  jaundice,  the  pan- 
creas may  be  justly  suspected  to  be  its  seat.  If  we  add  to  these  symptoms 
fatty  or  pancreatic  stools,  the  suspicion  is  fortified.  There  are  symptoms  of 
indigestion  and  a  dull  pain  in  the  epigastrium,  but  these  are  not  distinctive. 
Emaciation  and  loss  of  strength  proceed  irresistibly.  As  the  former  ad- 
vances the  aortic  pulse  is  transmitted  with  great  distinctness  through  the 
transverse  colon  and  pancreas.     There  may  be  ascites  and  diabetes  mellitus. 

Diagnosis. — Cancer  of  the  pancreas  must  be  differentiated  from  cancer 
of  the  pylorus,  of  the  transverse  colon,  of  the  glands  in  the  hilus  of  the  liver, 
and  from  aortic  aneurysm.  In  case  of  cancer  of  the  pylorus  there  should 
not  be  much  difficulty,  for  the  pyloric  tumor  is  movable  in  a  decided  major- 
ity of  cases,  and  the  pancreatic  is  fixed;  the  pyloric  cancer  is  rarely  associated 
with  jaundice,  the  pancreatic  is  almost  always  so;  pyloric  cancer  produces 
dilatation  of  the  stomach,  pancreatic  cancer  does  not. 

Cancer  of  the  transverse  colon  is  rare.  It  is  also  more  movable  than 
pancreatic  cancer,  and  sooner  or  later  obstruction  of  the  bowel  results. 
Cancer  in  the  hepatic  fissure  is  difficult  to  distinguish,  but  it  is  higher  up  and 
more  superficial.  The  tumor  is  also  tender.  It  is  accompanied  by  jaun- 
dice and  by  this  symptom  resembles  cancer  of  the  pancreas. 

The  pulsation  communicated  to  the  pancreas  is  very  different  from  the 
expansitle  dilatation  of  aneurysm.  Fatty  stools  are  of  great  assistance  in 
diagnosis,  but  they  are  by  no  means  always  present. 

Sarcoma  is  a  possible  tumor  of  the  pancreas,  but  it  is  not  distinguish- 
able from  cancer.  Tuberculosis  and  syphiloma  may  occur  and  present 
similar  difficulties.  The  Cammidge  reaction  is  of  value  in  differentiating 
obstruction  of  the  pancreatic  duct.  Fattj^  stools  are  also  of  value  both  in 
chronic  pancreatitis  and  in  cancer  of  pancreas. 

The  prognosis  of  cancer  is  unfavorable,  and  the  treatment  only  symp- 
tomatic. 

CYSTS  OF  THE  PANCREAS. 

Definition. — These  are  retention  cysts,  due  to  closure  of  Wirsung's  duct 
by  concretions  or  cicatricial  contraction.  They  may  become  very  large, 
and  may  even  occupy  the  entire  abdominal  cavity.  They  may  be  slow  or 
rapid  in  development. 

Symptoms. — In  none  of  the  53  cases  collected — 35  hy  W.  W.  Johnston 
and  18  by  N.  Senn — was  there  fatty  diarrhea,  a  condition  regarded  as 
symptomatic  of  suspended  function  of  the  pancreas.  On  the  other  hand, 
the  stools  may  be  clay  colored  and  putrescent,  probably  because  there  is  a 
simultaneous  obstruction  to  the  descent  of  bile.  A  resulting  tumor  presents 
itself  usually  in  the  left  part  of  the  epigastrium,  between  the  costal  cartilages 
and  the  median  line.  More  rarely  it  is  in  the  neighborhood  of  the  navel. 
It  is  globular,  resisting,  and  inelastic,  changes  its  position  slightly  with 
the  movements  of  the  diaphragm,  and  possesses  some  lateral  motion. 

The  differentiation  of  such  a  tumor,  in  the  absence  of  more  definite 


482  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

symptoms,  cannot  be  said  to  be  easy,  yet  the  diagnosis  was  made  in  seven 
out  of  Senn's  i8  cases.  Exploratory  laparotomy  should  be  done.  The  fluid 
is  usually  brown  or  chocolate  colored,  but  sometimes  it  is  transparent.  It 
presents  some  of  the  characteristics  of  pancreatic  fluid,  emulsifying  fats  and 
converting  starch  into  sugar. 

Treatment. — The  treatment  is  surgical. 

PANCREATIC  CALCULI. 

Etiology. — Pancreatic  calculi  can  only  be  regarded  as  a  precipitation 
from  an  inspissated  pancreatic  juice  determined  by  some  unknown  cause. 

Morbid  Anatomy. — The  calculi,  commonly  about  as  large  as  a  pea,  are 
contained  in  the  pancreatic  duct  and  its  branches.  They  are  usually 
numerous.  They  may  be  smooth,  round,  faceted,  or  irregular  and  rough 
of  .surface.     They  are  composed  of  carbonate  and  phosphate  of  lime. 

Symptoms. — Pancreatic  calculi  are  often  unattended  by  sj^mptoms,  but 
deep-seated  colicky  pain  may  be  present.  The  difficulty  in  distinguishing 
this  from  the  pain  of  biliary  colic  is  increased  by  the  fact  that  jaundice  may 
be  associated  with  either.  Theoretically,  the  pain  of  pancreatic  colic  shovdd 
be  more  deep-seated,  more  central,  and  more  to  the  left.  Practically,  this 
is  not  often  found  to  be  the  case.  If  fatty  diarrhea  and  diabetes  are  asso- 
ciated with  the  colic,  pancreatic  calculus  may  be  inferred.  Rareh'  stones 
are  passed  by  the  bowel,  and  if  such  stones  are  found  to  be  made  up  of  phos- 
phate and  carbonate  of  lime,  they  probably  come  from  the  pancreas. 

Treatment  is  mainly  palliative  bj^  morphin  or  other  anodynes.  Eich- 
horst  has  recommended  hj'podermic  injections  of  pilocarpin  to  stimulate 
the  pancreatic  secretion.     Surgery  is  indicated. 

DISEASES  OF  THE  PERITONEUM. 

ASCITES. 

Synonym. — Hydroperitonenm. 

Definition. — Any  freely  movable  collection  of  fluid  in  the  abdominal 
cavity  sufficiently  copious  to  be  recognizable  by  the  physical  signs  present. 

Etiology. — Ascites  is  a  symptom  of  any  one  of  a  number  of  diseases 
causing  venous  engorgement  of  the  vessels  draining  the  peritoneum,  but  a 
symptom  of  such  importance  as  to  demand  separate  consideration.  Its 
causes  are  in  situ  and  remote.  The  most  frequent  local  cause  is  obstruction 
to  the  portal  circulation,  commonly  by  some  disease  of  the  liver,  especially 
hepatic  cirrhosis.  Any  growth  or  inflammatory  new  formation  in  the 
gastrohepatic  omentum  or  hepatic  fissure  exerting  pressure  on  the  portal 
vein  may  have  the  same  effect.  Abdominal  tumors  outside  of  the  liver 
large  enough  to  exert  the  requisite  pressure  may  also  produce  ascites.  Such 
are  enlarged  spleen  and  tumor  of  the  ovarj^  and  even  of  the  uterus.  Chronic 
inflammation  of  the  peritoneum  is  also  a  cause,  whether  tubercular,  can- 
cerous, or  simple.  More  rarely  cirrhosis  and  emphysema  of  the  lungs 
and  chronic  pleurisy  cause  it.  This  is  the  resi.ilt  of  dilatation  of  the  right 
heart. 


ASCITES  483 

Remote  causes  include,  first  of  all,  valvular  heart  disease,  the  general 
obstruction  due  to  which  causes  ascites  as  a  part  of  a  general  anasarca,  the 
peritoneal  cavity  being  the  last  invaded.  Rarely,  it  is  the  only  dropsical 
symptom  of  heart  disease,  in  which  event  there  must  be  associated  some  in- 
termediate obstruction  of  the  liver.  Bright's  disease  is  also  a  cause  of 
abdominal  dropsy,  in  which  disease,  too,  the  peritoneum  is,  as  a  rule,  is 
last  invaded.  More  rarely  it  occurs  as  a  consequence  of  intense  cachectic 
states,  such  as  the  gravest  forms  of  anemia. 

Symptoms. — A  rather  large  amount  is  required  before  all  the  physical 
signs  to  be  described  are  developed.  The  abdominal  cav-ity  thus  occupied 
is  more  or  less  distended,  pendent  when  the  patient  is  upright  and  ■widened 
when  the  patient  is  on  his  back,  the  flanks  dropping  down  and  outward. 
The  fluid  also  flows  from  one  side  to  the  other  when  the  patient  tiims  on 
his  side.  If  the  distention  is  excessive,  "Lineal  albicentes"  such  as  extend 
across  the  abdomen  in  pregnancy,  make  their  appearance,  and  the  umbilicus 
is  obliterated  or  protuberant.  The  superficial  veins — branches  of  the 
epigastric — are  distended  and  distinctly  visible  due  to  pressure  by  the 
fluid  on  the  vena  cava,  such  pressure  obstructing  the  return  of  blood  from 
the  lower  extremities.  Sometimes  these  superficial  veins  from  below  are 
seen  to  join  those  of  the  mammarj^  from  above.  Such  distention,  however, 
is  often  contributed  to  by  coincident  portal  obstruction  (see  p.  458).  There 
may  also  be  edema  of  the  lower  extremities.  There  is  no  caput  medusae 
about  the  navel  unless  the  portal  circulation  is  also  obstructed. 

As  intimated  in  the  definition,  the  physical  examination  affords  the 
most  reliable  evidence.  To  palpation  there  is  the  succussion  wave,  which 
is  elicited  by  placing  the  palm  of  one  hand  on  the  side  of  the  abdomen  and 
tapping  with  the  fingers  on  the  opposite  side.  A  false  succussion  wave  is 
sometimes  produced  by  this  procedure  in  persons  with  fat,  flabby  beU}-- 
walls,  but  error  may  be  avoided  hv  ha%Tng  an  assistant  place  the  edge  of  his 
hand  vertically  on  the  median  line  and  pressing  firmly  downward  while 
the  tapping  is  done,  as  in  this  way  the  false  wave,  which  travels  around 
through  the  abdominal  wall,  is  obliterated.  It  is  always  difficult,  and 
sometimes  impossible,  to  palpate  solid  organs  when  the  abdomen  is  dis- 
tended with  fluid.  Such  palpation  is,  however,  facilitated  by  a  modifica- 
tion of  the  ordinary  method — ^H[z.,  first  appljdng  lightly  only  the  ends  of 
the  fingers,  then  suddenly  depressing  them,  and  so  displacing  the  fluid 
that  the  solid  organ  can  be  felt. 

Percussion  elicits  absolute  dullness  over  the  fluid,  while  over  the  bowels, 
which  are  floated  upward,  a  tympanitic  note  is  produced,  which  changes 
with  the  position  of  the  patient.  If  there  is  considerable  effusion  and  the 
patient  lies  on  his  back,  there  is  a  small  oval  area  of  tympany  in  the  middle 
of  the  abdomen.  If  a  small  amount  of  fluid  is  present,  the  flanks  only  are 
filled  in  this  position,  and  there  is  a  large  superficial  area  of  tympany  in 
front,  which  wiU  be  substituted  bj^  dullness  if  he  be  placed  in  the  knee- 
elbow  position. 

The  statement  that  in  ascites  there  is  dullness  in  the  flanks  must  be 
taken  with  some  allowance,  for  it  sometimes  happens  that  a  tympanitic 
note  may  be  produced  by  percussion  far  back  in  the  flank  behind  the  mid- 
axillary  line,  because  in  this  situation  lie  the  ascending  and  the  descending 


484  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

colon,  with  the  posterior  asjDect  uneovcrcd  l5y  peritoneum  and  therefore 
inaccessible  to  the  flnid. 

Differential  Diagnosis. — The  morlnd  condition  which  the  physician  is 
most  frequently  called  upon  to  distinguish  from  ascites  is  probably  the 
ovarian  cyst.  The  ovarian  cyst,  especially  when  large,  furnishes  some 
points  of  resemblance,  yet  there  are  striking  differences.  It  begins  in  one 
side  and  rises  from  the  pelvis  toward  the  center  of  the  abdomen,  which 
soon  becomes  the  most  prominent  portion,  while  the  dropsical  effusion 
spreads  out  into  both  flanks.  The  ovarian  cyst  distends  one  side  more  than 
the  other  at  first,  and  continues  to  do  this  even  when  large  and  fully  devel- 
oped. It  produces  no  obliteration  or  projection  of  the  naval,  as  does  ab- 
dominal dropsy.  Palpation  also  recognizes  fluctuation  in  the  ovarian  cyst, 
but  it  is  usually  less  distinct  and  more  circtunscribcd,  while  in  ascites  the 
wave  passes  all  the  way  across  the  abdomen.  To  percussion,  the  latter 
condition  affords  a  central  tympany  and  dullness  in  the  flanks,  while  in 
ovarian  cyst  the  flanks  are  resonant  because  the  bowels  are  pushed  into 
them.  This  is  at  least  true  of  one  flank,  even  if  the  other  is  completely 
occupied  by  a  large  tumor.  If  there  is  tjonpany  in  the  upper  abdomen, 
with  an  ovarian  tumor,  it  is  bounded  below  by  a  convex  line,  while  in  as- 
cites its  lower  border  is  concave. 

A  change  of  position  has  less  influence  on  the  dullness  in  ovarian  tumor 
than  in  ascites.  Vaginal  examination  affords  some  information.  In  ascites 
the  vaginal  vault  is  obliterated,  the  uterus  prolapsed,  but  freely  movable, 
while  in  ovarian  tumor  the  vagina  is  less  encroached  upon,  the  uterus  being 
sometimes  drawn  up  and  less  movable. 

The  characters  of  the  contained  fltiid  are,  as  a  rule,  widely  different. 
The  fluid  of  a  simple  ascites  is  usually  transparent,  has  a  low  specific  gravity-, 
commonly  below  1012,  and  contains  a  small  quantity  only  of  albumin  and  a 
few  leukocytes.  The  ovarian  fluid  is  usuallj'  dark  and  grumous  in  appear- 
ance, highly  albuminous,  mth  a  specific  gravity  of  1020  or  more,  and  reveals 
to  microscopic  examination  numerous  granular  fatty  cells  (compound  granule 
cells),  cholesterin  plates,  and  small,  pale  granular  cells.  These  last  are 
round  or  slightly  oval,  about  the  size  of  a  white  blood-corpuscle,  and  are  by 
some  regarded  as  pathognomonic  of  ovarian  cyst  contents,  and  therefore 
called  "ovarian  cells."  They  are  found  in  pleuritic  fluids,  pus,  and  even 
ascitic  fluids,  but  they  are  much  less  numerous  in  these.  The  cell  is  prob- 
ably a  degenerated  endothelial  cell  from  the  peritoneum.  The  presence  of 
these  cells  in  large  numbers  is  certainly  a  help  to  the  identification  of  ovarian 
fluids. 

In  rare  instances  the  fluid  of  ascites  is  milk-white.  This  occurs  when 
from  any  cause  there  is  leaking  of  chyle  into  the  peritoneal  ca\dty — ascites 
chylosus  and  the  same  condition  due,  not  to  chyle  but  to  fat  drops,  is  present 
in  certain  malignant  cases.  In  the  effusion  associated  with  morbid  growths, 
such  as  cancer  and  tuberculosis,  the  fluid  is  also  sometimes  white  in  color, 
from  the  presence  of  an  unusual  number  of  fattily  degenerated  cells  from 
these  sources  or  from  the  peritoneal  endothelium. 

The  overdistended  bladder  has  been  more  than  once  ]3unctured  b\-  mis- 
take for  ascitic  fluid,  but  this  accident  cg,n  never  occur  if  the  patient  is 
dii-ected  to  empt>'  his  bladder  or  the  catheter  is  used  before  tapping. 


ACUTE  PEIUTOXITIS  485 

Hydronephrosis  has  been  confounded  with  ascites,  and  this  is  less  ex- 
cusable than  the  confounding  of  hydronephrosis  and  ovarian  cyst.  In  ad- 
vanced hydronephrosis  the  fluid  may  be  almost  identical  with  that  of 
ascites,  but  its  mode  of  development  is  from  one  side  and  exceedingly  slow, 
while  there  are  pain  and  tenderness  in  the  region  of  the  kidney.  W.  von 
Leube  relates  a  case  in  which  he  mistook  an  enormously  dilated  stomach 
filled  with  fluid,  for  ascites,  and  points  out  how  easily  the  mistake  could  ha\-e 
been  avoided  by  the  previous  use  of  a   stomach-tube. 

A  cyst  of  the  omentum  is  a  rare  condition,  but  should  be  remembered  as  a 
possible  one  to  be  distinguished  from  ascites. 

Chronic  peritonitis  is  also  attended  by  effusion,  which  is,  however,  more 
limited  than  in  ascites,  and  the  change  in  the  area  of  dullness  on  change  of 
position  is  less  complete  because  of  the  peritoneal  adhesions,  which  interfere 
with  the  ready  movement  of  the  fluid.  In  tubercular  peritonitis,  where 
there  is  less  limitation  by  adhesions,  there  is  also  tenderness.  The  with- 
drawn fluid  is  more  highly  albuminous  and  of  higher  specific  gravity  than 
the  ascitic  fluid  and  is  likely  to  be  purulent. 

Treatment. — The  treatment  of  ascites  is  that  of  the  primary  disease. 
Paracentesis  is  often  necessary  to  relieve  the  discomfort  of  the  patient.  In 
any  case  of  ascites  in  which  the  origin  is  obscure  a  laparotomy  should  be 
performed  instead  of  tapping.  The  fluid  may  accumulate  with  rapidit}- 
and  the  tapping  require  to  be  repeated  quite  frequently,  but  it  is  not  true, 
as  commonly  supposed  by  the  laity,  that  a  first  tapping  necessitates  a  second 
per  se.  When  frequent  tapping  is  necessary,  it  is  sometimes  better  to 
keep  the  orifice  open  and  allow  the  fluid  to  drain  away  continuously,  rigid 
antiseptic  precautions  being  taken.  Under  these  ciraunstances  the  patient 
sometimes  improves  rapidly,  as  he  is  relieved  from  the  exhausting  effect 
of  the  pressure  and  weight  of  the  large  amount  of  liquid  and  of  the  constant 
dread  of  repeated  tappings. 


ACUTE  PERITONITIS. 

Definition. — An  acute  inflammation  of  the  peritoneal  membrane. 

Etiology. — I.  Of  Primary  Peritonitis. — Primary  peritonitis,  or  that  form 
which  originates  independently  of  inflammation  of  adjacent  structures,  is 
spoken  of  as  idiopathic  in  origin.  It  is  a  disease  of  such  rarity  that  its 
existence  may  reasonably  be  questioned,  and  there  are  those  who  deny  its 
occurrence  in  toto. 

2.  Of  Secondary  Peritonitis. — By  this  is  meant  an  inflammation  the 
result  of  invasion  of  the  peritoneum  from  a  primary  focus  of  disease  some- 
where in  the  vicinity,  or  traumatic  agencies,  like  blows  or  punctures  involv- 
ing the  peritoneum.  Formerly,  operations  involving  the  peritoneum  were 
fruitful  causes  of  peritonitis,  but  since  aseptic  surgery  has  become  general, 
such  operations  are  done  with  an  immunity  previously  undreamed  of. 
There  are  two  chief  foci  whence  such  inflammation  originates.  One  of 
these  is  the  digestive  tract;  the  other,  the  genito-urinary  system,  more 
particularly  of  women.  Inflammation  may  also  invade  the  peritoneum 
from  the  liver,  gall-bladder,  spleen,  or  perinephritic  region,  or  from  Pott's 


486  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

disease  or  psoas  abscess.  Perforation  of  the  api:)endix,  stomach  in  ulcer 
or  cancer,  of  the  intestine  in  typhoid  fever,  and  dysentery,  are  the  com- 
monest causes  originating  in  the  gastro-intcstinal  tract.  The  second  focus 
is  purulent  inflammation  of  the  Fallopian  tubes  and  the  genito-urinary 
tract.  Endometritis  and  metritis  may  be  the  starting-point  of  such  in- 
flammation, which  may  extend  up  the  Fallopian  tube,  or  there  may  be 
parametritis  with  suppuration,  the  abscess  arising  from  which  may  rupture 
into  the  peritoneal  cavity.  All  of  the  different  forms  of  secondary'  perit- 
onitis are  infectious,  and  caused  either  by  organisms  responsible  for  the 
primary  disease  or  by  such  as  are  set  free  with  the  gastric  or  intestinal  con- 
tents by  perforation.  The  organisms  found  under  these  circumstances 
are  the  streptococcus  pyogenes,  the  staphylococcus  pyogenes  aureus  or  albus, 
and  the  bacterium  colt  commune,  the  latter  especially  after  perforation  of  the 
appendix,  also  the  tubercule  bacillus.  The  ameba  coli  has  been  found  in  the 
peritoneal  fluid  in  amebic  dysentery.  Peritonitis  maj^  also  occur  from  in- 
fection from  more  distant  foci  of  suppuration,  when  it  is  also  called  pyemic 
peritonitis.  Tubercidar  peritonitis  is  rather  common,  and  when  of  the 
miliary  type,  the  symptoms  are  very  acute. 

Finally,  peritonitis  not  infrequently  becomes  a  complication  of  pleurisy, 
also  articular  rheimiatism,  and  nephritis  by  a  process  not  thoroughly  deter- 
mined. The  first  is  probably  the  result  of  extension  by  continuit}',  since 
the  two  cavities  communicate  by  the  lymph-vessels  of  the  diaphragm. 

Morbid  Anatomy. — This  varies  somewhat  with  the  extent  of  the  perit- 
onitis and  the  duration  of  the  attack.  First,  there  may  be  a  "general"  or 
"diffuse"  peritonitis,  or  it  may  be  "circumscribed."  In  general  peritonitis 
the  peritoneal  surface  of  the  intestinal  coils  is  hyperemic  and  covered  more 
or  less  continuously  wath  flakes  of  yellow  hinph  made  up  of  fibrin  and 
leukocytes.  This  is  especially  abundant  in  the  sulci  between  the  coils, 
while  it  also  covers  the  convexity.  In  an  earlier  stage,  before  the  exudate 
appears,  the  surface  of  the  peritoneiun  is  dull  and  rough,  owing  to  a  des- 
quamation of  the  epitheliimi.  In  the  flanks  is  found  a  variable  amount  of 
fluid,  which  may  be  serous,  sero-fibrinous,  or  purulent,  which,  increasing, 
produces  an  appreciable  ascites.  In  prolonged  cases  organization  and 
vascularization  from  the  capillaries  of  the  peritoneum  take  place,  the  solid 
contingent  being  formed  from  the  epithelium  or  wandering  cells,  resulting  in 
adhesions  between  the  coils  of  intestine  and  adjacent  organs.  These  are  at 
first  soft  and  easily  iniptured,  but  later  become  firm  bands.  These  latter 
are,  however,  more  common  in  the  circumscribed  form. 

In  circumscribed  peritonitis  limited  areas  of  Ij'mph  formation  occur  and 
adhesions  are  more  pronounced.  Copious  fibrinoserous  exudate  is  less  fre- 
quent, though  sometimes  quite  large  circumscribed  collections  of  pus  occur, 
laced  off  from  the  remainder  of  the  peritoneal  ca\dty  by  organized  tissue. 
Such  abscesses  sometimes  nipture  into  the  general  peritoneal  cavity, 
producing  general  inflammation,  collapse,  and  death. 

Symptoms. — i.  Of  an  Acute  Diffuse  Peritonitis. — -The  most  decided 
symptom  is  pain,  usually  of  extreme  severity,  which  is  commensurate  in 
extent  with  that  of  the  inflammation.  There  is  also  extreme  tenderness, 
which  is  similarly  limited.  So  great  is  this  that  any  tension  on  the  abdom- 
inal walls  excites  pain;  hence  the  legs  are  drawn  up  to  relieve  this,  and  we 


ACUTE  PERITONITIS  487 

have  the  well-known  position  almost  characteristic  of  diffuse  peritonitis — 
dorsal  decubitus,  with  the  thighs  flexed  on  the  abdomen.  Any  motion  such 
as  straining,  even  the  act  of  breathing  and  the  emptying  of  the  bladder, 
increases  pain.  From  the  nature  of  the  causes  this  pain  is  usually  sudden  in 
occurrence,  succeeding,  as  it  does,  on  perforation,  on  abscess  rupture,  and 
the  like.  Sometimes,  indeed,  it  is  the  first  intimation  of  any  illness  what- 
ever. Abdominal  distention  is  a  third  characteristic  symptom  of  peritonitis, 
ascribed  to  a  paralysis  of  the  muscular  coat  of  the  bowel,  and  continues 
throughout  the  attack.  Rarely,  however,  the  abdomen  is  flat,  hard,  and 
board-like.     As  rarely,  too,  pain  is  altogether  absent. 

Among  the  symptoms  which  may  usher  in  the  attack  is  vomiting.  It 
is  regarded  as  reflex  in  origin,  excited  by  the  inflammation  of  the  peritoneum. 
The  effort  is  sometimes  ineffectual,  and  sometimes  a  perforation  of  the 
stomach  permits  the  more  ready  discharge  of  its  contents  into  the  abdominal 
cavity.  The  vomitus  consists  of  what  happens  to  be  in  the  stomach  at  the 
time,  or  of  mucus  and,  if  the  symptom  is  prolonged,  of  green,  bilious  matter. 
The  primary  vomiting  is  followed  by  abatement  or  exacerbation. 

The  symptoms  which  are  associated  with  these  or  succeed  upon  them 
vary  with  the  nature  of  the  cause  and  extent  of  the  disease.  In  fulminating 
cases  due  to  perforation  of  the  bowel,  as  in  typhoid  and  appendicitis,  they 
are  the  symptoms  of  collapse — ^viz.,  extreme  weakness,  cold,  clammy  skin, 
frequent,  small,  and  feeble  pulse.  The  pulse  exceeds  120  and  often  reaches 
1 60  and  even  more.  The  breathing-rate  is  from  30  to  40.  The  temperature 
is  slightly  raised,  remains  about  normal,  or  may  be  subnormal.  Rarely,  it  is 
high — 104°  to  105°  F.  (40°  to  40.6°  C.) — though  the  skin  may  feel  cool  and 
clammy.  The  expression  is  characteristic — Hippocratic.  The  eyes  are 
sunken,  the  cheeks  and  temples  are  collapsed,  and  the  nose  is  pinched.  The 
urine  is  scanty  and  contains  indican. 

If  the  patient  survive,  the  physical  signs  of  effusion  make  their  appear- 
ance. There  is  dullness  on  percussion,  first  in  the  flanks,  whence  it  ascends 
as  the  fiuid  increases.  If  sufficiently  abundant,  the  dullness  becomes 
general  and  fluctuation  maj^  be  recognized.  Palpation  and  percussion  both 
occasion  pain.  A  change  of  position  from  the  back  to  the  side  causes  a 
change  in  the  position  of  the  fluid,  and  corresponding  alterations  in  the 
physical  signs.  In  severe  cases  the  diaphragm  is  raised,  the  apex  of  the 
heart  dislocated,  and  the  liver  dullness  may  be  obliterated  in  the  mammillary 
line  by  combined  effusion  and  extreme  tympany.  Similar  obliteration  may 
happen  to  the  splenic  dullness.  Both  may  be  restored  by  turning  the 
patient  on  his  side.  Such  obliteration  is,  however,  far  more  characteristic 
in  what  is  known  as  pneumo-peritonitis ,  a  form  of  peritonitis  caused  by  per- 
foration from  an  air-containing  organ  into  the  peritoneal  cavity,  and  of 
intense  severity,  excited  by  the  pathogenic  bacteria  thus  admitted.  Acute 
pain,  rapidly  developing  collapse,  scarcely  appreciable  pulse,  icy  coldness  of 
the  skin,  and  great  distention  of  the  abdomen  are  the  symptoms.  The  air, 
of  course,  occupies  the  highest  part  of  the  abdominal  cavity,  covering  the 
liver  and  spleen,  causing  the  obliteration  referred  to.  The  distinctive  point 
in  the  diagnosis  between  pneumo-peritonitis  and  the  extreme  degrees  of  the 
ordinary  form  is  the  fact  that  in  the  former  hepatic  dullness  is  absent  even 
in  the  midaxillary  line  when  the  patient  is  on  his  left  side,  whereas,  in  simple 


488  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

peritonitis,  hepatic  dullness  may  be  elicited  when  the  patient  is  in  this 
position,  though  it  may  not  be  if  he  is  on  his  back. 

Throughout  all,  the  intellect  is  clear,  and  while  there  is  often  a  total 
lack  of  realization  of  the  inevitable  and  usually  dreaded  end,  it  is  as  often 
thoroughly  appreciated  by .  the  patient  and  is  viewed  with  a  calmness 
which  increases  the  awe  which  always  attaches  to  the  presence  of  the 
shadow  of  death.  Rarely,  in  the  course  of  his  experience,  is  the  physician 
called  upon  to  witness  a  more  painftd  scene.  Toward  the  very  end,  how- 
ever, a  somnolence  commonly  supervenes  which  obscures  the  expiring 
moment,  or  a  slight  delirium  the  visions  of  which  may  be  interpreted  b>- 
surrounding  friends  as  the  first  glimpses  into  another  world. 

The  course  of  such  a  case  is  steadily  do\\"nward,  reaching  its  end  in  from 
two  to  six  days. 

2.  Of  Acute  Circumscribed  Peritonitis. — The  symptoms  include  those 
of  the  general  form  in  a  very  much  milder  degree.  The  pain  is  less  severe 
and  more  circumscribed,  the  tenderness  proportionate,  while  neither  is 
sharply  defined.  Vomiting  may  also  usher  in  the  attack,  and  may  be 
similarly  modified.  There  may  likewise  be  the  signs  of  collapse,  and  the 
patient  is  often  very  weak.  There  is,  however,  more  decided  and  constant 
fever  though  remittent,  as  in  septic  fever  generally,  and  the  cases  run  a 
longer  course,  ending  not  rarely  in  recovery,  but  more  frequently  in  death 
from  exhaustion. 

As  already  mentioned,  circumscribed  abscesses  are  more  frequently 
recognized  by  fluctuation,  and  may  even  point  toward  the  surface,  though 
they  are  as  liable  to  rupture  into  the  general  peritoneal  cavity,  producing 
there  the  symptoms  and  more  usual  fatal  termination  of  general  peritonitis. 
This  serious  termination,  at  the  present  day,  is  often  prevented  by  the 
timely  interference  of  the  surgeon.  As  varieties  of  such  abscess  may  be 
mentioned  the  perinephric  abscess,  the  pelvic  abscess,  the  subdiaphrag- 
matic abscess,  arising  from  perforation  of  the  stomach  or  colon  or  disease 
of  the  liver  or  spleen,  and  the  periappcndicial  abscess.  The  results  of  cir- 
cumscribed peritonitis  in  children  are  sometimes  seen  in  the  shape  of  a  pain- 
ful, fluctuating  tumor  in  the  groin.  Circumscribed  peritonitis  is  also  more 
or  less  associated  with  the  symptoms  of  the  disease  which  causes  it. 

Diagnosis. — That  of  general  peritonitis  is  seldom  difficult,  especially  in 
the  fulminating  variety.  Some  days  may,  however,  elapse  before  the  ques- 
tion is  settled,  for  sometimes  the  symptoms  are  closely  simulated  by  those 
of  other  conditions.  Particularly  is  this  the  case  with  extreme  tympany 
and  tenderness  which  are  sometimes  associated  with  typhoid  fever,  espe- 
cially when  there  is  deep-seated  ulceration.  It  not  rarely  happens  that 
on  these  symptoms  is  based  the  diagnosis  of  a  peritonitis,  which  is  not 
found  at  necropsy.  Entero-colitis  may  give  rise  to  similar  symptoms.  On 
the  other  hand,  it  has  happened  that  grave  and  fatal  peritonitis  has  eluded 
detection,  ha^^ng  been  found  for  the  first  tim.e  at  autopsy.  Obstruction 
of  the  bowel  has  been  spoken  of  in  a  former  chapter. 

Acute  hemorrhagic  peritonitis  should  be  mentioned  as  a  variety,  the 
symptoms  of  which  sometimes  are  the  same  as  those  of  the  ordinary  form. 

Circumscribed  peritonitis  is  more  frequently  difficult  of  detection,  and 
its  diagnosis  aftcn  requires  a  knowledge  of  the  presence  of  the  causative 


CHKOX/C  PERITOXITIS  489 

disease  to  suggest  it.  Fluctuation  is  only  available  in  diagnosis  when  there 
is  superficial  abscess. 

Prognosis. — This,  in  general  peritonitis,  is  almost  invariably  fatal,  only 
the  mildest  cases  offering  the  possibility  of  recovery  under  medical  treat- 
ment. Modem  surgery  has  many  times  saved  life  even  in  peritonitis  which 
succeeds  perforation  in  typhoid  fever,  gastric  ulcer,  and  perforated  gall- 
bladder.    The  duration  of  untreated  cases  is  from  two  to  six  days. 

Localized  peritonitis  is  a  more  promising  malady.  A  few  cases  get  well 
by  spontaneous  discharge  of  resulting  abscesses,  more  with  the  assistance 
of  the  surgeon,  and  some  neglected  cases  doubtless  perish  when  timely  aid 
from  this  source  would  have  saved  life. 

Treatment. — The  treatment  of  general  peritonitis  succeeding  perfora- 
tion consists  in  immediate  surgical  interference,  repair  of  the  ruptured 
organ  and  drainage  of  the  cavit3^  If  this  for  an}^  reason  fails  an  operation 
cannot  be  done  or  will  not  be  accepted,  or  if  a  peritonitis  is  present  or  de- 
velops with  an  operation  the  best  treatment  is  as  follows :  Put  the  patient 
upright  in  bed,  Fowler's  position,  give  absolutely  nothing  by  the  mouth, 
introduce  by  the  drop  method  into  the  rectum  a  normal  saline  solution. 
Control  pain  with  morphine.  Hot  or  cold  applications  to  the  abdomen. 
When  doubt  as  to  diagnosis  exists — as  to  whether  there  is  true  peritonitis 
or  painful  distention  of  the  bowel — turpentine  may  be  administered  with 
full  doses  of  strychnin,  say  1/30  to  1/20  grain  (o.  002  to  0.003  gni-).  while 
turpentine  may  be  applied  locally.  Iced  turpentine  stupes  are  often  ex- 
ceptionally grateful.  Turpentine  enemas  under  these  circumstances  are 
of  doubtful  utility,  in  fact,  may  do  more  harm  than  good,  and  should  be 
discouraged. 

Special  symptoms,  such  as  nausea,  faintness,  and  exhaustion,  require 
the  treatment  usually  appropriate  to  control  them.  For  failing  strength, 
stimulants,  local  heat,  hypodermic  injections  of  ether,  digitalis,  brandy, 
and  strychnin  are  available,  as  the  case  improves  small  quantities  of  pep- 
tonized milk,  albumin  water  or  beef  juice  may  be  given. 

The  treatment  of  circumscribed  peritonitis  permits  the  use  of  local 
measures  not  admissible  in  the  general  form.  The  ice  bag  is  sometimes 
of  signal  ser^dce  in  relieving  symptoms  and  may  even  effect  a  cure  if  the 
cause  is  rem.oved.  Blisters  and  leeches  should  not  be  used  as  they  interfere 
with  the  expected  field  of  operation.  The  surgeon  and  the  gynecologist 
shoiild  be  early  summoned,  as  it  is  most  frequently  through  their  assistance 
that  a  cure  is  accomplished. 


CHRONIC  PERITONITIS. 

Etiology. — By  far  the  largest  majority  of  cases  of  chronic  peritonitis 
are  tubercular  in  origin.  Some  cases  are  caused  by  cancer  and  other  morbid 
growths  in  the  abdomen,  while  there  are  also  others  of  simpler  origin.  Thus 
originating,  we  have  both  a  circumscribed  adhesive  peritonitis  and  a  diffuse 
form  of  the  same  disease.  See  also  Section  on  Tuberculosis  of  the  Perito- 
neum, p.  308. 


490  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Chronic  Adhesive  Peritonitis. 

Synonyms. — Chronic  Adhesive  Sclerosive  Peritonitis;  Chronic  Circumscribed 

Peritonitis. 

This  occurs  between  adjacent  organs,  such  as  the  spleen  and  diaphragm, 
liver  and  diaphragm,  stomach  and  liver,  and  organs  in  similar  relation,  as 
the  result  of  chronic  disease  in  one  or  the  other.  The  spaces  about  the  gall- 
bladder, the  flexures  of  the  bowels,  posterior  peritoneum  and  the  omentum 
ma-Y  be  sites.  These  adhesive  connections  are  not  always  close,  but  some- 
times consist  of  bands  of  considerable  length,  such  as  have  already  been 
referred  to  as  occasional  causes  of  obstruction  of  the  bowel. 

Morbid  Anatomy. — The  primary  result  is  a  thickening  of  the  peritoneimi 
with  subsequent  contraction  and  adhesion.  The  condition  may  begin  as  a 
subperitoneal  fibroid  infiltration. 

Symptoms. — Constipation  or  symptoms  of  obstruction  of  the  bowel 
are  often  the  first  evidence  of  the  existence  of  such  adhesive  bands.  Other 
symptoms  are  a  sense  of  restriction  in  the  motion  of  organs  involved,  with 
pain  when  such  motion  occurs;  also  colicky  pains,  and  pains  resulting 
from  traction  exerted  in  peristalsis.  Other  vague  symptoms  occtir  which 
go  to  make  the  patient  uncomfortable,  but  are  not  distinctive.  Should  a 
peritoneal  friction,  however,  be  felt,  more  conclusive  evidence  is  thus 
furnished.  Should  suppuration  attend  chronic  inflammation,  more  dis- 
tinctive symptoms  also  arise.  In  addition  to  the  pain  and  tenderness  a 
hectic  fever  may  be  present,  which  may  guide  to  a  correct  conclusion,  or 
eventual  rupture  into  one  of  the  hollow  abdominal  organs  may  occur. 

Diffuse  Chronic  Peritonitis. 

This  may  succeed  upon  acute  difliuse  inflammation  of  mild  degree, 
which  is  followed  by  an  abatement  in  all  the  sjTnptoms.  It  may  occur  in 
connection  with  chronic  cardiac  disease  including  pericarditis  or  hepatic 
disease  where  there  has  been  long-continued  venous  stasis;  or  it  may  suc- 
ceed the  punctures  of  numerous  tappings  and,  most  rarely,  chronic  intestinal 
disease. 

Morbid  Anatomy. — The  peritoneum  is  thickened.  The  intestinal  coils 
may  be  cemented  to  one  another  and  to  neighboring  organs.  The  liver 
and  spleen  are  sometimes  covered  by  thick,  tough,  gristly  capsules.  The 
omentum  and  mesentery  may  be  thickened  and  shrunken.  There  may 
be  thickened  nodules,  not  tubercular.  There  is  in  these  cases  rarely  con- 
siderable effusion.  A  hemorrhagic  form,  suggesting  hemorrhagic  pachy- 
meningitis, was  described  by  Virchow.  It  is  more  commonly  situated  in 
the  pelvis  and  characterized  by  bloody  effusion. 

Symptoms. — These  exhibit  for  the  most  part  a  diminished  degree  of 
those  characteristics  of  acute  peritonitis,  to  wliich  may  be  added  tumor-like 
swellings  and  thickenings  and  swelling  difficult  to  interpret.  Other  vague 
symptoms  are  engendered  by  them  as  the  result  of  contraction  and  pressure, 
including  pain,  edema,  albuminuria,  irregularity  of  the  bowel  action,  and 
sometimes  feverishness.  There  is  little  that  is  characteristic  unless  it  be 
the  occasional  presence  of  recognizable  effusion.     The  very  slow  forms 


MULTIPLE  SEROSITIS  491 

attended  with  extensive  effusion  are  not  separable  from  ascites,  the  result 
of  hepatic  disease,  although  there  are  differences  in  the  effusion.  In  peri- 
tonitis the  effusion  is  more  turbid,  contains  abundant  albimiin,  and  has  a 
specific  gravity  rather  higher  than  the  fluid  of  an  ascites:  1018  as  compared 
with  1012. 

A  chronic  peritonitis  not  unusual  in  children  from  two  to  ten  years  old 
is  described  by  Striimpell  and  others.  It  is  associated  with  decided  ascites, 
debility,  and  other  symptoms  of  ill  health  more  or  less  marked,  while  re- 
covery is  the  usual  termination.  Such  a  cause  for  the  ascites  should  not 
be  assigned  without  careful  search  for  others,  especially  disease  of  the 
liver. 

Treatment. — The  treatment  must  be  determined  by  circumstances.  It 
is  chiefly  palliative,  unless  operative  interference  promises  more. 

MULTIPLE  SEROSITIS. 

Synonyms. — Multiple  hyaloserositis;   Zuckergussleher    {Iced   liver);   Hyper- 
plastic perihepatitis;  Pericarditic  pseudocirrhosis  of  the  liver; 
Indurative  mediastinopericarditis;  Polyorrhomenitis . 

Definition. — An  inflammatory  affection  invading  extensive  areas  of 
serous  membrane,  beginning  in  the  pericardium,  the  pleura,  or  peritoneum 
and  further  characterized  by  ascites  and  more  rarely  by  edema  of  the 
extremities. 

Etiology. — No  special  pathogenic  organism  has  been  found  associated 
with  the  disease,  but  as  suggested  by  Nicholls,^  some  germ  of  relatively 
low  virulence  with  a  penchant  for  serous  membrane  is  likely  to  be  the 
cause  of  the  proliferative  inflammation.  Such  a  bacillus  may  be  the  pneu- 
mococcus,  the  bacillus  of  typhoid  fever,  the  bacillus  coli  and  the  bacillus 
tuberculosis. 

Morbid  Anatomy. — The  morbid  anatomy  of  the  process  varies  with  the 
seat  of  the  membrane  first  invaded  and  the  organs  covered  or  embraced  by 
it.  Thus  where  perihepatitis  is  primary  the  primary  perihepatitis  of 
Nicholls,  ascites  appears  early  and  is  prone  to  recur  after  tapping.  The 
liver  itself  is  large,  smooth,  subsequently  contracted  and  the  Glisson's 
capsule  may  take  on  the  appearance  of  "icing"  which  has  given  rise  to  one 
of  the  names  of  the  affection.  After  this,  the  pleura  is  usually  invaded, 
and  finally  the  pericardivim.  In  the  cases  where  pericarditis  (primary 
pericarditis  of  Nicholls)  is  primary,  an  adhesive  pericarditis  sets  in  which 
may  be  obliterative,  and  even  invade  the  entire  mediastinum.  Occasionally 
only  there  is  a  little  pericardial  effusion.  From  the  pericardium  the  in- 
flammation extends  to  the  pleura  and  finally  the  peritoneum  and  capsule 
of  the  liver.  Pleuritic  adhesions  may  be  marked  as  the  result  of  the  pleu- 
risy. The  spleen  is  sometimes  enclosed  in  the  "icing"  capsule,  so  striking- 
in  the  case  of  the  liver. 

Symptoms. — These  also  vary  with  the  seat  of  beginning.  In  the  peri- 
cardial variety,  the  symptoms  and  physical  signs,  more  or  less  pronounced, 
of  .-pericarditis,  usher  in  the  disease.     It  is  in  this  form  that  edema  of  the 

iNichoIla:  Stu  lies  from  the  Royal  Victoria  Hospital,  vol.  (i.,  No.  3,  April,  1902. 


492  DISEASES  01-   THE  DIGESTIVE  SYSTEM 

extremities  and  face  appears  early  as  the  result  of  cardiac  weakness,  but 
may  disappear  later  and  be  replaced  by  ascites.  Previous  to  the  latter, 
however,  the  signs  of  pleurisy  on  one  or  both  sides  have  probably  appeared. 
In  the  perihcpatitic  form,  enlarged  liver,  often  palpable,  with  subsequent 
contraction  and  ascites,  is  first  noted,  followed  by  s\'mptoms  of  pleurisy 
with  or  without  effusion. 

Fullness  of  the  abdomen,  oppression  and  dragging  weight  are  also 
symptoms  depending  upon  the  abdominal  contingent  of  the  disease.  Pulsa- 
tion of  the  liver  may  be  present  and  distinguish  the  associated  disease  of 
this  organ  from  cirrhosis  of  the  liver. 

Diagnosis. — The  chief  cause  of  en^ors  in  diagnosis  and  of  late  diagnosis 
is  the  latencj-  of  the  affection  and  the  slowness  of  its  development.  But 
this  very  slowness  in  association  with  the  signs  and  sj^mptoms  named  should 
be  a,  valuable  aid  to  diagnosis.  Emphasis  should  be  laid  on  the  fact  that 
this  disease  is  something  different  from  cirrhosis  of  the  liver  which  is  also 
associated  with  ascites  but  not  with  pericarditis  and  pleurisy. 

Prognosis. — Slowness  of  development  and  gradually  failing  phj-sical 
strength,  with  ultimate  death  from  exhaustion  are  characteristic,  but 
occasional  interruptions  in  the  progress  of  the  disease,  during  which  the 
patient  may  even  resimme  work  for  a  time,  should  be  added  as  a  feature. 

Treatment. — There  is  no  treatment  except  that  of  the  symptoms,  in- 
cluding especially  effort  to  build  up  the  strength  of  the  patient.^ 

CANCER  OF  THE  PERITONEUM. 

Primary  cancer  of  the  peritoneum  is  an  event  of  extreme  rarity.  Its 
occurrence  as  a  true  epithelial  cancer  must,  however,  be  admitted.  Colloid 
cancer  also  occurs  as  a  diffuse  and  extensive  growth,  relatively  firm,  and 
without  fluctuation.  More  frequently  peritoneal  cancer  is  secondary  to  can- 
cer of  the  stomach,  bowel,  pancreas,  uterus,  or  other  organ;  most  frequently, 
perhaps,  as  an  extension  by  contiguity,  though  also  by  metastasis.  It 
occurs  in  the  shape  of  small  or  large  nodules  scattered  over  the  peritoneum. 
The  former  constitutes  what  is  known  as  miliary  carcinoma.  The  larger 
nodules  are  found  in  the  omentum,  in  Douglas'  culdcsac,  around  the  navel 
and  elsewhere,  while  the  retroperitoneal  glands  may  be  simultaneously 
involved. 

Symptoms. — These  are  those  of  chronic  peritonitis,  including  effusion, 
with  the  added  cachexia,  and  a  diagnosis  must  be  based  on  these,  the  ante- 
cedent history,  and  the  possible  presence  of  cancer  elsewhere.  The  investi- 
gation must  inckide  the  uterus  and  the  rectum.  The  physical  resemblance 
of  the  miliary  form  to  tuberculosis  is  very  marked,  and  in  primary  carcinoma 

'  This  disease  is  exhaustively  discussed  in  a  valuable  paper  "On  Multiple  Serositis."  read  before  the 
College  of  Physicians  of  Philadelphia  by  A.  O.  J.  Kelly,  in  March,  1902,  and  published  in  the  Transactions 
of  the  ColIcRe  for  that  year;  also  in  the  "American  Journal  of  Medical  Sciences,"  Jan.,  1903,  p.  ri6.  Other 
papers  on  the  same  subject  are  by: 

Curschmann,  "2ur  differential  Dia^ostik  der  mit  Ascites  verbundenen  Erlcrankungen  der  Leber  und 
der  Pfortadersystem."     "Deutsche  medicinische  Wochenschrift,"  1884.  vol.  x.,  p.  564. 

Harris,  "Indurative  Mediastino-pericarditis."     "Medical  Chronicle,"  1895,  vol.  ii..  pp.  I,  87,  178,  250. 

Nicholls,  "Studies  from  the  Royal  Victoria  Hospital,"  vol,  i..  No.  3.  April.  1902. 

Pick.  "Ucber  chronischer,  unter  dem  Bilde  der  Lebercirrhose  verlaufendc  Pericarditis"  (pericarditische 
Pseudolebercirrbose).     "Zcitschrift  fur  klinische  Medicin,"  1896,  vol.  xxix..  p.  385. 

Siegert,  "Ueber  die  Zuckergussleber  (Curschmann)  und  die  pericarditische  Pseudolebercirrbose" 
(Pick),  "Virchow's  Archiv.  fur  path.  Anatomic."  1898,  vol.  cliii.,  p.  251. 

Howard  Fussell  and  Henry  D.  Jump,  A  Case  of  Probable  Multiple  Serositis. 

"Transactions  of  the  College  of  Physicians  of  Philadelphia."  vol.  xxv.,  p.  55,  1903. 

Kelly's  paper  also  contains  a  large  number  of  references  to  which  the  interested  reader  is  referred. 


HYDATID  OF  THE  PEIUTOXELM  493 

the  distinction  is  difficult.  Palpation  may  recognize  friction  in  both.  In 
both  the  effusion  may  be  bloody,  but  is  more  apt  to  be  so  in  cancer  than  in 
tuberctolosis.  The  test  injection  of  tuberculin  should  be  availed  of.  The 
cancerous  patient  is  past  middle  life,  the  tubercular  younger,  tubercular 
peritonitis  being  especially  frequent  in  children. 

HYDATID  DISEASE  OF  THE  PERITONEUM. 

The  possible  presence  of  echinococci  in  the  peritoneum  is  to  be  remem- 
bered. The  local  symptoms  may  resemble  those  of  cancer  very  closely. 
The  presence  of  hydatid  tumors  elsewhere,  as  in  the  liver,  of  course  suggests 
the  true  nature  of  the  simulating  disease. 


SECTION  III. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ACUTE  RHINITIS. 

Synonym. — Coryza. 

Definition. — Simple  acute  inflammation  of  the  nasal  passages. 

Etiology. — Simple  acute  rhinitis  in  manj'  instances  is  unquestionably 
infectious.  In  many  victims  there  is  a  tendency  to  recurring  attacks. 
The  exudative  forms,  including  simple  fibrinous  rhinitis  and  nasal  diph- 
theria, are,  of  course,  of  a  specific  infectious  nature. 

Symptoms. — The  well-known  uncomfortable  full  feeling  which  all  have 
experienced  under  the  name  of  "cold  in  the  head,"  is  a  frequent  event. 
There  may  be  previous  sneezing.  The  fullness  is  due  to  swelling  of  the 
mucous  membrane,  the  result  of  inflammation,  and  is  sooner  or  later  followed 
by  a  discharge  which,  at  first  watery,  may  or  may  not  become  mucopuru- 
lent. With  it  comes  relief  of  the  most  uncomfortable  symptom,  the  nasal 
obstruction.  This  is  most  serious  in  nursing  children,  in  whom  it  renders 
sucking  often  very  difficult.  There  may  be  slight  fever,  but  the  consti- 
tutional disturbance  is  seldom  decided,  and  the  elevation  of  temperature 
is  correspondingly  trifling,  rarely  exceeding  a  degree.  There  is  sometimes 
dullness  in  hearing  and  perverted  sense  of  taste  and  smell. 

Treatment. — Prophjdaxis  is  important.  Unquestionably  most,  if  not 
all,  common  colds  including  a  "cold  in  the  head"  are  infectious.  Living 
in  shut-in  rooms,  frequently  unventilated  places  where  others  congregate 
are  further  sources  of  the  condition.  Fresh  air  and  avoidance  of  close 
rooms  is  important.  Sleeping  in  well-ventilated  rooms  or  even  protected 
places  in  the  open  wiU  do  more  to  cure  a  cold  in  the  head  than  any  other 
remedy.  When  this  condition  is  associated  with  inflammation  of  the  ad- 
jacent mucous  membrane  of  the  respiratory  passages  and  of  the  throat, 
its  treatment  is  that  of  the  concurrent  affection.  A  promptly  acting  saline 
aperient,  such  as  citrate  of  magnesium  of  Epsom  salts,  maj'  with  advantage 
precede  other  treatment.  The  discomfort  is  partialh^  due  to  the  dryness, 
and  this  is  overcome  by  the  application  of  any  simple  ointment,  as  liqiud 
petrolatum,  cold  cream  or  vaselin,  applied  by  means  of  a  brush  or  the  end 
of  the  finger.  The  same  result  is  better  accomplished  by  the  oil  spray,  for 
which  liquid  paraffin  may  be  used.  Such  applications  to  the  adjacent 
parts  are  also  useful  when  the  discharge  is  irritating.  Dobell's  solution 
may  also  be  sprayed  into  the  nose,  and  when  dry  discharges  accumiolate, 
they  shoiold  be  washed  out  by  gentle  injections  of  tepid  normal  salt  solu- 
tion. Dobell's  solution  is  composed  of  sodium  borate  i  dram  (4  gm.), 
sodium  bicarbonate  i  dram  (4  gm.),  ghxerite  of  carbolic  acid  (U.  S.  P.) 
2  drams  (S  gm.),  and  water  i  pint  (0.5  liter). 

494 


CHRONIC  RHINITIS  495 

The  liquor  antisepticus  of  U.  S.  P.  may  be  used.  Hexamethylenamine 
in  doses  of  from  3  to  5  grains  (o.  18-0.3)  may  be  used  even'  3  hours.  A  spray 
of  adrenalin  chloride  1-4000  may  be  used  with  benefit.  Cocaine  should  not 
he  used  for  fear  of  causing  the  drug  habit. 


CHRONIC  NASAL  CATARRH. 

Synonyms. — Chronic  Rhinitis;  Ozena. 

Definition. — Chronic  inflammation  of  the  nasal  mucous  membrane, 
associated  with  increased  secretion  and  loss  of  the  sense  of  smell. 

Etiology. — Chronic  catarrh  of  the  nasal  passages  may  be  the  result  of 
acute  inflammation  frequently  recturing,  but  it  may  arise  from  speical 
causes.  A  few  cases  of  rhinitis  are  the  result  of  tuberculosis  of  the  mucous 
membrane  of  the  nose.  A  frequent  cause  is  syphilis.  In  consequence  of 
the  offensive  odor  frequently  associated  with  one  form  of  chronic  nasal 
catarrh — the  atrophic — it  has  been  termed  ozena. 

Morbid  Anatomy. — Two  broad  divisions  of  chronic  nasal  catarrh  are 
made  from  the  anatomical  standpoint — the  hypertrophic  and  the  atrophic. 
In  the  hypertrophic  there  is  a  thickening  of  the  mucous  membrane,  while 
in  the  atrophic,  a  thinning  or  atrophy  is  present.  In  the  hypertrophic 
catarrh,  the  membrane  is  red,  swollen,  and  spongy.  The  cavernous  tissue 
over  the  turbinated  bones  shares  in  the  process,  and  the  nasal  cavities  may 
be  encroached  upon  from  all  sides.  The  protrusion  becomes  more  marked 
as  the  disease  progresses,  and  to  it  is  added  a  greater  or  less  hypersecretion 
of  mucus. 

In  the  atrophic  or  fetid  form,  the  nasal  mucous  membrane  is  thinned, 
the  cavities  are  enlarged,  and  within  them  are  found  the  thick,  yellowish- 
green  crusts  which,  in  decomposing,  give  rise  to  the  characteristic  offensive 
odor  of  this  form  of  rhinitis.  The  atrophic  process  involves  all  the  tissues, 
from  the  epithelium  down  to  and  including  the  underljdng  bone.  The 
accessory  sinuses  connected  with  the  nose — the  frontal,  ethmoidal,  and 
maxillary — may  all  become  implicated  in  this  disease  by  extension  from  the 
nasal  chambers,  and  may  become  the  seats  of  chronic  purulent  inflammation. 

Symptoms. — The  two  principal  forms  of  nasal  catarrh  have  certain 
symptoms  in  common.  In  both  there  is  more  or  less  marked  obstruction 
to  nasal  respiration.  In  the  hypertrophic  form,  however,  this  is  due  to 
actual  narrowing  of  the  nasal  chambers  by  the  overgrowth  of  the  con- 
tained structures,  while  in  the  atrophic  form  it  is  due  to  the  choking  of 
the  passages  by  the  large  masses  of  inspissated  mucus  and  mucopus. 
There  is  generally  some  slight  impairment  oj  the  sense  of  smell  in  the  hyper- 
trophic form,  while  in  the  atrophic  it  is  more  often  completely  abolished. 
Both  forms  are  usually  accompanied  by  disturbances  of  secretion  in  the 
nasopharynx,  and  these  lead  to  those  noisy  efforts  at  clearing  the  throat 
termed  "hawking."  The  ozena,  or  fetid  odor,  is  symptomatic  only  of 
the  atrophic  variety.     No  odor  is  produced  by  simple  hypertrophic  catarrh. 

Hypertrophic  nasal  catarrh  is  apparently  much  more  common  in  the 
United  States  of  America  than  in  Europe — indeed,  the  observations  of  the 
specialists  go  to  show  that  almost  every  person  is  more  or  less  the  subject 


496  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

of  these  hypertrophic  iirocesses,  of  which,  in  many  instances,  he  is  quite 
ignorant  until  examination  has  shown  their  presence. 

Treatment. — The  proper  local  treatment  of  chronic  nasal  catarrh, 
which  is  by  far  the  most  important,  demands  such  special  measures  as  in 
the  main  can  only  be  carried  out  by  accomplished  specialists.  This  treat- 
ment, therefore,  so  far  as  can  betaken  up  in  this  book,  can  only  be  palliative, 
or,  if  curative,  limited  to  the  early  stage  of  the  disease.  In  all  forms  of 
chronic  catarrh  the  most  important  measures  to  be  employed  by  the  physi- 
cian, as  distinguished  from  the  specialist,  are  those  which  have  for  their 
purpose  the  most  thorough  cleanliness  of  the  affected  regions.  The  simplest 
means  for  accomplishing  this  purpose  is  sniffing  from  the  palm  of  the  hand 
simple  salt  solution  of  the  strength  of  a  teaspoonful  of  sodivun  chlorid  to  a 
pint  (0.5  liter)  of  water,  or  some  one  of  the  substitutes  named  below. 

As  ordinarily  used,  it  is,  however,  much  less  efficient.  We  may  use 
with  it  varying  proportions  of  Dobell's  solution  or  liquor  antisepticus 
and  water,  say  from  i  to  4  up  to  equal  parts;  also  an  alkaline  solution 
composed  of  liquor  alkalinis  compositus  i  part,  water  4  parts,  and  1/2 
dram  (2  gm.)  each  of  soditun  bicarbonate  and  sodiimi  borate  to  the  pint  of 
this  mixttorfe.  When  large  quantities  are  required  to  wash  out  the  nasal 
cavities,  the  postnasal  syringe  may  be  used  instead  of  the  nasal  douche. 
Liquor  alkalinis  antisepticus  is  disinfectant  and  deoderizing.  A  plug  of 
borated  or  salicylated  cotton  may  be  used  for  a  like  purpose. 

General  treatment,  although  not  so  important  as  the  local,  is  still  of 
great  value,  and  the  health  of  the  patient  should  be  carefully  looked  after. 
In  view  of  the  fact  that  atrophic  rhinitis  is  verj-  apt  to  occur  in  tuber- 
culous persons,  cod-liver  oil  is  a  tonic  always  indicated,  and  should  be 
given  for  a  long  time,  intermitting  occasionalh'  to  avoid  derangement  of  the 
stomach.  It  should  be  associated  with  iron,  and  even  with  arsenic.  Other 
tonics  should  be  given  as  indicated,  and  the  best  food  should  be  prescribed, 
including  an  abundance  of  meat,  eggs,  and  cream.  Wholesome  ventilation 
should  be  secured  for  the  indoor  life,  while  as  much  time  should  be  spent 
in  the  open  air  as  possible.  The  air  indoors  is  especially  apt  to  be  con- 
taminated by  the  breathing  of  the  patient  with  atrophic  rhinitis,  and  on 
this  account  good  ventilation  is  imperative.  If  syphilis  is  present,  it  should 
receive  appropriate  treatment  at  once. 


HAY  FEVER. 

SvNON-YMS. — Catarrhus    cestivus;    Hay    Asthma;    Autumnal    Catarrh;    Rose 
Cold;  Pollen  Catarrh;  Vasomotor  Coryza. 

Definition. — -A  catarrhal  affection  of  the  upper  air-passages,  associated 
with  asthmatic  dyspnea,  occurring  in  the  spring,  late  summer  or  autumn, 
ascribed  to  the  pollen  of  plants  and  grasses  as  exciting  causes. 

Etiology. — In  a  large  proportion  of  cases,  hay  fever  has  as  its  funda- 
mental condition  an  anatomical  change  in  the  nasal  passages,  such  as  hyper- 
trophy of  the  mucous  membrane,  a  polypoid  growth,  a  deflection  of  the 
septum,  or  a  lowered  position  of  the  inferior  turbinated  bones  so  that  thej- 
rest  upon  the  floor  of  the  nose.     These  conditions  are  not  always  demon- 


HAY  FEVER  497 

strable,  but  they,  or  some  allied  source  of  reflex  irritation,  produce  an  irrita- 
bility. This  may  be  increased  by  a  neurotic  constitution,  though  the  latter 
may  not  manifest  itself  until  after  the  attacks  have  become  habitual,  so  that 
at  times,  at  least,  it  is  more  likely  that  the  neurosis  is  a  result,  rather  than  a 
cause  of  the  disease.  A  third  necessary  etiological  factor  is  an  irritant. 
This  irritant,  whatever  it  is,  originates  usually  in  the  spring  or  the  late 
summer.  In  the  spring,  it  has  been  regarded  as  due  to  a  pollen  coexistent 
with  the  fragrance  of  roses;  hence  the  term,  "rose  cold"  or  "Jime  cold." 
In  August  and  September  the  pollen  of  flowering  plants  is  commonly 
regarded  as  the  exciting  cause,  and  in  certain  early  instances  this  seems 
to  have  been  conclusively  demonstrated,  as  by  Blakely  in  his  owti  case. 
These  suppositions  have  been  shown  by  the  studies  of  Dunbar  to  be  facts. 
He  has  proven  that  it  is  caused  by  the  pollen  of  certain  grasses  and  plants. 
Thus  far  there  have  been  isolated  about  2  5  grasses  and  seven  plants  whose 
pollen  is  active.  The  pollen  of  rj^e  is  one  of  these,  and  in  this  country  the 
pollen  of  rag  weed  and  golden  rod  are  conspicuous  in  the  fall  of  the  year. 
Almost  infinitestinal  quantities  0.00002  s  of  a  milligram  of  an  albuminous  sub- 
stance isolated  from  pollen  is  capable  of  producing  the  required  conjunctival 
irritation  in  susceptible  persons:  On  the  other  hand,  the  pollen  of  roses, 
linden  flowers  and  other  plants  reputed  to  cause  hay  fever  are  without 
effect.  This  form  of  haj^  fever  is  unquestionably  the  result  of  sensitization 
a  true  example  of  anaphylaxis,  cases  exactly  resembling  the  hay  fever  caused 
by  the  pollen  of  grasses  occur  from  the  inhalation  of  effluvia  from  horses, 
guinea  pigs  and  rabbits.  In  the  case  of  a  famous  medical  man  every  time 
he  enters  the  rabbit  house  of  the  laborator)^  he  is  seized  with  coryza, 
lachrymation  and  more  or  less  asthma.  These  attacks  are  certainl}^  due 
to  anaphylaxis,  as  vaccination  with  the  serum  of  the  rabbit  is  followed  by  a 
prompt  skin  reaction  of  Von  Pirquet. 

Changes  of  temperature  may  excite  attacks  and  in  warm  countries, 
as  in  the  Southern  United  States,  it  may  prevail  the  year  round.  Emotional 
causes,  imaginary  odors,  and  the  like  may  cause  it.  Heredity  is  an  im- 
portant factor  in  its  causation,  successive  generations  being  attacked  with 
astonishing  regularity. 

Localities  variously  favor  it.  Generally,  cities  furnish  more  cases  than 
the  country,  and  low  countries  more  than  elevated  ones,  3^et  certain  seaside 
places  are  absolute  ciures  for  many  cases.  Such  a  place  is  Long  Beach, 
N.  J.,  where  is  located  Beach  Haven,  a  seaside  resort,  50  miles  from  Phila- 
delphia, which  has  long  been  a  resort  for  the  victims  of  hay  fever.  The 
disease  is  more  common  in  the  United  States  than  in  Europe,  and  in  the 
United  States  than  elsewhere  in  America.  It  is  more  common  in  men  than 
in  women,  there  being  three  cases  of  the  former  to  every  two  of  the  latter. 

Morbid  Anatomy. — There  is  no  morbid  anatomy  other  than  that  re- 
ferred to  in  the  remarks  on  the  etiology  of  the  disease. 

Symptoms. — The  onset  of  hay  fever  may  be  quite  sudden,  coming  on 
with  remarkable  regularity  often  on  the  same  day  of  the  month  each  year. 
At  other  times  it  is  more  gradual  in  its  onset.  It  frequently  begins  with 
sneezing,  and  indeed  may  consist  entirely  of  inveterate  sneezing.  At  other 
times  there  are  asthmatic  attacks  of  great  severity,  closely  resembling  those 


498  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

of  bronchial  asthma,  constituting  the  "asthmatic  tj-pe"  of  the  disease. 
Again,  there  may  be  obstinate  cough,  with  or  without  expectoration;  or 
there  may  be  an  alternation  of  the  two  symptoms,  but  generally  there  is 
more  or  less  persistent  shortness  of  breath.  There  is  also  often  great  de- 
pression of  spirits,  and  victims  have  even  been  impelled  to  suicide.  The 
eyes  are  suffused  with  redness,  and  there  may  be  conjunctivitis. 

Diagnosis. — The  diagnosis  furnishes  no  difficulty.  The  reason  of  the 
year  and  the  periodical  recurrence  of  the  cough  corj'za  and  asthma  combine 
to  make  the  recognition  easy. 

Prognosis. — Patients  seldom  die  of  hay  asthma,  yet  we  have  loiown  cases 
which  seemed  to  be  very  ill  when  they  reached  the  haven  which  afforded 
them  relief. 

Treatment. — The  complete  cure  of  an  individual  attack  is  seldom  ac- 
complished except  by  removal  from  the  district  in  which  the  patient  resides. 
The  White  Mountains  and  the  Adirondack  Mountains  are  favorite  resorts  in 
the  eastern  part  of  the  United  States,  and  Bethlehem,  N.  H.,  is  the  Mecca  of 
American  hay-fever  victims,  though  other  places  in  the  same  neighborhood 
are  equally  exempt.  The  Catsldlls  and  Alleghanies  are  less  celebrated. 
Certain  seaside  resorts  have  also  a  deser\?ed  reputation;  Beach  Haven,  N.  J., 
has  already  been  mentioned;  Fire  Island,  on  the  Atlantic  Coast  outside  of 
New  York  Bay;  the  Isles  of  Shoals,  Nantucket,  and  Mount  Desert,  on  the 
New  England  coast,  are  others.  Sometimes  a  sea  voyage  will  abort  a  threat- 
ened attack,  and  some  persons  are  quite  exempt  while  at  sea. 

A  few  cases  have  been  totally  cured  by  operations  on  the  nasal  cavi- 
ties such  as  correcting  deviations,  and  the  removal  of  hypertrophic  proc- 
esses by  the  knife  or  actual  cautery,  but  the  confident  expectation  which 
followed  some  of  the  earlier  of  these  operations  has  not  been  realized. 

Home  treatment,  at  best,  has  been  uncertain  and  but  partially  successful, 
and,  as  is  always  the  case  with  a  malady  so  difficult  to  cure,  the  number  of 
remedies  is  legion. 

Dunbar's  serum  is  based  upon  proper  series  of  observation.  Its  use  as 
claimed  by  Dunbar  is  certain  to  result  in  cure,  but  this  is  not  the  rule.  Both 
a  liquid  senun  and  a  dry  powder  are  prepared  and  are  applied  to  the  nasal 
or  conjunctival  mucous  membrane  two  or  three  times  a  day,  while  the 
prophylactic  treatment  is  far  more  satisfactory  than  the  curative.  In 
using  this  treatment  doors  and  windows  should  be  kept  closed  at  night 
during  the  hay-fever  season. 

Irrigation  of  the  nasal  passages  by  the  nasal  douche  or  spray  with 
simple  salt  solution  or  weak  solutions  of  quinin,  i  grain  (0.065  g™-)  to  the 
ounce  (15  c.c),  has  been  used,  with  varying  results.  Hclmholtz  was  the 
first  to  suggest  quinin  solution,  and  thought  it  efficient.  The  oil  spray  is 
another  efficient  measure  of  this  land.  A  strong  solution  of  cocain — foiu*  to 
ten  per  cent. — applied  with  a  brush  affords  temporary  relief,  but  it  should 
not  be  used  because  of  danger  of  forming  the  cocain  habit.  Subnitrate 
of  bismuth  and  boric  acid,  1/2  dram  (2  gm.)  to  the  ounce  (15  gm.)  of  vaselin 
of  simple  ointment,  will  sometimes  allay  the  itching.  Solution  of  suprarenal 
extract  will  be  considered  later.  Boric  acid,  10  grains  (0.65  gm.)  to  the 
ounce_(3o  c.c.)  of  water,  may  be  used  for  the  conjunctivitis. 


ACUTE  LARYNGITIS  499 

Sodium  iodide  is  given  in  small  doses,  frequently  repeated,  as  i  grain 
(0.2  gm.)  every  two  hours.  Fowler's  solution  has  some  reputation.  Mor- 
phin  is  undoubtedly  a  useful  palliative,  but  its  employment  is  extermely 
dangerous.  Prom  1/8  to  1/2  grain  (0.008  to  0.03  gm.)  may  be  required, 
and  the  smaller  doses  should  be  tried  first.  Chloral  is  also  of  undoubted 
use  as  a  palliative,  and  is  much  safer  than  morphin,  with  which  it  may  be 
combined.  It  renders  smaller  doses  of  the  anodyne  more  efficient,  and  may 
be  given  in  combination  with  1/24  to  1/12  grain  (0.0027  to  0.0055  gm.) 
of  morphin  at  short  intervals.  Suprarenal  extract  has  acquired  considerable 
reputation  in  the  treatment  of  hay  fever.  S.  Solis  Cohen  and  Beamon 
Douglass  were  among  the  first  to  report  favorably  on  its  effect.  It  acts 
by  reducing  turgescence  of  the  turbinated  tissue.  It  is  used  externally 
and  internally.  For  local  applications  solution  of  adrenalin  chloride,  in 
the  shape  of  a  spray  is  valuable  the  solution  may  be  used  every  two  hours 
until  the  symptoms  have  subsided,  repeating  the  treatment  on  the  appear- 
ance of  obstruction,  coryza,  and  sneezing.  Adrenalin  solution,  strength  i 
to  1000,  is  of  late  the  usual  proportion,  applied  with  a  brush;  or  a  mixture 
of  the  same  solution  of  adrenalin  with  equal  parts  of  four  per  cent,  solution 
of  cocain  may  be  used.  Internally  suprarenal  extract  may  be  given  in 
the  tablet  form  or  in  a  capsule.  Five  to  10  grains  are  administered,  day 
and  night,  every  two  hotirs  until  an  examination  of  the  nasal  membrane 
shows  that  the  vasomotor  paralysis  is  under  control,  or  until  giddiness  or 
palpitation  is  noticed.  After  this  improvement  the  same  dose  may  be  given 
every  three  hours,  then  every  six  hours,  and  finally,  only  twice  daily,  which 
is  continued  during  the  hay-fever  season.  If  the  dose  is  too  rapidly  dimin- 
ished and  the  symptoms  reappear,  one  tablet  should  again  be  given  every 
two  hours  until  the  symptoms  are  controlled.  Adrenalin  solution  is  also 
administered  internally  in  doses  of  10  minims  (0.3  c.c,  of  the  i  to  1000 
solution.  Mild  cases  may  be  comparatively  comfortable  during  the  season 
when  the  extract  is  used  in  this  way.  If  the  pure  dried  extract  is  used  i 
to  3  grains  may  be  given  in  a  capsule. 

ACUTE  CATARRHAL  LARYNGITIS. 

Etiology. — The  most  common  cause  of  catarrhal  larjmgitis  is  some  infec- 
tion, but  predisposition  plays  a  most  important  part.  Such  predisposition 
may  be  the  result  of  previous  attacks  of  laryngitis,  or  it  may  be  brought 
about  by  constant  use  of  the  organ  in  speaking  and  singing;  whence  it  is 
common  with  persons  thus  engaged.  In  these  occupations  the  larynx  is 
hyperemic  from  overuse,  and  this  hyperemia  is  ever  ready  to  be  fanned  into 
active  inflammation.  Exposure  to  cold  is  constantly  at  hand  to  furnish  the 
exciting  cause.  Laryngitis  is  also  brought  about  by  the  inhalation  of  irritat- 
ing vapors  or  gases,  while  intemperate  smoking  and  the  use  of  strong 
alcoholic  drinks  are  also  causes  of  the  hyperemia  so  readily  converted  into 
an  inflammation.  Catarrhal  laryngitis  is  frequently  associated  with 
catarrh  of  the  adjacent  parts,  as  of  the  nose  and  pharynx,  trachea,  and 
bronchi. 

Morbid  Anatomy. — It  is  characteristic  of  the  mucous  membrane  of  the 
larynx,  and,  indeed,  of  the  trachea  and  larger  bronchi  below  it,  that  it  loses, 


500  DISEASED  OF  THE  RESPIRATORY  SYSTEM 

])ostmortem,  the  anatomical  characters  of  the  inflammatory  process  as  they 
appear  during  life.  It  is  only  by  the  image  in  the  laryngeal  mirror,  there- 
fore, that  we  can  obtain  an  idea  of  these  appearances  as  they  present  them- 
selves during  active  inflammation.  The  picture  thus  obtained  by  the  laryn- 
geal mirror  is  one  of  intense  redness,  with  swelling.  These  changes  involve 
the  true  and  false  vocal  cords  and  the  trachea  below,  as  well  as  the  epiglottis 
above.  The  latter  appears  in  strong  contrast  to  the  yellowish-pink  of 
health.  Even  greater  is  the  contrast  between  the  appearance  of  the  vocal 
cords  and  the  pearly  white  of  health.  If  secretion  has  set  in,  streaks  of 
mucus  may  be  seen  in  places.  Escessive  swelling  of  these  parts  may  occur 
in  edema  of  the  glottis,  but  it  is  not  frequent  in  simple  acute  larjmgitis  and  will 
be  described  separateh". 

Symptoms. — The  most  constant  symptoms  of  acute  laryngitis  arc 
hoarseness  and  cough,  which  vary  with  the  degree  of  the  swelling  and 
hyperemia,  and  which  also  give  rise  to  a  sense  as  of  something  present  in  the 
larynx  and  a  constant  desire  to  clear  the  throat.  In  high  degrees  of  inflam- 
mation there  may  be  aphonia.  To  these  there  is  sometimes  added  pain 
during  deglutition;  with  higher  degree  of  inflammation  there  is  a  feeling  of 
constriction  or  oppression.  The  cough  is  more  or  less  husky  and  often  stridu- 
lous.  It  is  further  characterized  by  its  dryness  and  sometimes  the  act  is 
painful.  Both  these  features  disappear  with  the  establishment  of  secretion. 
There  is  generally  a  slight  febrile  movement,  seldom  very  high.  All  of  these 
symptoms  are  aggravated  as  the  disease  becomes  more  severe,  culminating 
in  the  intense  distress  and  impending  suft'ocation  accompanying  edema  of 
the  glottis. 

Treatment. — The  cases  due  to  infection  of  a  common  cold  are  best 
treated  b}-  abundance  of  fresh  air  in  a  protected  room  or  porch,  while  special 
inhalations  of  such  air  are  extremely  useful  both  in  giving  the  patient 
comfort  and  in  abating  the  inflammation.  They  reqmre  no  complicated 
apparatus.  A  piece  of  rubber  tubing  may  be  attached  to  the  spout  of 
a  teapot  or  kettle,  or  the  steam  may  be  collected  by  an  ordinary  funnel  and 
carried  thence  to  the  mouth.  For  obvious  reasons,  care  should  be  taken 
that  the  funnel  be  not  allowed  to  become  too  hot.  Special  appliances  in  the 
shape  of  a  steam  atomizer,  more  costly  and  scarcely  more  useful,  may  be 
used  instead  of  the  simple  measures.  Cold  applications  may  be  made  to  the 
outside  of  the  throat.  More  rarely  counterirritation  by  mustard  may 
answer  better.  The  irritative  cough  may  require  to  be  relieved  by  anodynes, 
which  may  consist  of  small  doses  of  opium  or  some  one  of  its  preparations  or 
derivatives.  Expectorants  are  of  doubtful  value,  and  certainly  are  not 
nearly  so  useful  as  the  simple  measures  which  have  been  mentioned. 

SPASMODIC  CATARRHAL  LARYNGITIS  OR  FALSE  CROUP. 

Definition  and  Symptoms. — What  is  known  as  spasmodic  croup  in 
children  of  from  one  to  fi^•c  years  is  acute  catarrhal  laryngitis,  to  which  is 
added  a  spasm  of  the  glottis,  producing  the  hard,  stridulous  breathing,  with 
croupy  cough  characteristic  of  this  affection,  which,  once  heard,  is  never 
forgotten.  It  is  produced  by  the  same  causes.  To  the  croupy  cough  are 
added  extreme  restlessness  and  an  anxious  expression.     The  attacks  generally 


SPASMODIC  LARYNGITIS  501 

come  on  suddenly  at  night,  the  child  waking  from  a  sound  sleep,  although 
warning  is  often  given  by  some  disturbance  of  respiration  while  the  child 
still  sleeps.  There  is  little  fever.  The  next  day  the  child  may  appear 
almost  or  quite  well,  or  there  may  be  a  slight  croupy  cough,  yet  there  ma\- 
occur  another  attack  on  the  following  night  and  even  the  third,  while  in 
very  severe  cases  the  recurrences  continue  for  a  week. 

Diagnosis. — The  only  condition  with  which  spasmodic  croup  can  be 
confounded  in  diphtheritic  croup,  and  then  only  if  no  membrane  is  visible  in 
the  latter.  The  throat  should  always  be  examined;  the  nose  as  well.  In 
diphtheria,  suddenness  of  onset  seldom  occurs,  but  the  patient  usually  is 
hoarse  several  hours  before  much  attention  is  paid  to  it.  The  hoarseness 
gradually  increases,  and  as  a  rule  the  patient  cannot  speak  above  .a  whisper 
and  cannot  make  a  high  note.  The  cough  is  smothered  and  sometimes 
harsh.     In  doubtful  cases  a  bacteriological  examipation  should  be  made. 

Prognosis. — The  prognosis  in  all  forms  of  acute  laryngitis  not  diphtheritic 
is  generally  favorable,  and  death  is  very  rare  from  spasmodic  croup.  Care- 
lessness ma}'',  however,  prolong  an  attack. 

Treatment. — The  favorite  measvire  to  break  the  paroxysm  of  croup  in 
children  is  an  einetic.  The  simplest  of  emetics  is  ipecacuanha,  which  may 
be  given  in  the  shape  of  the  wine  or  syrup  in  the  dose  of  1/2  dram  to  a  dram 
(2  to-  4  c.c.)  every  few  minutes  until  vomiting  is  produced.  The  mineral 
emetics  are  more  prompt,  but  more  depressing  in  their  action.  While  wait- 
ing for  the  action  of  the  emetic  the  little  patient  may  be  put  into  a  hot  bath 
— temperature  98°  to  112°  P.  (36.7°  to  44. 4°  C.) — and  some  mustard  may 
be  added.  The  temperatiure  is  kept  up  by  the  addition  of  hot  water,  as 
required.  The  majority  of  attacks  of  spasmodic  croup  may  be  broken  up 
in  this  way  without  further  treatment.  Between  the  paroxysms  the  child 
should  receive  small  doses  of  sjo-up  or  wine  of  ipecac,  say  5  to  10  minms 
(0.33  to  0.66  c.c),  until  nausea  is  produced,  or  small  doses  of  powder  of 
ipecac  conveniently  in  the  shape  of  triturates  containing  1/20  grain  (0.003 
gm.)  every  two  hours,  for  an  infant  a  year  old.  An  opiate  isparticularly 
useful  at  bedtime,  and  by  means  of  it  a  child  may  often  be  tided  through  a 
night  without  an  attack. 

Just  as  early  as  possible  in  the  treatment  an  aperient  should  be  given, 
than  which  none  is  better  than  castor  oil,  but  calomel  is  also  an  admirable 
remedy  for  children,  given  in  doses  of  from  i  to  3  grains  (0.06  to  0.2  gm.). 
When  there  is  fever,  aconite  and  sweet  spirits  of  niter  in  appropriate  doses 
should  be  given.  Special  pains  should  be  taken  to  maintain  a  uniform 
temperature  and  avoid  drafts,  especially  when  the  child  is  perspiring  freely, 
and  it  is  on  this  account  that  bed  is  the  safest  place. 

Counterritation  by  weak  mustard  plasters  is  an  adjunct  to  treatment 
which  should  never  be  omitted,  while  gentle  permanent  irritation  is  verv 
useful.  It  may  be  secured  by  any  of  the  rubber-spread  plasters  now  sold, 
known  as  porous  plasters  or  capcine,  plasters.  In  severe  cases,  ice  to  the 
exterior  of  the  throat,  or  clothes  wrung  out  of  iced  water  should  be  used, 
especially  when  there  is  much  fever. 

Parents  are  naturally  anxious  to  secure  some  treatment  by  which  the 
recurrence  of  attacks  is  prevented.  It  is  to  be  remembered  that  a  gradually 
increasing  immunity  comes  with  a,dded  years.     Certainly  no  medicine  can 


502  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

produce  immunity.  It  is  possible,  however,  to  do  something  by  care  and 
judicious  outdoor  life,  by  which  is  secured  a  "hardening"  or  protection 
against  the  more  usual  causes  of  laryngitis.  Children  who  are  housed  are 
much  more  susceptible  to  croup  than  those  who  spend  a  portion  of  each 
day  in  the  open  air  because  they  are  more  subjected  to  the  infection 
causing  it. 

SIMPLE  CHRONIC  CATARRHAL  LARYNGITIS. 

Etiology. — The  causes  of  nonspecific  chronic  catarrhal  larj'ngitis  are 
chiefly  those  which  have  been  already  mentioned  as  producing  the  predispo- 
sition to  acute  laryngitis — that  is,  the  constant  use  of  the  voice  in  speaking 
and  singing,  excessive  smoking,  and  the  use  of  strong  alcoholic  drinks. 
Laryngitis  occasioned  by  smoking  and  whisky  drinking  is  often  accom- 
]Danied  by  chronic  granular  pharyngitis.  So,  too,  frequently  recurring 
attacks  of  acute  catarrhal  laryngitis  independent  of  predisposing  cause,  and 
the  long-continued  inhalation  of  slightly  irritating  substances  are  to  be 
included  among  the  causes  of  chronic  inflammation. 

Morbid  Anatomy. — The  morbid  anatomy  of  simple  chronic  catarrhal 
laryngitis  is  commonly  not  widely  different  from  that  of  the  acute  form. 
There  are  the  same  redness  and  swelling,  but  the  former  is  less  vi\dd.  The 
chronic  hoarseness  which  is  so  constantly  associated  with  it  is  due  to  a  per- 
manent thickening  of  the  parts  concerned  in  the  production  of  the  voice. 
LUceration  is  not  common,  although  there  may  be  superficial  erosions. 
The  follicular  glands  are  often  distended,  and,  if  the  inflammation  is  long 
kept  up,  a  hyperplasia  of  the  squamous  epithelium  may  result  in  a  moderate 
villous  outgrowth  on  the  cords.  Nodular  swellings  on  the  vocal  cords  are 
also  a  recognized,  but  rare  condition,  known  as  chorditis  tuberosa  or  pachy- 
dermia laryngis.  Relaxation  of  one  or  both  cords  is  often  present,  and 
maintains  the  voice  symptoms  as  long  as  it  continues. 

Symptoms. — The  most  prominent  symptom  of  chronic  laryngitis  is 
hoarseness,  which  is  found  in  every  degree  from  a  simple  roughness  of  the 
\'oice  to  almost  entire  loss  of  it.  There  are  also  more  or  less  pain  and  dis- 
comfort, but  these  are  not  ordinarily  conspicuous  symptoms,  except  when 
an  attempt  is  made  to  use  the  voice.  There  is  a  decided  disposition  to 
cough,  with  a  \'iew  of  getting  rid  of  some  foreign  substance  which  seems 
to  be  in  the  larynx.  The  cough  also  varies  in  degree.  It  may  be  a  mere 
hack,  or  it  may  be  scraping  or  ringing.  It  is  also  variously  effectual  in 
bringing  up  a  secretion  of  mucus  and  mucopus,  scantj''  for  the  most  part. 

Prognosis. — The  prognosis  of  chronic  catarrhal  laryngitis  is  not  en- 
couraging for  total  recovery,  largely,  perhaps,  because  it  is  so  difficult 
to  induce  the  patient  to  comply  with  the  conditions  essential  to  his 
cure.  Could  this  entire  cooperation  be  secured,  sometimes  withheld 
through  no  fault  of  his  own,  it  is  not  unlikelj-  that  better  results  would  fol- 
low   treatment. 

Treatment. — The  treatment  of  chronic  catarrhal  laryngitis  requires, 
first,  the  removal  of  its  causes,  whatever  they  maj'  be.  The  public  speaker 
cannot  expect  to  be  cured  of  his  malad}'  while  he  continues  the  use  of  his 
voice,  nor  can  the  singer,  or  he  who  works  among  irritating  \-apors,  nor 


TUBERCULAR  LARYXGITIS  503 

the  bon  vivant  who  will  not  give  up  his  alcohol.  Next  to  the  removal  of 
the  cause  comes  the  use  of  local  measures  because  internal  medication  is 
not  promising.  Of  course,  the  patient's  general  condition  must  be  looked 
after  and  his  strength  maintained,  but  local  treatment  is  the  most  important. 
This  must  be  done  by  one  versed  in  laryngeal  applications. 

TUBERCULOUS  LARYNGITIS. 

Etiology. — The  occurrence  of  primary  tuberculous  laryngitis,  long  de- 
nied, has  come  to  be  generally  conceded  as  possible,  though  rare.  With 
the  accepted  view  of  the  etiology  of  tuberculosis,  tuberculosis  laryn- 
gitis of  the  primary  kind  ought  to  be  of  frequent  occurrence,  for  if  the 
tubercle  bacillus  reaches  the  respiratory  passages  from  without,  the  first 
point  of  attack  would  naturally  be  the  larynx.  The  fact  that  such  is  not 
the  case  can  only  be  explained  on  the  ground  that  the  bacillus  fails  to  find 
in  the  mucous  membrane  of  the  larynx  conditions  as  favorable  for  its  growth 
and  multiplication  as  it  finds  in  the  deeper  portions  of  the  lung.  Since 
tuberculosis  of  the  larynx  is  commonly  secondary  to  the  same  affection  of 
the  lungs,  the  bacillus  probably  invades  the  larynx  from  the  expectoration 
inoculation  being  favored  by  the  greater  or  less  friction  between  the  vocal 
cords.  Tuberculous  lamygitis  occurs  as  a  complication  of  20  to  25  per 
cent,  of  all  cases  of  pulmonary  tuberculosis. 

Morbid  Anatomy. — To  the  essential  morbid  anatomy  of  tuberculous 
laryngitis  is  always  added  that  of  simple  catarrhal  laryngitis.  The  latter 
has  been  described.  The  first  stage  of  miliary  tuberculosis  without  ulcera- 
tion is  sometimes  recognized  by  the  laryngoscope,  appearing  sometimes  as 
pearly  granulations  in  the  mucous  membrane,  more  frequently  as  a  less 
distinctive,  close,  small-celled  infiltrate.  The  tuberculous  ulcer  is  more 
easily  discovered,  3'et  it  possesses  no  one  anatomical  character  by  which 
it  can  be  infallibly  recognized.  Nor  are  aU  the  ulcers  in  the  larynx  as- 
sociated with  tuberculosis  of  the  lungs  necessarily  tuberculous.  The  larynx 
is  more  vulnerable  to  the  ordinary  causes  of  simple  laryngitis  under  these 
circumstances,  while  the  constant  coughing  and  gagging  in  consumption 
may  of  themselves  cause  laryngitis.  The  true  tuberculous  ulcer  results 
from  the  caseation  and  disintegration  of  the  miliary  tubercle.  The  ulcer 
thus  produced  by  the  fusion  of  adjacent  miliary  tubercles  is  at  one  stage 
more  or  less  characteristic  by  its  racemose  or  sinuous  edge,  resembling  in 
this  respect  the  conglomerate  tuberculous  ulcer  elsewhere.  Its  favorite 
seat  is  the  posterior  part  of  the  larynx,  i.  e.,  the  posterior  part  of  the  vocal 
cords,  the  interar}i;enoid  fold  and  the  larjmgeal  surface  of  the  arj^tenoid 
cartilages.  The  epiglottis  is  less  commonly  invaded,  and  the  ventricular 
bands  more  seldom.  In  the  case  of  the  epiglottis  there  is  swelling,  suc- 
ceeded by  ulceration. 

Symptoms. — The  early  symptoms  of  tuberculous  laryngitis  differ  in  no 
way  from  those  of  simple  catarrhal  laryngitis,  and  it  is  the  intractability 
of  the  disease  which  often  gives  the  first  intimation  of  its  tuberculous  nature. 
The  stage  of  simple  hoarseness  with  which  it  is  always  ushered  in  varies 
also  in  duration,  but  sooner  or  later  it  is  succeeded  by  the  aphonia  and  the 
painful  whispering  voice  which  are  so  characteristic  of  ulceration  of  the  vocal 


504  DISEASES  0J<   THE  RESPIRATORY  SYSTEM 

cords  or  the  other  parts  intimately  concerned  in  the  production  of  the  voice. 
Sooner  or  later,  too,  painful  deglutition  sets  in  as  a  result  of  the  extension 
of  the  ulcerative  process  to  the  more  exposed  portions  of  the  larynx.  The 
pain  on  deglutition  is  often  agonizing,  and  is  due  to  the  fact  that  during  the 
act  the  constrictor  muscles  of  the  pharynx  squeeze  the  sensitive  epiglottis 
and  arytenoids.  The  pain  is  frequenty  referred  to  the  ear  in  the  same 
side.  Inanition  and'  emaciation  characteristic  of  the  latter  stages  of  the 
disease  now  rapidly  increase,  and  death  is  often  a  welcome  relief  to  the 
sufferer. 

Diagnosis. — Just  suspicion  attaches  to  an  obstinate  laryngitis  associated 
with  acknowledged  tuberculosis  of  the  lung.  With  obstruction  of  the 
larynx  the  auscultatory  signs  of  tuberculosis  are  sometimes  wanting,  so  that 
we  must  depend  on  the  percussion  sounds  entirely.  As  has  been  intimated, 
the  distinctive  features  of  the  ulceration  are  scarcely  sufficiently  well  marked 
to  enable  us  to  recognize  the  tuberculous  ulcer  by  the  laryngoscope,  and  to 
distinguish  it  either  from  the  ulceration  of  syphilis  or  that  of  certain  stages 
of  malignant  disease.  To  distinguish  it  from  the  former,  tuberculosis  else- 
where and  the  history  of  the  case  may  help  to  a  conclusion,  therapeutic 
test  by  iodids  and  mercurials  ma}^  be  used.  vSyphilitic  laryngitis,  even 
when  it  is  ulcerative,  quickly  yields  to  these  remedies,  as  a  rule,  while  the 
tuberculous  condition  is  quite  unaffected  by  them.  With  the  healing  of 
the  fonner  comes  also  the  tendency  to  contraction  so  characteristic  of  all 
cicatrization,  and  especially  of  that  of  syphilitic  ulcers.  It  is  also  to  be 
remembered  that  syphilitic  ulceration  and  tuberculous  ulceration  are  some- 
times associated.  The  involvement  of  the  tongue  in  the  infiltrating  and 
ulcerating  process  is  more  characteristic  of  tuberculosis. 

Prognosis. — The  prognosis  of  tuberculous  laryngitis  is  unfa\'orable  at 
best.  It  is  true  that  of  late  years  the  reported  cures  of  laiyngeal  tubercu- 
losis have  become  much  more  numerous,  but  these  still  bear  a  very  small 
proportion  to  the  cases  that  progress  from  bad  to  worse,  in  spite  of  the  most 
slalled  treatment.  It  is  to  be  expected  that  primary  tuberculous  laryngitis 
is  much  more  easily  curable  than  the  form  secondary  to  consumption  of 
the  lungs.  Severe  pain  and  signs  of  stenosis  of  the  larynx  are  unfavorable 
symptoms. 

Treatment. — All  measures  which  have  been  mentioned  as  useful  in  the 
treatment  of  chronic  catarrhal  laryngitis  are  also  more  or  less  so  in  tubercu- 
lous disease,  with,  however,  less  complete  and  less  permanent  results. 
Mars'elous  effects  have  been  reported  as  following  the  use  of  lactic  acid, 
while  iodoform  and  even  alkaline  inhalations  are  also  said  to  have  healed 
tuberculous  ulcers.  All  local  treatment  must  be,  of  course,  associated  with 
that  for  general  tuberculosis  of  the  lungs.  The  painful  deglutition,  which 
is  at  once  so  characteristic  and  so  distressing,  has  been  relieved  bj'  the  use 
of  cocain  applied  directly  to  the  larynx  by  the  brush  or  by  the  spraying 
apparatus.  The  latter  is  the  more  convenient,  because  it  can  be  used  by 
the  patient  liimself.  For  this  purpose  a  two  per  cent,  solution  is  suitable. 
A  stronger — lo  or  20  per  cent. — ma}'  be  necessar\%  but  this  must  be  applied 
with  a  brush  by  a  second  person.  They  should  be  used  some  minutes  before 
the  taking  of  food,  as  deglutition  is  rendered  less  painful  for  the  time  being 
by  their  successful  application.     Solutions  of  morphin  may  be  spraj'ed  for 


SYPHILITIC  LARYNGITIS  oOo 

the  same  purpose,  or  the  morphin,  either  pure  or  mixed  with  powder  or 
stareh,  may  be  insufflated  upon  the  painful  larynx.  Iodoform  is  used 
for  the  same  purpose  in  the  same  manner.  When  the  pain  is  persistent 
and  frequent  applications  are  necessary,  we  have  found  none  more  satis- 
factory than  the  official  solution  of  morphin  sprayed  into  the  larynx. 
Food  may  be  introduced  by  Wolfenden's  method,  placing  the  patient  on 
his  back  with  the  head  lower  than  the  body.  General  treatment  Ijy  fresh 
air  and  an  abundance  of  food  as  directed  in  the  article  on  tuberculosis  arc 
imperative  in  this  condition. 

SYPHILITIC  LARYNGITIS. 

Etiology  and  Morbid  Anatomy. — It  is  not  necessary  to  dwell  on  the 

etiology  of  syphilitic  laryngitis,  as  there  is  but  one  cause — the  virus  of 
syphilis.  Syphilitic  laryngitis  may  be  either  secondary  or  tertiary,  and  may 
occur  at  any  time  in  the  course  of  the  disease  subsequent  to  the  second  or 
third  month  following  infection.  Like  tuberculous  laryngitis,  the  morbid 
anatomj'  of  the  sj^philitic  fonn  is  associated  with  that  of  simple  catarrhal 
laryngitis  of  the  chronic  kind.  Excessive  mucous  and  muco-purulent  se- 
cretions cover  the  surface  of  the  epiglottis  and  the  vocal  cords,  while  the 
ulcer  of  syphilitic  laryngitis  is  usually  more  distinctive  in  it.s  characters 
than  is  that  of  tuberculous  laryngitis.  The  milder  forms  of  syphilitic 
laryngitis  are  not  accompanied  by  ulceration  and  are  in  no  way  peculiar, 
from  the  anatomical  standpoint.  The  most  distinctive  anatomical  mani- 
festation of  syphilis  in  the  larynx  is  the  mucous  patch,  like  that  on  mucous 
membranes  elsewhere.  It  is  found  on  the  epiglottis,  in  the  laryngeal  wall , 
and  on  the  epiglottidean  folds;  rarely,  on  the  vocal  cords.  The  patches 
are  rarely  replaced  by  ulceration.  The  breaking  down  of  the  sj^philitic 
gumma  gives  rise  to  another  form  of  syphilitic  ulcer,  often  of  greater  depth. 
The  ulcer  may  come  to  a  standstill  at  any  stage,  and  cicatrization  take 
place  with  deformity  and  permanent  change  of  voice.  In  addition,  necrosis 
of  the  laryngeal  cartilages  is  not  infrequent,  portions  of  these  being  at  times 
expectorated.  Among  the  results  of  cicatrization  are  stenosis,  resulting 
sometimes  in  complete  obstruction,  necessitating  even  tracheotom}'  for 
their  relief. 

Symptoms. — These  are  essentially  the  same  as  in  tuberculous  laryn- 
gitis, hoarseness,  cough,  aphonia,  pain  in  deglutition. 

Diagnosis. — The  diagnosis  of  syphilitic  laryngitis  is  justified  in  the 
absence  of  tuberculosis  elsewhere,  especially  when  the  history  of  primar}" 
syphilis  is  present.     A  Wasserman  reaction  will  make  the  diagnosis. 

Prognosis. — The  prognosis  of  this  form  of  laryngitis  is  much  more 
favorable  than  that  of  tuberculous  disease,  especially  if  the  diagnosis  be 
made  early.  The  efEect  of  contraction  after  healing  is,  however,  often 
serious  in  producing  stenosis,  or,  at  least,  a  permanent  impairment  of  the 
voice. 

Treatment. — The  treatment  of  syphilitic  laryngitis  is  the  treatment  for 
the  general  affection  plus  the  topical  treatment.  The  latter  includes  the 
use  of  measures  to  free  larynx  of  mucus  and  muco-pus,  these  being  fol- 
lowed by  applications  of  strong  solutions  of  nitrate  of  silver  to  the  ulcers, 


506  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

or  even  the  solid  stick.     An  insufflation  of  iodoform,  in  combination  with 
bismuth  and  a  little  morphin,  is  an  excellent  addition  to  the  treatment. 

EDEMA  OF  THE  GLOTTIS. 

Definition. — By  edema  of  the  glottis  is  meant  edema  of  those  parts 
which  immediately  surround  that  opening. 

Symptoms. — It  commonly  results  from  the  other  conditions  which 
have  just  been  described,  or  accomapnies  them.  Thus,  it  may  occur  in 
connection  with  acute  laryngitis,  though  rarely,  and  occasionally  with  the 
tubercu.ous  and  syphilitic  form  of  chronic  laryngitis.  It  not  iirfrequently, 
also,  is  a  complication  of  general  diseases  attended  with  dropsj',  especially 
Bright's  disease,  small-pox,  and  even  diseases  of  the  heart.  It  maj'  occur  as 
a  part  of  the  symptomatolog>'  of  perchondrites  of  the  larynx  accompanying 
typhoid  fever.  In  any  of  the  latter  conditions  it  may  come  on  quite  sud- 
denly. The  more  precise  situation  is  the  submucous  tissues  of  the  aryteno- 
epiglottic  folds  or  of  the  ventricular  bands.  The  edema  may  also  involve 
the  epiglottis.  It  occurs  most  frequently  in  middle  life,  but  it  also  happens 
in  the  toung. 

An  additional  s}'mptom  of  this  condition  is  a  feeling  of  intense  oppres- 
sion or  stiffocation.  The  breathing  is  stridulous,  and  the  efforts  of  the  pa- 
tient to  obtain  air  may  bring  into  play  all  the  extraordinary  muscles  of 
respiration,  the  whole  expression  being  in  extreme  cases  one  of  great  anguish. 

Treatment. — For  the  mild  degrees  of  edema  of  the  glottis  the  prompt 
application  of  a  blister  to  the  larynx  is  often  sufficient  to  relieve  the  symp- 
toms. Another  remedy  of  some  value  in  the  milder  cases  is  a  direct  spray, 
frequently  repeated,  of  a  solution  of  alum,  20  grains  (1.3  gm.)  to  the  fluid 
ounce  (30  c.c).  Spraying  with  solution  of  adrenalin  chloride  is  of  value. 
In  the  treatment  of  the  severer  cases,  cold  plays  an  important  rdle.  Ice 
should  be  constantly  kept  in  the  mouth,  as  well  as  applied  externally  by 
means  of  ice-bags.  If  obtainable,  the  Leiter  coil  may  be  used.  When 
danger  is  imminent,  and  time  is  too  limited  to  wait  for  the  tardy  action  of 
blisters,  a  half  dozen  or  more  leeches  may  be  applied  over  the  region  of  the 
larynx.  These  failing  to  afford  relief,  scarification  of  the  edematous  tissues 
is  to  be  promptly  performed,*  and,  as  dernier  ressorts,  either  intubation  or 
tracheotomy. 

The  hypodermic  administration  of  pilocarpin  has  been  remarkably 
successful  in  some  cases,  and  particularly  when  the  sjTnptoms  are  of  a 
sthenic  nature  this  should  never  be  omitted.  One-quarter  of  a  grain 
(0.0165  grn.)  is  the  proper  dose  thus  administered. 

DISEASES  OF  THE  TRACHEA  AND  BRONCHIAL  TUBES. 

ACUTE  BRONCHITIS. 

Synonyms. — Acute  Bronchial  Catarrh;  Acute  Tracheobronchitis. 

Definition. — An  acute  inflammation  of  the  tracheal  and  bronchial 
mucous  membrane.  It  is  essential!}'  a  symmetrical  disease,  the  bronchial 
tree  in  both  lungs  being  more  or  less  uniformly  invaded. 


ACUTE  BRONCHITIS  507 

Etiology. — The  most  frequent  cause  of  acute  bronchitis  is  some  infection 
due  either  to  some  organism  already  in  situ  or  to  one  introduced  from  with- 
out (the  specific  organism  if  one  exists  is  not  yet  identified) .  Exposure  to  wet 
and  cold  may  be  and  frequently  is  a  predisposing  factor,  the  resistance  of 
the  body  being  thereby  lowered  and  the  infection  then  becoming  active. 
"Catching  cold"  is  such  an  old  and  common  expression  that  it  may  be  re- 
tained, but  it  should  be  well  understood,  that  cold  per  se  does  not  cause  the 
symptoms.  This  is  amply  proven  by  the  results  in  the  treatment  of  tubercu- 
losis, pneumonia,  etc.,  in  the  open  air,  and  by  those  who  live  out  doors  night 
and  day.  Such  individuals  do  not  "catch  cold"  however  low  the  tempera- 
ture, or  however  many  drafts  in  the  room,  provided  they  are  not  exposed  to 
infections  and  are  well  protected.  Chilling  of  the  body  due  to  lack  of  pro- 
tection may  bring  about  the  infection  and  all  its  symptoms.  It  often  suc- 
ceeds an  ordinary  coryza  or  cold  in  the  head  or  a  laryngitis,  the  inflammation 
extending  from  the  upper  air-passages  downward.  It  is  naturally  more 
prevalent  in  the  winter  than  in  the  summer.  It  is  usually  a  symptom  of 
influenza,  whether  epidemic  or  sporadic.  Invariably  too,  it  accompanies 
measles,  of  which  it  is  the  most  annoying  symptom.  More  rarely  it  is 
caused  by  irritating  fumes. 

Morbid  Anatomy. — The  mucous  membrane  of  the  trachea  and  large 
bronchi  is  congested  and  more  or  less  covered  with  a  tough  mucus,  rich  in 
cells,  the  hyperemia  being  especially  marked  about  the  glands  whence  comes 
the  secretion.  Decided  cellular  infiltration  of  the  mucosa  does  not  occur  in 
ordinary  cases,  because  of  the  almost  tendinous  basement  membrane  which 
intervenes  between  the  blood-vessels  and  the  mucosa. 

Symptoms. — Cough  is  the  most  constant  and  conspicuous  symptom. 
At  the  beginning  it  is  hard  and  dry,  without  expectoration;  sometimes  it  is 
painful.  As  the  disease  advances  it  gradually  becomes  looser.  In  the  milder 
degrees  there  is  no  shortness  of  breath,  but  in  the  severe  there  is  a  varying 
degree  of  dyspnea  with  a  sense  of  oppression  or  constriction  in  the  front  of  the 
chest,  caused  by  stenosis  of  the  bronchial  lumina,  due  to  the  swelling  of  the 
mucous  membrane  and  the  presence  of  secretion.  Fever  in  mild  degree  is 
commonly  present,  but  the  temperature  rarely  exceeds  ioi°  F.  (38.3°  C). 
If  it  does,  there  is  reason  to  suspect  a  more  deep-seated  involvement  of  the 
smallest  or  capillary  tubules,  whence  the  name  capillary  bronchitis,  referred 
to  in  considering  bronchopneumonia.  This  extension  is  particularly  apt  to 
take  place  in  children  and  old  persons,  in  whom  the  physicians  should  always 
be  on  the  lookout  for  it.  With  the  access  of  fever  the  pulse  is  correspondingly 
accelerated.  Rarely,  a  chill  may  usher  in  the  disease.  It  cannot  be  too 
strongly'  impressed  that  a  continue  d  high  temperature  indicates  a  more  seri- 
ous infection  than  that  affecting  the  bronchila  tubes. 

The  scanty  expectoration  of  acute  bronchitis  is  at  first  glairy  or  mucoid, 
and  later  mucopurulent.  With  the  appearance  of  the  latter  the  cellular 
element,  composed  of  pus-cells  and  desquamated  epithelium,  becomes  more 
abundant.  With  the  abatement  of  the  disease  the  pus-cells  become  again 
less  numerous  and  finally  disappear. 

Physical  Signs. — There  may  be  absolutely  no  physical  signs — inspection, 
palpation,  percussion,  and  auscultation  being  alike  negative.  When  the 
trachea  alone  is  involved  there  may  be  roughened  breathing   over  the 


508  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

trachea.  In  other  cases  inspection  may  reveal  increased  frequency  of 
breathing,  and  possibly  increased  rate  of  the  cardiac  apex-beat  if  there  be 
■fever.  Palpation  may  appreciate  a  rhonchal  fremitus  if  there  be  sufficient 
narrowing  of  the  l^rcathing  tubes.  It  may  be  found  anywhere  on  either 
side,  and  is  usually  transient.  Percussion  continues  invariably  clear  so 
long  as  the  bronchitis  is  uncomplicated.  Auscultation  furnishes  the  most 
distinctive  and  constant  physical  sign,  the  presence  of  dry  rales,  the  sonorous 
and  sibilant  which  may  invade  either  or  laoth  lungs,  and  may  also  be  tran- 
sient, coming  and  going.  To  these  may  be  added  harshness  of  breathing 
sounds.  When  resolution  sets  in,  bubbling  rales  maj'  take  the  place  of  the 
sonorous  and  sibilant,  in  consequence  of  the  presence  of  liquid  secretion. 
For  physical  signs  of  capillary  bronchitis  see  Bronchopneumonia. 

Diagnosis. — This  is  generally  easy.  The  presence  of  the  dry  rales  and 
a  clear  percussion  note  belong  to  no  other  condition  than  acute  bronchitis 
and  bronchial  asthma,  but  to  the  latter  are  added  the  signs  of  spasmodic 
contraction  of  the  bronchi,  notablj'  the  panting  breathing.  The  same  clear- 
ness of  percussion  note  continues  with  the  appearance  of  moist  rales,  unless 
there  be  the  complication  of  capillary  bronchitis  or  pneumonia. 

Prognosis. — Very  often  the  symptoms  subside  without  treatment  in  the 
course  of  two  or  three  days.  The  cough  becomes  loose,  expectoration  is 
easy,  fever  and  other  unpleasant  symptoms  disappear,  and  in  a  week  the 
patient  is  well.  Suitable  treatment  Taa.y  hasten  such  an  issue.  In  other 
instances,  especially  in  persons  who  are  weak  and  debilitated,  no  such  speedy 
termination  takes  place,  but  even  in  many  of  these  after  a  long  interval  the 
patient  recovers.  More  rarely,  particularly  in  the  very  young  and  old.  the 
inflammation  travels  down  into  the  smallest  tubes,  producing  the  capillary 
bronchitis  alluded  to.  In  other  instances  still,  especially  after  several 
attacks,  and  in  the  old  particularly,  chronic  bronchitis  may  supervene  with 
the  symptoms  and  physical  signs  which  will  be  described  when  considering 
it. 

Treatment. — The  best  treatment  for  a  case  of  ordinary  acute  bronchitis 
is  "the  bed."  Twenty-four  to  48  hours  in  bed  with  the  windows  wide  open 
and  the  patient  well  protected  by  clothing  will  go  farther  to  cure  such  a  case 
promptly  than  all  the  cough  medicines  ever  prescribed.  Such  a  course  is 
not,  however,  always  possible,  and  the  physician  is  often  expected  to  cure 
acute  bronchitis  while  the  patient  is  on  his  feet  and  even  attending  to  busi- 
ness. Every  patient,  however,  can  sleep  at  night  with  his  windows  open  much 
to  his  benefit.  The  patient  should,  however,  be  put  to  bed  if  possible. 
Next  to  rest  in  bed  is  counterirritation.  Turpentine  and  mustard  are  the 
best  agents.  A  turpentine  stupe  or  weak  mustard-plaster  applied  to  the 
front  and  back  of  the  chest  will  aid  greatly  in  allaA^ing  cough  and  relieving 
the  sense  of  oppression. 

Cough  medicines  are,  of  course,  expected,  and  are  useful.  In  the  ordi- 
nary simple  bronchitis,  especially  when  there  is  moderate  fever,  there  are 
few  remedies  more  efficient  than  the  simple  solution  of  citrate  of  potash  of 
the  United  States  Pharmacopeia,  in  doses  of  1/2  ounce  (15  c.c.)  every  two 
hours.  It  may  be  desirable  to  add  a  few  drops  of  wine  of  ipecac  or  wine  of 
antimony  to  each  dose  to  increase  the  relaxing  effect,  whUe,  if  the  fever  is 
decided,  i  or  2  minims  (0.06  or  0.12  c.c.)  of  the  tinctitre  of  aconite  will  aid 


CHRONIC  BRONCHITIS  509 

in  breaking  it.  A  diaphoretic  efiEect  is  further  encouraged  by  adding  30 
minims  (2  c.c.)  of  the  spirit  of  nitrous  ether.  By  such  measures  the  cough  is 
usually  loosened  in  24  hours,  the  dry  rales  are  substituted  by  moist  ones,  and 
convalescence  progresses.  If  there  is  decided  oppression,  it  may  be  relieved 
by  inhaling  the  steam  from  a  hot  saturated  solution  of  chlorid  of  ammonium, 
or  the  compound  tincture  of  benzoin  floated  on  hot  water,  while  in  children 
an  emetic  dose  of  ipecac  may  produce  the  desired  relaxation. 

The  cough  may,  however,  be  so  constant  as  to  harass  the  patient  and 
keep  him  awake  in  spite  of  the  measures  suggested.  In  this  event  an  opiate 
is  necessary,  and  a  small  quantity  of  morphin  or  heroin,  1/16  to  1/12 
grain  (0.004  to  0.0055  gm.)  for  an  adult,  may  be  added  to  the  combination 
jjreviously  recommended.  It  is,  perhaps,  on  the  whole  better  to  administer 
the  opium  separately,  and  of  all  the  preparations,  Dover's  powder  is  prob- 
ably the  best.  Indeed,  Dover's  powder  alone  is  one  of  the  best  medicines  in 
acute  cough  in  doses  of  2  1/2  grains  (0.16  gm.)  every  two  hours,  preferably 
in  a  pill  or  capsule;  or  if  it  be  at  night  and  a  prompt  effect  be  desired,  5 
(0.32  gm.)  or  even  10  grains  (0.65  gm.)  in  one  dose  will  often  act  like  a 
charm.  Codein  is  a  good  preparation  of  opium,  and  has  the  advantage  of 
disturbing  the  system  less  than  some  others.  It  may  be  given  in  doses  of 
1/4  to  1/2  grain  (0.016  to  0.032  gm.)  as  often  as  necessary  to  quiet  cough. 
Heroin  is  a  popular  modem  remedy  of  this  class,  given  in  doses  of  1/20  to 
1/12  of  a  grain  (0.003  to  0.0055  gm.).  This  must  be  given  tentatively,  the 
writers  have  seen  0.005  of  heroin  give  rise  to  toxic  symptoms  when  used 
every  three  hours. 

Should  convalescence  be  slow  and  expectoration  prolonged,  the  ammo- 
nium chlorid  in  5  to  10  grain  (0.32  to  0.65  gm.)  doses  with  syrup  or  tincture 
of  squills  may  be  substituted  for  the  sedative  mixture,  and  quinin  and 
restorative  measures  added  to  the  treatment.  If  the  cough  is  paroxysmal, 
the  preparations  of  belladonna  may  be  given,  and  are  often  efficient  in  con- 
trolling the  paroxysms  where  opium  is  contraindicated  or  deemed  unneces- 
sary. So,  too,  when  secretion  is  copious  and  cannot  be  expectorated, 
belladonna  tends  to  diminish  it,  and  may  be  given  with  expectation  of 
relief.  Copious  secretion  in  children  may  be  removed  by  an  emetic.  To 
this  end  alum  and  honey  may  be  given  or  syrup  of  ipecacuanha  in  teaspoon- 
ful  doses.  All  such  measures  are,  however,  depressing  and  may  be  suc- 
ceeded bj-  recurrence  of  secretion,  and  should  be  used  onlj-  when  necessary 
and  in  very  severe  cases. 


CHRONIC  BRONCHITIS. 

Synonym. — Chronic  Bronchial  Catarrh. 

Definition. — A  chronic  inflammation  of  the  mucous  lining  of  the  large 
and  medium-sized  bronchial  tubes,  commonly  symmetrical. 

Etiology. — Uncomplicated  and  primary  chronic  bronchitis  usually 
develops  gradually,  representing  the  accumulating  remnants  of  frequently 
recurring  "colds,"  each  of  which  leaves  soraething  behind  it  until  the  chronic 
condition  is  established.  A  bronchitis  that  is  associated  with  or  consequent 
upon  another  disease  may  continue  and  become  chronic  after  the  disease 


510  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

has  disappeared.  This  may  happen  with  measles  or  influenza,  or  even, 
rarely,  pneumonia. 

Chronic  bronchitis  constantly  attends  other  affections  as  a  consequence. 
The  most  common  of  these  causes  is  tuberculosis,  but  it  is  also  the  result 
of  diseases  which  favor  congestion  of  the  air-tubes  by  reason  of  the  ob- 
struction to  the  circulation  which  they  cause,  such  as  cardiac  valvular  dis- 
ease.    Especially  is  this  true  of  mitral  valve  disease  and  Bright's  disease. 

Morbid  Anatomy. — The  bronchial  mucous  membrane  is  bathed  with  a 
dirty  gray  secretion  derived  from  the  mucous  glands,  which  are  sometimes 
hypertrophied.  The  darker  color  is  due  to  inhaled  "blacks,"  exfoliated 
degenerated  cells,  and  sometimes  to  decomposed  blood.  On  scraping  this 
mucus  away,  there  may  be  little  or  no  change  of  appearance;  at  other  times 
there  may  be  a  decided  hyperemia.  In  places  the  mucous  membrane  may 
be  thickened  by  cellular  infiltration ;  at  others  it  may  be  thinned,  producing 
sometimes  a  lattice-like  appearance,  because  of  the  prominence  of  the  bands 
of  elastic  tissue  which  resist  the  atrophic  process.  In  old  cases  there  is 
often  dilatation,  which  may  be  saccular,  fusiform,  or  cylindrical,  and  some- 
times cavernous  dilatations  are  present,  usually  about  the  center  of  the  lung. 
It  is  in  the  latter  more  particularly  that  the  mucous  membrane  is  found 
thinned  and  the  mucous  glands  atrophied;  at  others,  ulcerated.  In  other 
old  cases  there  are  ulceration  and  necrosis  of  the  cartilaginous  rings. 

Symptoms  and  Course. — The  chief  s^nnptom  of  chronic  bronchitis  is 
cough,  which  is  troublesome  in  various  degrees,  and  is  apt  to  be  worse  at 
night  or  in  the  morning.  Frequently  it  is  paroxysmal,  the  spells  terminat- 
ing in  free  expectoration  of  the  secretion  which  has  excited  the  coughing. 

Chronic  bronchitis  is  commonly  attended  with  free  expectoration,  either 
in  the  manner  just  described  or  more  uniformly  distributed  through  the 
day.  The  expectorated  matter  is  usually  mucopurulent  or  purulent,  the 
color  deepening  to  yellow  as  the  proportion  of  pus  corpuscles  increases, 
and  becoming  darker  in  hue  with  the  admixture  of  dead  epithelium  and 
"black"  inhaled.  The  quantity  is  sometimes  very  large,  amounting  to  1/2 
liter  (a  pint)  or  more  in  the  24  hours.  As  the  quantity  increases,  however, 
the  consistence  diminishes,  and  it  may  be  thin  and  waters-.  To  such 
copious  expectoration  the  name  of  bronchorrhea  is  applied,  giving  the  name 
to  one  of  three  varieties  of  chronic  bronchitis.  It  is  probably  the  asthma 
humidum  of  the  older  authors,  the  catarrhe  pituiteux  of  Laennec. 

More  commonly  the  expectoration  is  piunilent,  containing  greenish- 
yellow  masses  which  are  coughed  up  easUy.  The  bronchi  are  usually  more 
or  less  dilated  in  these  cases.  The  more  copious  secretion  of  bronchorrhea 
usually  separates,  on  standing,  into  two  portions — a  superficial  seromucous 
portion,  which  may  be  frothy,  and  a  lower  thick  portion  made  up  more 
largely  of  pus-cells.  In  addition  to  such  pus-cells  the  microscope  discovers 
squamous  epithelium  from  the  mouth,  columnar  cells  from  the  deeper  air- 
passages,  bacteria,  and  sometimes  a  few  blood -corpuscles,  as  well  as  the 
delicate  whetstone-shaped  crystals  knowm  as  Charcot's  crj'stals. 

Respiration  is  accelerated  in  various  degrees,  but  except  in  the  rare 
forms  to  be  described  and  on  exertion,  dyspnea  is  never  so  marked  as 
even  in  mild  cases  of  tuberculosis.  The  absence  of  fever  is  characteristic 
as   contrasted   vnth   tuberculosis    of    the  limgs   which   chronic   bronchitis 


SEPTIC  BRONCHITIS  511 

so  often  resembles  in  other  respects,  tuberculossis  being  constantly  diag- 
nosed bronchitis.  Again  after  chronic  bronchitis  has  existed  for  a  long 
time  in  the  old,  especially  when  secretion  continues  copious  while  expec- 
toration becomes  difficult,  there  sometimes  superv'enes  a  condition  of 
low  fever,  probably  septic,  from  absorption  of  putrid  matters,  and  unless 
expectoration  can  be  reestablished,  the  patient  sinks  and  the  fatal  end  is 
not  very  remote. 

The  appetite  and  digestion  commonly  remain  good,  and  the  patient 
maintains  his  weight  for  a  long  time.  After  a  while,  however,  these 
may  fail,  especially  if  there  is  much  expectoration,  and  then  the  patient 
loses  weight.  On  the  other  hand,  some  subjects  of  chronic  bronchial 
catarrh  remain  quite  corpulent  and  well  nourished  throughout  a  long  illness, 
and,  except  for  the  cough,  the  amount  of  disturbance  is  often  remarkably 
slight.  There  is  no  pain,  except  sometimes  about  the  attachment  of  the 
diaphragm  in  the  lower  thorax  caused  by  the  harassing  cough. 

In  a  second  variety  the  cough  is  "dry,"  without  expectoration  except 
small,  tough,  tenacious  masses  of  mucoid  matter.  These  are  raised  after 
paroxysms  of  coughing,  often  of  great  severity.  This  dr^'  variety — the 
catarrhe  sec  of  Laennec — is  commonly  associated  with  emphysema,  and  is 
a  very  troublesome  form. 

A  third  variety  of  chronic  bronchitis  is  well  called  putrid  or  fetid  bronchi- 
tis, in  which  the  secretions  decompose  in  the  air-passages  and  acquire 
a  sweetish,  sickening,  and  disgusting  odor,  which  may  pervade  an  entire 
apartment  and  make  the  patient  a  nuisance  to  himself  and  others.  In 
these  cases  there  is  apt  to  be  a  communication  with  a  cavity  due  to  bron- 
chiectasis or  tubercidosis.  The  decomposition  is  due  to  the  bacteria  of 
decomposition,  the  action  of  which  is  doubtless  favored  by  retention  of 
secretion  in  dilated  bronchi  and  phthisical  cavities,  and  in  a  decided  majority 
of  cases  it  succeeds  an  ordinary  chronic  bronchitis.  It  also  sometimes 
follows  an  empyema  which  perforates  into  the  lung.  At  times  it  is  said  to 
be  primary.  The  expectoration  is  copious  and  correspondinglj^  thin.  It 
is  also  separated  into  layers :  an  upper  one  of  frothy,  mucopurulent  matter 
in  which  occur  separate  masses,  and  a  lower  of  thicker,  greasy,  purulent 
matter.  In  the  latter  the  naked  eye  often  recognizes  dirty  gray  masses 
about  as  large  as  a  pea,  known  as  Dittrich's  plugs,  which  on  microscopic 
examination  are  found  to  contain  pus,  bacteria,  and  detritus  of  uncertain 
origin,  together  with  delicate  acicular  fat  crystals.  Among  other  fungi 
are  found  also  leptothrix  filaments,  which  must  not  be  mistaken  for  elastic 
tissue. 

The  chief  additional  symptoms  are  fever — it  may  be  septic — with 
increase  of  cough  and  pain  in  the  side.  There  is  also  sometimes  a  chill. 
These  symptoms  may  again  abate  and  those  of  the  more  usual  form  of 
chronic  bronchitis  prevail,  subject  to  exacerbation  and  improvement.  The 
effect  of  the  fetid  form,  as  might  be  expected,  is  more  severe  on  the  constitu- 
tion, and  there  are  loss  of  appetite,  indigestion,  and  failing  health.  The 
fingers  may  be  clubbed,  as  in  phthisis.  Secondary  purulent  meningitis 
and  abscess  have  appeared  from  the  transfer  of  pus  germs.  The  physical 
signs  do  not  differ  from  those  of  chronic  bronchitis  and  bronchiectasis,  to  be 
described. 


512  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Physical  Signs. — Ph}-sical  signs  of  a  decided  character  more  constantly 
attend  chronic  bronchitis  than  acute.  They  present,  however,  no  unchang- 
ing picture.  There  may  be  nothing  apparent  to  inspection,  or  the  fre- 
quently associated  complication  of  emphj-sema  of  the  lungs  may  be  the  cause 
of  a  diminished  excursion  of  respiratory  motion,  and  the  roundness  or  barrel 
shape  of  the  chest  characteristic  of  that  disease  may  be  seen.  Such  emphy- 
sema may  give  diminution  of  the  normal  tactile  fremitus  and  to  percussion  a 
hyperresonance.  In  the  vicinity  of  a  superficial  dilated  bronchus  filled  wdth 
secretion  there  may  be  impairment  of  resonance.  The  resonance  is,  however, 
restored  after  copious  expectoration,  or  the  percussion  signs  of  a  cavity 
may  be  substituted,  though  in  the  middle  or  lower  part  of  a  lung  instead  of 
the  apex,  as  in  consumption.  Vesiculo-tj-mpanitic  or  even  tj'mpanitic 
resonance  may  be  present  from  relaxation  of  lung  tissue,  especially  in  the 
lower  posterior  part  of  the  lungs. 

Auscultation  may  also  be  negative,  but  much  more  frequently  recog- 
nizes an  alternation  or  combination  of  harsh  and  feeble  breathing,  sonorous 
and  sibilant  rales,  with  moist  rales  of  all  sizes,  variously  modified  by  dif- 
ferent distances  from  the  ear  and  varying  consistence  of  the  secretion.  The 
moist  rale  is  the  most  constant  sign  of  chronic  bronchitis. 

Diagnosis. — This  is  not  usually  difficult,  for  while  the  symptoms,  in- 
cluding coarser  appearance  of  the  sputum,  sometimes  closely  resemble  those 
of  tuberculosis  of  the  lungs,  the  physical  signs  do  not,  except  when  a  dilated 
bronchus  presents  the  same  signs  as  a  cavity.  Such  a  dilatation  is,  however, 
found  in  the  middle  of  the  lung,  and  furnishes  its  signs  in  the  neighborhood 
of  the  angle  of  the  scapula,  rather  than  at  the  apex.  The  absence  of  fever 
and  especiall}^  of  tubercle  bacilli  from  the  sputum  after  careful  examination 
is  presumptive  evidence  of  the  absence  of  tuberculosis.  The  tuberctdin  test 
is  of  little  value  because  of  its  appearance  in  adults  as  the  result  of  non- 
active  tubercidosis.  A  great  danger  is  the  habit  of  considering  tuberculosis 
of  the  lungs  as  chronic  bronchitis. 

Prognosis. — This  is  unfavorable  as  to  recovery,  but  favorable  as  to 
fermination.  The  patient  rarely  dies  of  the  direct  effect  of  the  disease, 
being  generally  carried  off  by  seme  intercurrent  affection,  often  croupous 
pneumonia.  In  the  old,  however,  a  condition  described  on  page  268  ma 3' 
intervene,  or  a  bronchopneumonia  maj'  supervene  and  terminate  fatally-. 
On  the  other  hand,  many  patients  the  subject  of  chronic  bronchitis  live  for 
years  in  comparative  comfort,  getting  almost  well  in  the  summer  and  relaps- 
ing in  the  winter. 

Treatment. — If  it  were  possible  to  remove  every  person  with  simple 
chronic  bronchitis  uncomplicated  bj-  heart  or  kidney  disease  to  a  warm 
climate  where  thej^  could  live  continuously  in  unbreathed  air,  they  would 
probably  get  well.  Certainly  is  this  true  of  the  earlier  stages.  Much 
may,  however,  be  done  at  home  to  prevent  the  exacerbations  due  to  ex- 
posure, each  of  which  adds  a  little  to  the  previous  chronic  condition.  This 
consists  mainly  in  dressing  warmly,  living  day  and  night  in  thoroughly 
ventilated  rooms,  and  in  avoiding  exposure  to  rapid  changes  of  temperature 
without  adequate  protection  to  the  body.  Exercise  under  careful  super- 
vision is  very  necessary,  lack  of  exercise  may  lead  to  weakness  of  heart 
and  skeletal  muscles  which  may  be  ruinous.     It  is  especialh'  itnportant  that 


CHRONIC  BRONCHITIS  513 

the  old  should  be  warmly  clad  with  wool  next  the  skin,  and  precautions 
against  cold  feet  should  be  especially  secured.  When  bronchitis  complicates 
other  diseases,  as  heart  disease  and  kidney  disease,  the  treatment  of  these  is 
important. 

In  the  way  of  medicine,  much  can  be  done  by  the  stimulating  expector- 
ants. It  must  be  remembered  that  constant  dosing  with  an  excess  of  any 
of  the  following  drugs  which  are  recommended,  may  lead  to  two  things — 
impairment  of  digestion,  which  in  turn  will  lead  to  loss  of  general  health  and 
strength ;  and  second,  depending  upon  drugs  and  omitting  rational  hygiene 
rules.  The  terebinthinates  are  the  best,  and  of  these  one  of  the  best  is 
terebene.  Five  to  lo  minims  (0.3  to  0.6  c.c.)  in  a  capsule  every  three  hours 
is  a  proper  dose.  Terpene  hydrate  another  derivative  of  turpentine,  may 
be  given  in  doses  of  2  to  6  grains  (o .  1 3  to  o. 40  gm .)  in  pill  as  often ,  or  it  may  be 
given  in  mixtiore  with  enough  alcohol  to  dissolve  it.  Crease te  is  an  admir- 
able remedy  in  chronic  bronchitis;  i  grain  or  minim  (0.06  c".c.)  or  2  minims 
(0.12  c.c.)  three  times  a  day,  increased  gradually  to  s  grains  (0.3  c.c.),  or 
even  more  than  three  times  a  day,  will  after  a  while  diminish  the  secretion 
and  the  cough.  Creasotal,  or  the  carbonate  of  creasote,  is  a  much  more 
pleasant  remedy,  and  may  be  given  in  doses  of  10  minims  (0.6  c.c),  which 
may  be  increased.  Sandalwood  oil  or  balsam  of  tolu  or  Peru  may  be  given. 
The  compound  tincture  of  benzoin  is  another  old  but  good  remedy.  The 
oil  of  eucalyptus  is  another  remedy  of  the  same  class  in  5  minim  doses  in  a 
capsule  with  an  equal  quantity  of  oil  of  sweet  ahnonds.  Yerba  santa, 
in  the  shape  of  the  syrup  or  fluid  extract,  is  a  similar  and  very  agreeable 
remedy.  Other  stimulating  expectorants,  like  the  carbonate  of  ammonium 
or  the  aromatic  spirit  of  ammonium,  are  often  usefiil,  but  they  lose  their 
effect  after  a  time.  The  carbonate  of  ammonium,  to  be  useful,  must  be 
given  often — 5  to  10  grains  (0.32  to  0.65  gm.)  every  two  hotirs.  The 
ammonium  chlorid  is  indicated  where  less  of  a  stimulating  effect  is  necessary 
— 5  to  IS  grains  (0.32  to  i  gm.)  four  times  a  day  in  combination  with  the 
syrup  of  squill  in  15  minim  i  c.c.)  doses,  both  in  the  compound  licorice 
mixture.  In  some  cases  the  iodid  of  potassium  is  very  useful,  especially 
when  secretion  is  scanty.     It  should  be  kept  up  for  some  time. 

Inhalations  of  medicated  vapors  are  sometimes  useful.  The  compound 
tincture  of  benzoin  may  be  thus  used,  or  the  oil  of  eucalyptus,  also  turpen- 
tine. They  may  be  placed  on  the  surface  of  boiling-hot  water,  the  vapor 
from  which  will  carry  the  medicated  preparation  with  it,  and  may  be  con- 
ducted to  the  air-passages  through  a  cone  of  paper  placed  over  the  vessel 
containing  the  medicament.  These  vapors  are  more  efficient  than  atomized 
fluids.  Simple  steam  or  vapor  from  a  two  per  cent,  solution  of  common  salt 
or  of  sodium  bicarbonate  may  be  used.  If  there  is  fetor,  carbolic  acid  may 
be  used  in  the  atomizer,  a  two  per  cent,  solution,  or  thymol  one  part  in  1000. 

Alkalinity  is  an  essential  condition  of  easy  secretion  from  the  air-pas- 
sages, so  that  both  inhalations  and  internal  remedies  should  fulflll  this  con- 
dition. Hence,  simple  liquor  potassae,  U.  S.  P.,  in  15  to  20  minim  (i  c.c.  to 
1.25  c.c.)  doses  in  milk  is  a  good  remedy.  To  this  end  the  free  use  of  alkaline 
mineral  waters,  as  those  of  Vals,  Vichy,  and  Ems,  is  useful. 

Digitalis  and  strychnin  are  excellent  medicines,  especially  the  latter. 
Both  stimulate  the  cardiac  action  and  aid  in  pumping  the  blood  through 


514  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

the  lungs  with  increased  force,  thus  causing  reUcf  to  the  congested  mucous 
surfaces.     Strychnin  in  ascending  doses  may  be  given  with  advantage. 

As  to  health  resorts  suitable  for  cases  of  chronic  bronchitis,  those  with 
a  dry  climate,  not  too  cold,  should  be  selected  for  cases  with  copious  secre- 
tion, such  as  southern  Georgia  and  the  Carolinas  or  New  Mexico  in  this 
country,  or  for  stronger  persons  the  cooler  climate  of  Colorado.  For  cases 
of  dry  bronchitis  the  wanner  moist  climates  of  Florida  are  ver>^  suitable. 
In  this,  as  in  all  other  diseases,  the  factor  of  complete  bodily  and  mental 
rest  enters  largely  into  the  cure. 

Chronic  bronchial  catarrhs  always  improve  in  summer,  and  it  is  generally 
sufficient  if  the  patient  be  directed  to  leave  the  hot  and  noisome  city  and 
spend  his  summers  either  in  the  mountains  or  at  the  seaside,  where  the  air 
is  pure  and  bracing.  Surely  this  is  due  to  living  out  of  doors  and  not 
breathing  vitiated  air. 

Of  foreign  resorts,  those  of  southern  Europe,  especially  Italy,  the 
western  Riviera,  San  Remo,  Mentone,  and  Cannes,  are  suitable,  while  still 
better,  if  they  can  be  availed  of,  are  Egypt,  Algiers,  and  the  island  of 
Madeira. 

BRONCHIECTASIS,  OR  BRONCHIAL  DILATATION. 

Etiology. — The  most  common  cause  of  bronchiectasis  is  chronic  bron- 
chitis, either  simple  or  tubercular,  the  effect  of  the  inflammation  being  to 
weaken  the  bronchial  walls  so  that  they  yield  to  the  inspiratory  and  expira- 
tory strain  to  which  they  are  subjected  in  the  act  of  coughing.  It  is,  there- 
fore, often  associated  with  emphysema.  The  same  cause  contributes  to  the 
bronchial  dilatation  following  bronchopneumonia,  measles,  and  whooping- 
cough  in  children.  Accumulated  secretion  is  also  a  factor,  as  seen  in  the 
dilated  bronchi  which  succeed  obstruction  of  a  bronchial  tube  by  a  foreign 
body,  or  compression  by  aneurysm  or  mediastinal  tumor.  The  traction 
associated  with  fibroid  induration  is  also  a  cause  of  bronchial  dilatation; 
hence  we  find  it  in  association  with  interstitial  pneumonia  and  sometimes  in 
chronic  pleurisy.  Finally,  bronchial  dilatation  is  rarely  a  congenital  defect, 
in  which  event  it  is  also  commonly  unilateral  and  general — bronchiectasis 
universalis  of  Grawitz. 

Morbid  Anatomy. — Bronchial  dilatation  is  cylindrical  and  sacculated. 
The  terms  explain  themselves.     Both  forms  may  occur  in  the  same  lung. 

In  the  cylindrical  form,  which  is  the  more  common,  dilated  tubes  of 
nearly  equal  caliber  may  run  through  the  substance  of  the  lung,  from  the 
root  to  the  pleural  surface,  producing  an  appearance  not  unlike  the  fingers 
of  a  glove.  More  frequently  the  smaller  tubes  only  are  affected,  dilatation 
being  recognized  at  autopsy  by  the  inequality  of  lumen,  rather  than  by 
ante-mortem  physical  signs.  It  may,  however,  be  suspected  in  any  case  of 
chronic  bronchitis  ^\'ith  copious  expectoration. 

The  saccular  bronchiectases  are  spherical  or  oval  dilatations,  into  which 
the  tube  merges  gradually  or  suddenly.  They  may  attain  a  diameter  of 
from  two  to  three  inches  (5  to  8  cm.),  more  or  less.  The  lung  tissue  around 
a  saccular  dilatation  is  rarely  normal.  Commonly,  the  dilatations,  single  or 
multiple,  are  surrounded  by  indurated  and  contracted  lung  tissue,  the  trac- 


BRONCHIECTASIS  515 

tion  of  which  on  the  bronchial  wall  produces  the  dilatation.  Adhesion  of 
the  lung  to  the  costal  pleura  also  contributes,  and  large  subpleural  cysts  are 
at  times  thus  formed  by  the  contracting  tissue.  The  cavities  thus  pro- 
duced are  commonly  at  the  base  of  the  lung,  while  in  chronic  phthisis  they 
are  found  at  the  apex.  Cylindrical  and  saccular  dilatation  may  also  be 
associated  under  these  circumstances.  In  universal  bronchiectasis  the 
entire  bronchial  tree  is  converted  into  a  series  of  sacs  communicating  one 
with  the  other.  Many  cavities  in  pulmonary  consumption  are  primarily 
bronchiectatic  cavities. 

In  all  forms  there  is  decided  change  in  the  bronchial  wall,  the  principal 
feature  of  which  is  atrophy.  This  atrophy  not  only  attacks  the  mucous 
coat,  but  also  the  muscular,  and  sometimes  the  elastic  tissue  and  cartilage, 
reducing  the  wall  to  a  thin,  smooth  membrane,  lined  with  pavement  epithe- 
lium, instead  of  the  usual  cylindrical  form.  At  times  overgrowth,  involv- 
ing particularly  the  connective  tissue,  takes  place,  forming  lattice-like  pro- 
jections on  the  inner  surface  of  the  tube  already  referred  to  in  treating  of 
chronic  bronchitis.  At  other  times  ulcerative  processes  develop,  perfo- 
rating the  bronchus  and  invading  the  lung  parenchyma,  converting  the 
bronchiectasis  into  an  ulcerating  cavity. 

Symptoms. — These,  in  addition  to  those  of  the  disease  with  which  the 
bronchiectasis  is  associated,  are  the  peculiar  sputum  and  paroxysmal  cough. 
The  sputum  furnishes  the  most  distinctive  feature,  from  which  alone  the 
diagnosis  can  sometimes  be  made.  It  is  mucopurulent,  of  a  dirty  yellowish- 
green  color  and  unpleasant,  stale,  and  sweetish  odor,  though  not  exactly 
fetid,  as  in  fetid  bronchitis.  It  is  often  raised  in  mouthfuls — another  char- 
acteristic. It  also  separates  into  layers,  usually  three,  as  in  chronic  bron- 
chitis, of  which  the  upper  is  frothy  and  thin,  the  middle  mucoid,  and  the 
lowest  made  up  of  pus  and  epithelium  in  various  stages  of  fatty  degeneration, 
acicular  fat  crystals,  and  sometimes  red  blood  disks  and  hematoidin  crystals 
sufficient  to  color  it.  Elastic  tissue  of  the  lung  is  not  present;  nor  are 
tubercle  bacilli,  unless  there  is  associated  tuberculosis  with  ulceration  of  the 
bronchial  walls. 

The  cough  is  paroxysmal,  because  it  is  not  usually  excited  until  the  sac, 
which  is  often  insensitive,  becomes  full  enough  to  irritate  the  healthy  mucous 
membrane,  when  cough  is  at  once  excited  and  continues  until  the  cavity  is 
empty.  The  paroxysms  are  usually  in  the  morning,  when  they  may  be 
excited  by  a  change  in  position.  After  their  termination  there  is  commonly 
a  long  period  of  rest  until  the  sac  is  again  filled.  The  more  paroxysmal  the 
Cough  and  copious  the  expectoration  in  chronic  bronchitis,  the  more  likely 
is  there  to  be  a  dilated  bronchus.     Very  characteristic  is  the  absence  of  fever. 

Physical  Signs. — When  distinctively  present,  they  are  those  of  a  cavity 
in  the  lung,  readily  recognizable  when  near  enough  to  the  surface.  They 
include  tympanitic  percussion  note,  bronchial  and  even  amphoric  breathing, 
bronchophony  or  pectoriloquy  if  the  cavity  is  empty.  If  it  contains  liquid, 
gurgling  may  be  heard  and  the  percussion  note  is  dull.  To  palpation  there 
is  usually  increased  vocal  fremitus,  caused  by  surrounding  consolidation. 
All  signs  vary  according  as  the  cavity  is  filled  or  emptied  of  secretion.  A 
restricted  breathing  excursion  may  also  be  present,  uninfluenced  by  the 
state  of  the  cavity,  whether  full  or  empty. 


510  DISEASES  OF  THE  RILSPI RATORV  SYSTEM 

Diagnosis. — A  bronchiectatic  cavity  is  usually  distinguished  from  a 
phthisical  cavity  by  the  absence  of  tubercle  bacilli  and  elastic  tissue  from  the 
sputum  of  the  former,  the  situation  of  the  cavity  in  the  center  instead  of  at 
the  apex  of  the  lung,  although  a  cavity  from  tuberculosis  may  occur  any- 
where in  the  lung,  the  history  of  its  development,  the  absence  of  cachexia 
and  fever.  Hypertrophy  of  the  right  ventricle  is  more  frequent  in  bron- 
chiectasis, but  may  also  be  present  in  fibroid  phthisis  ■with  or  without 
bronchiectasis. 

A  circumscribed  empyema  which  has  ruptured  into  the  lung  is  much  more 
sudden  in  its  development  than  bronchiectasis,  while  the  history  of  a  pre- 
vious pleurisy  is  superadded.  A  coincident  external  perforation  of  an 
empyema  would  clear  up  all  doubt.  A  true  abscess  of  the  lung  which  has 
found  its  way  into  a  bronchus  has  also  a  different  historj^  of  origin,  succeed- 
ing, as  it  usually  does,  a  pneumonia,  a  massive  hemorrhage,  or  traumatic 
cause.  The  same  is  true  of  gangrene  of  the  lung,  which  is,  however,  dis- 
closed by  the  extreme  fetor  of  the  breath  and  expectoration. 

Treatment. — This  includes  that  of  chronic  and  fetid  bronchitis,  to 
which  may  be  added,  under  favorable  circumstances,  the  injection  of  sacs 
and  their  drainage.  It  is  to  be  remembered,  however,  that  physical  signs 
are  sometimes  misleading,  and  that  what  seems  to  be  the  clearest  evidence 
as  to  the  exact  site  of  a  sac  is  not  always  to  be  relied  upon.  The  newer 
methods  of  pneumosurgery  allow  the  exploration  of  the  chest  cavitj^  with 
relative  ease  and  safety,  hence,  suspected  areas  can  thus  be  explored.  The 
location  of  such  cavities  can  sometimes  be  done  by  X-ray. 

The  cure  of  well-established  bronchiectasis  is  impossible  with  medical 
treatment  except,  perhaps,  in  young  persons.  Something  may  be  done  to 
prolong  life  and  make  the  patient  more  comfortable  and  less  disagreeable 
to  others.  To  this  end  we  must  aim  at  the  evacuation  and  disinfection 
of  the  offensive  punilent  secretion,  and  as  far  as  possible  the  obliteration 
of  cavities.  For  the  first  of  these,  the  inhalation  of  crude  creasote  vapor 
was  recommended,  first  by  Arnold  Chaplin,  and  indorsed  by  Theodore 
Dyke  Acland  in  an  exhaustive  paper  on  this  subject.  The  method  is  as 
follows:  The  patient  is  placed  in  a  small  air-tight  room  with  cotton  pads 
over  the  eyes  and  ears,  the  nostrils  stuffed  with  cotton-wool.  A  teaspoonful 
of  creasote  is  then  poured  upon  water  in  a  suitable  vessel  and  vaporized 
over  a  spirit  lamp.  The  fumes  are  at  first  very  irritating  and  provoke 
violent  coughing,  which  causes  the  offensive  material  to  be  entirely  expelled. 
The  treatment  should  at  first  be  kept  up  for  lo  to  15  minutes  only  every 
other  day.  As  the  patient  becomes  accustomed  to  it,  the  exposure  may  be 
lengthened  to  an  hour  daily.  A  simpler  method,  though  not  so  effectual, 
is  to  have  the  patient  inhale  through  an  inverted  funnel  the  fumes  of  creasote 
laid  upon  hot  water.  Intralar\'ngeal  injections  of  oily  and  antiseptic 
substances  have  been  employed,  mth  doubtful  results.  The  difficulties 
in  the  way  of  operation  are  shown  in  the  first  paragraph  on  treatment. 

BRONCHL^L  ASTHMA. 

Definition. — Bronchial  or  spasmodic  asthma  is  a  paroxysmal  dyspnea, 
which  is  the  direct  result  of  a  stenosis  of  bronchi. 


BRONCHIAL  ASTHMA  517 

Etiology.^There  is  some  diversity  of  opinion  as  to  the  etiology  of 
bronchial  asthma.  This  much,  however,  is  admitted,  that  in  some  way 
there  is  produced  a  narrowing  of  the  smaller  bronchi. 

Various  explanations  of  the  narrowing  are  suggested.  Some  allege  a 
simple  swelling  of  mucous  membrane  to  be  a  cause.  Such  swelling  is 
variously  spoken  of  as  " fluctionary "  (Traube),  "vasomotor  turgescence" 
(Weber),  "diffuse  hyperemic  swelling,"  or  "exudative"  inflammatory 
swelling  (Curschmann) .  On  the  whole,  the  older  view  of  Trousseau,  that 
the  narrowing  is  due  to  a  spasmodic  contraction  of  the  muscular  coat,  seems 
the  most  likely  one,  and  has  recently  received  the  support  of  Biermer  and 
still  later  of  Meltzer  based  upon  experiments  of  Auer  and  Lewis. 

Accepting  Trousseau's  view  of  a  primary  spasmodic  contraction  of 
the  bronchi,  it  becomes  necessarily  a  reflex  act,  the  causes  of  which  are 
various.  It  implies,  first,  a  hyperexcitability  of  the  reflex  center.  Hence 
bronchial  asthma  is  not  infrequent  in  neurotic  persons,  and  has  even  been 
classed  as  a  functional  nervous  disease  with  neuralgia  and  epileps}^  with 
which  it  is  said  to  alternate  at  times.  Such  hyperexcitability  is  sometimes 
inherited,  so  that  bronchial  asthma  often  runs  in  families.  Presupposing 
such  excitability,  numerous  peripheral  causes  maj'  supervene,  the  most  fre- 
quent of  which  is  bronchitis.  It  very  often  happens  that  an  asthmatic  sub- 
ject has  an  attack  of  asthma,  brought  on  by  "taking  cold,"  the  incident 
bronchitis  being  the  exciting  event. 

Comparatively  modern  studies  have  demonstrated  the  association  of 
some  affections  of  the  throat  and  nasal  passages  with  bronchial  asthma,  and 
that  their  removal  has  resulted  in  its  cure.  Among  these  have  been  en- 
larged tonsils,  chronic  catarrh,  nasal  polypi,  and  the  like.  Other  causes 
in  susceptible  persons  are  impressions  of  certain  odors,  pleasant  and  unpleas- 
ant, notably  that  of  flowers  or  plants  in  early  summer,  whence  the  term 
' '  rose ' '  asthma  and  hay  asthma,  both  of  which  are  allied  affections.  Similar 
attacks  come  from  inhalation  of  emanations  from  cats,  horses  and  rabbits. 
A  change  of  air,  as  from  town  to  country,  or  the  reverse,  or  from  mountain 
to  lowland,  acts  similarly.  Causes  more  remote  than  those  of  the  nasal 
passages,  such  as  gastric  derangement,  intestinal  worms,  uterine  disease, 
may  be  admitted.  Purely  emotional  causes,  as  fright  and  emotion,  may  also 
act.  The  f requeue j''  of  bronchial  asthma  in  children  has  already  been  men- 
tioned. It  is  more  common  in  the  male  sex.  Meltzer  in  igio  draws  atten- 
tion to  the  fact  that  many  cases  of  asthma  resemble  in  every  particxilar 
except  that  of  termination,  anaphylactic  shock.  He  therefore  makes  the 
suggestion  that  "asthma  is  an  anaphylactic  phenomenom.  That  is,  that 
asthamatics  are  individuals  who  are  '  sensitized '  to  a  specific  substance  and 
the  attack  of  asthma  sets  in  whenever  they  are  'intoxicated'  by  that 
substance. 

"It  was  proved  that  anaphylactic  shock  was  peripheral  and  not  of  central 
origin.  It  is  therefore  suggested  that  also  the  so-called  nervous  asthma  is 
due  to  a  peripheral  and  not  a  central  cause." 

This  theory  is  so  attractive  as  to  possibilities  of  treatment,  that  we 
accept  it. 

Morbid  Anatomy. — Whatever  may  be  the  morbid  state  of  the  tubular 
structure  of  the  lung  during  an  attack  of  asthma,  there  are  no  postmortem 


518 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


appearances  which  are  distinctive  of  it.  In  the  first  place,  the  chance  is 
seldom  offered  at  the  opportune  moment,  and  we  know  of  no  report  of  a 
necropsy  made  on  a  person  dying  during  an  attack  of  asthma.  In  the  case 
of  the  asthmatic  dying  at  other  times,  there  may  be  found  the  morbid 
states  peculiar  to  chronic  bronchitis  and  emphysema,  but  nothing  more. 
However,  autopsies  made  upon  animals  dead  of  anaphylactic  shock  show  the 
alveoli  dilated  as  the  result  of  spasm  of  the  bronchioles. 

Symptoms. — The  symptoms  of  an  attack  of  spasmodic  asthma  are 
unmistakable.  The  typical  asthmatic  is  apparently  in  good  health  between 
the  attacks,  and  often  is  so  up  to  the  time  of  the  attack,  which  then  comes 
on  suddenly,  often  at  night.  At  other  times  there  is  a  prodromal  stage,  a 
feeling  of  thoracic  discomfort,  or  "tightness"  in  the  chest,  or  an  anxious, 
nervous,  restless  feeling,  the  import  of  which  is  well  understood  by  the 
victim. 


Fig.  107. — Curschmann's  Spirals — (ajler  Curschmann). 
I,  Natural  size;  II  and  III,  enlarged;  a.  a,  central  thread. 


The  attack  consists  of  a  long-drawn-out  inspiratory  act,  in  which  it  is 
evident  the  air  cannot  get  into  the  lung  fast  enough  to  meet  the  demands 
of  the  besoin  de  respirer.  The  auxiliary  muscles  of  respiration,  the  sterno- 
cleidomastoid, and  the  scaleni,  do  their  best  to  enlarge  the  thorax,  but  that 
is  not  the  difficulty.  It  is  the  contracted  tubes  which  resist  the  entrance  of 
the  air.  Even  more  marked  are  the  effort  and  the  duration  of  expiration; 
hence  the  dyspnea  is  spoken  of  as  an  expiratory  dyspnea.  The  abdominal 
muscles  are  the  auxiliaries  here,  and  they  contract  strongly  and  assume  a 
board-like  hardness.  The  air  is  heard  to  whistle  as  it  enters  and  passes 
out  of  the  chest.  The  patient  sits  in  an  upright  position,  or  leans  slightly 
forward,  and  often  astride  of  a  chair  grasps  the  back  with  his  hands,  for  it 
is  by  fixing  the  shoulders  that  he  can  bring  the  extraordinary  muscles  of 
respiration  into  play.  His  face  is  anxious,  pale,  or  it  may  be  cyanotic,  and 
few  more  distressing  pictures  are  seen.  Notwithstanding  his  efforts,  they 
fail  of  their  purpose  and  comparatively  little  air  enters  the  lungs.  With 
all  these  efforts,  the  breathing  is  not  accelerated — at  least  accelerated  to  any 
marked  degree — while  in  a  few  instances  the  breathing-rate  is  diminished. 


BRONCHIAL  ASTHMA  519 

The  temperature  is  normal  or  subnormal,  and  the  pulse  is  accelerated  and 
small. 

The  attacks  last  for  a  variable  period,  rarely  less  than  an  hour,  and 
unless  broken  up,  sometimes  several  hours.  They  may  terminate  as  suddenly 
as  they  began,  sometimes  with  a  spell  of  coughing.  On  the  other  hand, 
cough  is  not  a  marked  symptom,  and  in  brief  paroxysms  of  asthma  may  be 
altogether  wanting.  In  severe  ones,  however,  it  is  present,  accompanied 
by  a  tough  and  scanty  expectoration,  containing  rounded  masses  of  matter, 
either  yellowish  or  grayish  translucent — the  "perles"  of  Laennec.  On 
minute  examination,  these  are  found  to  be  made  up  of  the  so-called  Cursch- 
mann's  spirals,  together  with  numerous  swollen  and  fatty  degenerated  pus- 
cells  and  cells  shed  by  the  bronchial  mucous  membrane  and  alveoli.  The 
spirals  have  long  been  recognized,  but  were  first  studied  by  Ungar  and 
Curschmann.  Two  shapes  are  found.  The  first  appears  to  be  made  up  of 
mucin  spirally  arranged,  entangling  pus-cells  and  alveolar  epithelium.  A 
second  form  consists  of  a  tightly  wound  spiral  of  mucin  fibrils,  containing  in 
its  center  another  bright,  clear  filament.  The  spirals  are  believed  by 
Curschmann  to  be  formed  in  the  finer  bronchioles,  and  to  be  a  product  of 
bronchiolitis.  Their  spiral  form  is  unexplained.  The  sputum  also  some- 
times contains  crystals  of  calcium  oxalate  and  calcitim  phosphate.  The 
yellow  masses  contain,  in  addition  to  the  cells  named,  various  numbers  of 
acicular  crystals,  which  were  first  found  by  Ley  den  in  the  sputum  of  asth- 
matic patients,  and  therefore  called  Leyden's  crystals.  They  are  identical 
with  the  so-called  Charcot's  crystals,  found  in  leukemic  spleen,  bone- 
marrow,  and  semen. 

In  the  blood  of  cases  of  bronchial  asthma  an  increase  of  eosinophiles 
is  noted  at  about  the  time  of  the  paroxysm,  amounting  from  lo  to  53.6 
per  cent.,  according  to  J.  S.  Billings,  Jr.  This  fact  is  of  value  in  diagnosis 
as  such  leukocj'tosis  is  said  not  to  occur  in  renal  and  cardiac  asthma.  In 
like  manner,  eosinophilic,  leukocytes  and  granules  are  found  in  the  sputum 
of  asthmatic  attacks.  The  latter  are  often  attached  to  the  Curschmann's 
spirals. 

In  addition  to  the  cases  of  typical  asthma  in  patients  perfectly  comfort- 
able between  attacks,  and  for  which  the  foregoing  description  is  intended, 
patients  with  chronic  bronchitis  and  emphysema  are  subject  to  attacks 
which  may  be  called  sjonptomatic  asthma.  The  symptoms  are,  however, 
similar  and  need  not  be  repeated.  It  is  to  be  remembered,  too,  that  emphy- 
sema is  caused  by  asthma,  as  well  as  that  chronic  bronchitis  and  emphysema 
may  cause  asthma. 

Physical  Signs. — These  are  also  characteristic.  Inspection  notes  the 
most  labored  effort  in  breathing,  yet  the  chest  moves  but  slightly.  It  is  in 
a  state  of  permanent  inflation.  The  spaces  above  and  below  the  clavicle 
and  above  the  sternum,  the  intercostal  spaces,  and  the  pit  of  the  stomach 
are  drawn  in  from  the  same  cause — that  is,  the  thoracic  cavity  not  being 
filled  from  within,  the  external  atmospheric  pressure  forces  the  jdelding 
portions  inward.  Rhonchal  fremitus  is  recognized  by  palpation,  while 
vocal  fremitus,  obscured  by  the  rhoncus,  is  further  diminished  by  a  fre- 
quently associated  emphysema.  Percussion  may  produce  abnormal 
resonance  which  is  due  to  temporary  emphysema.     This  disappears  after 


520  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

the  attack  unless  the  emphysema  is  long  standing.  Auscultation  discovers 
the  most  striking  and  easiest  recognized  of  the  ph^-sical  signs.  All  over 
the  chest  are  heard  sonorous  and  sibilant  rales,  inspirator}^  and  expiratory, 
the  latter  longer  and  more  marked.  In  fact,  for  the  most  part,  they  do  not 
require  the  ear  to  be  placed  close  to  the  chest.  They  ma}'  be  heard  at  a 
distance.  The  vesicular  murmur,  on  the  other  hand,  is  inaudible.  Later 
in  the  attack,  as  secretion  increases,  the  rales  become  moist.  It  is  to  be 
remembered  that  chronic  bronchitis,  emphysema,  and  asthma  may  also 
complicate  one  another  and  render  correspondingly  complex  the  physical 
signs. 

Diagnosis. — This  can  usually  be  made  at  a  glance.  Spasm  of  the  glottis 
and  paralysis  of  the  abductors  of  the  glottis  produce  similar  efforts  at  breath- 
ing, but  the  dyspnea  is  inspiratory  and  unattended  by  the  lung  sounds 
characteristic  of  asthma,  while  the  history  will  be  found  different.  Hys- 
terical dyspnea  furnishes  no  physical  signs,  while  in  cardiac  asthma  also  the 
breathing  sounds  are  normal,  or  there  are  many  moist  rales.  (See  also 
Cardiac  Asthma.) 

Prognosis. — Bronchial  asthma,  though  a  distressing  disease,  is  not  a 
fatal  one.  Very  often  the  attacks  grow  more  infrequent  and  milder  as  the 
patient  grows  older,  and  they  may  disappear  altogether,  while  in  some  cases 
they  increase  in  severity  and  frequency  with  age.  In  other  cases  a  cure  is 
effected  by  discovering  and  removing  the  cause.  In  still  other  cases  a 
grave  emphysema  develops  which  may  give  rise  to  all  the  distressing  symp- 
toms of  that  condition. 

Treatment. — The  first  object  in  the  treatment  of  asthma  is  to  relieve 
the  paroxysm..  This  is  best  accomplished  hy  a  hypodermic  injection  of 
morphin,  1/4  grain  (0.0165  gm.),  with  1/150  grain  (0.00044  gm.)  of  atropin, 
which  may  be  repeated  in  an  hour  if  ineffectual.  If  morphin  and  atropin 
are  not  at  hand,  nitrite  of  amyl  may  be  inhaled  from  a  handkerchief  on 
which  a  few  drops  have  been  placed,  or  a  pearl  may  be  broken,  if  one  of 
these  be  at  hand.  In  the  absence  of  amyl  nitrite,  chloroform  or  ether  may 
be  similarly  used.  Nitro-glycerine  maj'  be  used  hypodermically.  Adrena- 
lin chloride  in  10  to  15  minims  hypodermically  is  sometimes  useful.  After 
the  paroxysm  is  broken,  every  effort  should  be  made  to  discover  a  cause  for 
the  recurring  attacks.  The  nose  may  be  responsible,  and  should  be  care- 
full}'  examined  for  any  one  of  the  causes  referred  to.  Possible  peripheral 
irritation,  whether  by  error  of  diet,  gastric  derangement,  uterine  or  other 
distant  reflex  cause,  should  be  sought  and  corrected.  These  are  not  alwa}"s 
easily  found,  but  sometimes  they  are.  Bronchitis,  when  present  also  re- 
quires treatment  by  the  usual  remedies. 

It  is  needless  to  say  that  when  special  external  causes,  such  as  odors 
or  exhalations,  or  undiscoverable  peculiarities  of  location  are  responsible, 
they  should  be  eliminated.  With  all  our  efforts,  however,  the  cause  remains 
in  perhaps  a  decided  majority  of  cases  undiscovered,  but  the  theory  of 
asthma  being  an  anaph}dactic  phenomenon  gives  hope  that  the  cause  in 
individual  instances  may  be  discovered  and  its  simple  avoidance  be  all  the 
necessary  treatment.  But  even  under  these  circumstances  we  have  in  the 
iodid  of  potassium  and  belladonna  two  drugs  which  possess  undoubted  power 
to  relieve  bronchial  asthma  and  even  to  avert  attacks.     A  certain  measure 


INTERSTITIAL  PNEUMONIA  521 

of  relief  is  almost  always  secured  by  these  drugs,  and  in  many  cases  the  effect 
is  magical.  From  5  to  lo  grains  (0.33  to  0.65  gm.)  of  the  iodid,  and  3  to  7 
minims  (0.2  to  0.5  c.c.)  of  the  tincture  of  belladonna  should  be  given  every 
three  hours  until  relief  is  permanent.  A  combination  of  tincture  of  bella- 
donna, tincture  of  hyoscyamus,  tincture  of  cannabis  indica  and  deodorized 
tincture  of  opium,  equal  parts,  given  in  20  drop  doses  every  two  hours, 
signally  efficient  in  cases  of  asthma.  The  hypodermic  injection  of  a  com- 
bination of  hyoscin  and  atropin,  1/200  of  the  former  and  1/300  of  the 
latter,  has  been  found  useful  in  the  wards  of  the  University  Hospital. 

The  fumes  of  burning  paper  impregnated  with  nitrate  of  potash  and 
stramonium,  are  also  useful  adjuvants,  and  cigarettes  and  pastiles  made 
out  of  such  paper  are  constantly  employed  for  their  effect.  These  sub- 
stances form  the  basis  of  most  of  the  advertised  remedies  for  asthma. 

The  diet  of  asthmatics  shovdd  be  exceedingly  simple,  as  indiscretions 
in  it  are  often  the  exciting  causes  of  attacks.  No  fixed  rules  for  climatic 
treatment  can  be  laid  down,  as  conditions  favorable  to  different  cases  are 
exceedingly  capricious.  Certain  patients  can  live  comfortably  in  one 
part  of  the  same  country  and  not  in  another,  possibty  because  in  the  "bad" 
climate  they  are  "intoxicated"  by  the  substance  to  which  they  are  sensi- 
tized. On  the  whole,  high,  dry  climates  are  most  suitable  for  pure  asth- 
matics— i.  e.,  those  cases  uncomplicated  with  emphysema — though  moist, 
warm  climates,  such  as  those  of  Florida  and  Madeira  and  the  Canary 
Islands,  are  also  serviceable,  especially  when  there  are  catarrhal  symptoms ; 
or  southern  California,  where  the  climate  is  also-  warm  and  equable,  but 
drier.  When  there  is  emphysema,  high  altitudes  are  not  well  borne.  Cold 
and  moist  climates  are  harmful.  Oxygen  breathing  is  often  helpful,  as  is 
also  inhalation  of  compressed  air  in  the  pneumatic  cabinet.  The  final 
treatment  of  cases  eventuating  in  emphysema  is  that  of  emphysema. 

CHRONIC  INTERSTITIAL  PNEUMONIA. 
Synonym. — Cirrhosis  of  the  Lung. 

Definition. — A  chronic  inflammatory  disease  consisting  in  a  gradual 
invasion  of  a  lung  by  fibroid  tissue,  with  a  corresponding  reduction  in  the 
vesicular  structure  of  the  lung.  According  as  it  involves  limited  or  more 
extensive  areas  it  is  local  or  diffuse. 

Etiology. — Interstitial  pnetunonia  is  mainly  a  secondary  affection. 
There  are  few  chronic  affections  of  the  lung  which  do  not  cause  a  certain 
amount  of  fibroid  overgrowth.  Especially  is  this  true  of  tuberculosis 
and  bronchopneumonia.  A  form  of  the  latter  is  the  so-called  pneu- 
moconiosis, a  fibroid  indirration  succeeding  a  bronchopneumonia  due  to 
the  irritating  effects  of  minute  particles  arising  in  the  occupations  of 
coal-mining,  stone-cutting,  steel-grinding,  and  iron-working  in  general.  To 
the  form  associated  with  tuberculosis  the  term  fibroid  phthisis  is  applied, 
and  it  will  receive  separate  consideration.  The  seat  of  a  healed  tuber- 
culosis is  also  occupied  by  fibroid  tissue,  which  may  be  regarded  as  an 
example  of  interstitial  pnerunonia.  Less  frequently  it  succeeds  croupous 
pneumonia  as  fibroid  indirration,  which  has  been  considered  on  page  253 
and  constitutes  an  important  product  in  pleurogenic  pneumonia  mentioned 


522  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

on  page  253.  Even  abscesses  of  the  lung  may  excite  it,  while  the  various 
forms  of  morbid  growths,  as  sarcoma,  carcinoma,  chondroma  and  hydatid 
cysts,  are  causes  of  it,  and  are  surrounded  by  fibroid  growths.  Especially 
does  the  fibroid  change  occur  in  a  lung  that  has  been  long  in  a  state  of  com- 
pression, as  by  a  pleuritic  effusion.  Since  the  majoritj^  of  cases  of  chronic 
interstitial  pneumonia  are  directly  or  indirectly  the  result  of  microbic 
agents,  it  has  appeared  to  us  best  to  retain  its  consideration  in  this  section, 
even  though  some  cases  may  be  due  to  other  causes. 

Morbid  Anatomy.  Pathological  Histology. — In  bronchopneumonia  the 
fibrosis  usually  starts  from  the  outer  sheath  of  the  bronchi,  invading  the 
alveolar  walls  and  converting  the  entire  lobule  into  grayish  fibroid  tissue, 
in  which  no  lung  structure  is  distinguishable.  This  form  is  frequently 
associated  with  dilated  bronchus,  of  which  the  fibrosis  is  probably  the  direct 
cause,  its  contraction  drawing  the  walls  apart. 

The  line  of  demarcation  between  interstitial  pneumonia  on  the  one 
hand  and  tuberculosis  on  the  other  is  often  not  very  sharp.  In  interstitial 
pneumonia  after  croupous  pneumonia  a  gradual  organization  takes  place  of 
the  fibrinous  plugs  in  the  air-vesicles;  the  alveolar  walls  themselves  become 
thickened  by  a  new  formation,  at  first  cellular  and  subsequently  fibrU- 
lated.  Death  usually  occurs  in  these  cases  in  one  to  three  months  after  the 
onset  of  the  disease.  The  whole  of  the  part  primarily  invaded  may  become 
thus  altered. 

Macroscopic  Morbid  Anatomy. — The  chest-walls  of  the  side  affected 
are  often  depressed,  and  on  opening  the  thorax,  the  lung,  or  as  much  of  it  as 
is  involved,  is  found  retracted;  it  may  be  drawn  back  into  the  spinal  gutter. 
If  on  the  left  side,  the  heart  may  be  retracted  with  it.  Commonly  the  two 
pleurje  are  found  united,  but  not  always.  On  section  the  lung  is  hard  and 
tough.  It  is  gray,  fibrous,  and  the  alveolar  structure  has,  to  a  varying 
extent,  disappeared.  The  bronchi  and  the  blood-vessels,  however,  remain, 
the  former  being  often  dilated,  to  produce  the  so-called  bronchiectatic 
cavity,  of  which  there  may  be  a  number.  The  pulmonary  artery  may  be 
atheromatous.  In  the  phthisical  variety  there  may  also  be  a  cavity  at  the 
apex,  and  a  recognition  of  this  before  death  will  be  an  aid  to  diagnosis. 
Otherwise  a  careful  study  is  often  necessary  to  distinguish  the  two  varieties, 
unless  the  tubercle  bacillus  has  been  found. 

The  uninvolved  lung  is  usually  enlarged  and  emphysematous  in  propor- 
tion to  the  degree  of  contraction  of  the  affected  lung.  The  right  ventricle 
of  the  heart,  which  has  increased  work  imposed  upon  it  in  forcing  the  blood 
through  the  contracted  lung,  becomes  hypertrophied  and  ma}'  become 
ultimately  dilated. 

Symptoms. — The  principal  symptom  is  cough,  which  starts  with  the 
condition  causing  the  fibrosis  and  continues  to  the  end.  It  varies  greatly 
in  its  severity,  being  sometimes  trifling,  at  others  very  troublesome.  The 
expectoration  is  as  variable  as  the  cough;  more  copious  as  the  cough  is  more 
troublesome.  Persons  thus  affected  have  the  appearance  of  delicate  health, 
and  are  commonl}'  regarded  as  phthisical,  although  they  have  often  con- 
siderable strength  and  can  pursue  some  occupation.  In  nontubercular 
interstitial  pneiimonia  there  is  less  fever  than  is  present  as  a  rule  in  phthisis, 
but  the  recognition  of  the  tubercle  bacillus  is  the  crucial  test,  for  otherwise 


EMBOLIC  PNEUMONIA  523 

the  symptoms  are  very  similar.  In  both  conditions  there  is  paroxysmal 
cough,  with  copious  expectoration  of  mucopurulent  matter.  The  resem- 
blance is  still  more  close  if  there  is  bronchiectasis,  when  the  usual  emptying 
of  the  cavity  by  cough  takes  place,  commonly  in  the  morning,  sometimes 
twice  a  day,  and  even  oftener.  The  expectorated  matter  of  the  bronchiec- 
tatic  cavities  may  be  fetid  from  decomposition.  There  is  usually  less  dysp- 
nea than  in  true  phthisis,  and  except  where  the  disease  is  the  sequel  of  true 
pneumonia,  the  fatal  termination  is  longer  deferred  than  in  tuberculosis — 
it  may  be  for  years. 

Physical  Signs. — The  chest  is  more  or  less  retracted,  its  circumference 
diminished.  Its  movements  are  restricted  and  its  topography  altered. 
When  the  left  lung  is  extensively  affected,  the  heart  is  pulled  far  to  the  left. 
Retraction  of  the  right  lung  causes  the  heart  to  be  drawn  over  the  right  side 
of  the  chest.  In  high  degrees  of  the  disease  the  shoulder  is  drawn  down  and 
the  spinal  column  laterally  ciu-ved,  just  as  in  recovery  after  empyemic 
pleurisy.  The  unaffected  side  is  more  prominent  than  in  health,  due  to 
compensatory  emphysema.  The  tactile  fremitus  may  be  diminished  or 
increased  according  as  the  pleural  membrane  is  thickened  or  not.  The 
same  is  true  of  vocal  resonance.  Percussion  generally  elicits  impairment  of 
resonance  over  the  affected  lung,  though  there  may  be  high-pitched  tymp- 
any and  even  amphoric  resonance  over  a  dilated  bronchus.  The  lung  on 
the  sound  side  furnishes  hyperresonance.  To  auscultation  the  breathing 
sounds  may  be  feeble,  but  there  may  be  bronchovesicular  or  bronchial  and 
even  amphoric  breathing  of  the  most  intense  kind  on  the  affected  side. 
The  other  side  gives  the  signs  of  compensatory  emphysema. 

There  is  usually  sharp  accentuation  of  the  second  pulmonic  sound 
because  of  the  forcible  effort  of  the  right  ventricle  to  push  the  blood  through 
the  contracted  lung;  and  when  the  right  ventricle  begins  to  yield,  cardiac 
murmurs  may  develop  at  the  tricuspid  valve. 

Diagnosis. — Chronic  interstitial  pneumonia  is  mainly  to  be  distin- 
guished from  fibroid  phthisis,  which  is  often  impossible  without  an  examina- 
tion of  that  sputum  for  bacilli.  The  history  and  duration  of  the  case  may 
be  of  assistance.  The  fact  that  the  right  lung  is  contracted  maj^  be  assumed 
by  the  physical. 

Prognosis. — Recovery  is  impossible,  yet  cases  last  many  years — ten, 
fifteen,  and  even  longer. 

Treatment. — As  intimated,  treatment  for  the  fibrosis  is  unavailing, 
though  lung  gymnastics  should  be  practiced  with  a  view  to  developing  lung 
expansion.  Intercurrent  bronchitis  may  be  helped  by  the  usual  remedies 
for  that  disease.  Antispasmodics,  belladonna,  and  hyoscyamus  are  often 
usefiil  adjuvants  to  the  cough  medicines.  Patients  are  generally  better  in 
summer  and  in  a  warm  climate,  where  they  should  dwell,  if  possible.  They 
should  be  fed  with  an  abundance  of  rich,  nutritious  food,  and  surrounded 
by  the  most  favorable  hygienic  conditions. 

EMBOLIC  PNEUMONIA. 

Definition. — An  embolic  pneumonia  is  a  pnetimonia  caused  by  an 
embolus  or,  more  rarely,  by  a  thrombus  in  smaller  branches  of  the  pul- 
monary artery.     Embolic  pneumonia  is  either  nonseptic  or  septic. 


524  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Embolic  Nonseptic  Pneumonia. 
Synonym. — Hemorrhagic  Infarct  of  the  Lung. 

Etiology. — The  nonseptic  hemorrhagic  infarct  of  the  lung  is  the  result 
of  nonseptic  embolism,  or  thrombosis.  The  emboli  come  from  the  right 
side  of  the  heart,  where  they  either  originate  as  fragments  of  thrombi,  often 
found  in  the  tips  of  the  auricles,  or  have  entered  from  the  systemic  veins. 
Emboli  usually  lodge  at  the  bifurcation  of  the  branches  of  the  pulmonary 
artery.  The  usual  transudation  of  blood  takes  place  in  a  cone-shaped  area. 
Not  every  embolus  is  followed  by  an  infarct.  An  embolus  may  be  so  large 
as  to  cause  death  before  an  infarct  can  be  formed.  Nor  is  every  hemorrhagic 
infarct  followed  by  a  pneumonia.  The  ultimate  consequences  of  non- 
infectious emboli  depend  on  their  size.  A  large  embolus  and  a  corre- 
sponding infarct  with  free  extravasation  of  blood  are  liable  to  be  followed 
by  gangrene  of  the  lung,  which  may  excite  intense  reactive  inflammation 
in  its  neighborhood,  and  the  aspirated  blood  may  cause  pneiunonia.  When 
the  lodged  particle  is  small,  the  hemorrhagic  infarct  is  small,  and  the  transu- 
date is  a  diapedesis  rather  than  a  hemorrhage.  From  this,  true  embolic 
pneumonia  results  only  when  there  is  no  collateral  circulation — that  is, 
when  it  is  supplied  by  an  end-artery. '  When  hemorrhagic  infarct  is  caused 
by  thromboses,  the  thrombus  is  commonly  preceded  by  pulmonary  endart- 
eritis. They  are  most  common  in  diseases  of  the  heart  especially  the  myo- 
cardial conditions  where  there  is  an  extremely  weak  heart  muscle. 

Morbid  Anatomy. — The  infarct  thus  caused  is  conical  in  shape  with 
its  base  toward  the  pleura,  and  varies  in  size  from  that  of  a  cherry-stone  to 
that  of  a  hen's  egg.  The  pleura  over  the  infarct  at  first  projects  above  the 
surrounding  surface,  and  is  at  first  smooth,  but  later  is  roughened  bj'  a  film 
of  lymph.  The  infarct  when  recent  is  dark  reddish-brown  in  color,  and  on 
section  rises  also  above  the  surrounding  surface. 

This  transudation  is  the  preliminary  of  a  peculiar  reactive  inflamma- 
tion— the  embolic  pneumonia  under  consideration.  Succeeding  a  slight 
preliminary  contraction  there  takes  place  an  immigration  of  leukocytes  from 
the  contiguous  vessels  which  accelerates  the  reabsorption  of  the  blood.  To 
the  disintegration  and  absorption  of  the  red  blood-disks  succeed  a  more 
rapid  paling  and  contraction,  until  no  color  remains,  or  there  may  be  a  hard- 
ening of  the  pulmonary  tissue,  with  a  cicatricial-like  contraction,  into  which 
the  pleural  membrane  is  drawn,  producing  fibroid  thickening  with  radiated 
prolongations.  Such  hardening  is  partly  due  to  a  condensation  of  the  lung 
and  partly  to  an  organization  of  the  cells  in  the  infiltrated  alveolio  and  alveo- 
lar walls.  Such  remnant  is  slate-gray  from  the  residue  of  hematin  derived 
from  the  extravasated  blood,  or  it  may  be  dark  red,  owing  to  hematoidin 
crystals  throughout  it.  If  the  infarct  is  large,  a  part  may  break  down  into 
reddish  inodorous  pulp,  which  may  be  absorbed,  or  a  part  may  make  its 
way  into  a  bronchus  and  maj-  be  expectorated.  In  the  event  of  so  large,  an 
infarct  the  residue  of  cicatricial  tissue  is  larger.  Caseation  and  calcification 
of  the  remains  are  possible  results. 

The  embolus  itself  is  in  like  manner  removed,  a  few  filaments  or  slight 
wrinkles  in  the  walls  of  the  vessel  being  the  sole  residue. 

1  AU  the  large  branches  of  the  pulmonary  artery  are  end-arteries,  and  many  of  the  smaller  branches 
also.     The  reader  Is  referred  to  W.  H.  Welch's  article  in  Clifford  AUbutt's  System  of  Medicine,  vol.  vi. 


SEPTIC  FN  EU  MOM  A  525 

Symptoms. — There  may  be  no  symptoms,  or  these  may  be  confined 
to  a  transient  pleuritic  pain  in  the  pleura  covering  the  embolus.  With 
increase  in  size  of  the  infarct  such  pain  increases,  and  may  be  associated 
with  some  shortness  of  breath,  due  to  destruction  of  the  aerating  surface. 
There  is  often  marked  collapse.  To  this  may  be  added  expectoration  of 
blood  if  the  effused  blood  gets  into  the  bronchus.  If  the  infarcted  area  be 
sufficiently  large,  there  may  be  dullness  on  percussion,  increased  vocal 
fremitus  and  resonance,  crepitant  and  subcrepitant  rales,  bronchial  breath- 
ing, and  bronchophony.  Further  characteristics  are  the  absence  of  fever 
and  suddenness  of  onset  and  the  presence  of  intravascular  disease.  It  has 
been  mentioned  that  the  embolus  may  be  so  large,  and  cut  off  so  large  a 
supply  of  blood  to  the  lung,  that  death  will  take  place  before  an  infarct  can 
form.  Jaundice  has  sometimes  been  noted,  probably  hematogenetic  in 
origin,  a  consequence  of  the  extensive  blood  destruction.  , 

Diagnosis. — Embolic  nonseptic  pneumonia  is  often  overlooked.  The 
foregoing  symptoms,  suddenly  occurring  in  connection  with  states  leading 
to  thromboses  in  the  veins  or  the  right  heart,  may  be  suspected  to  be  due  to 
nonseptic  embolic  pneumonia.  Infarcts  that  form  in  the  lung  from  non- 
infectious emboli  arising  in  the  left  heart  or  arterial  system  must  be  so  small 
as  to  escape  detection,  since  the  emboli  themselves  must  be  so  small  as  to 
pass  through  capillaries  into  the  veins,  thence  into  the  right  heart,  and  thence 
to  the  lung. 

Prognosis. — The  prognosis  of  nonseptic  embolic  pneumonia  is  favor- 
able unless  the  embolus  is  so  large  as  to  stop  up  a  large  vessel,  producing 
a  correspondingly  large  infarct.  An  embolus  plugging  one  of  the  largest 
branches  of  the  pulmonary  artery  is  fatal  before  an  infarct  can  form. 

Treatment. — Nothing  can  be  done  actively  to  relieve  an  embolic  pneu- 
monia of  this  kind.  A  patient  in  whom  it  is  suspected  must,  of  course,  be 
kept  absolutely  at  rest.  Counterirritation  may  be  applied  to  the  chest-wall 
over  the  area  involved.  Anodynes  should  be  used  to  a  degree  required  to 
relieve  pain. 

Embolic  Septic  Pneumonia. 

Synonym. — Metastatic  Abscess. 

Etiology. — The  cause  of  septic  pneumonia  or  metastatic  abscess  of 
the  lung  is  a  septic  embolus.  Such  a  septic  embolus  may  originate  in  a 
thrombus  at  a  seat  of  putrid  inflammation  or  suppuration,  such  as  the  wound 
of  an  operation  or  a  compound  fracture,  or  in  the  uterus  after  child-birth. 
The  veins  of  such  a  focus  are  filled  with  thrombi,  which  extend  into  the 
larger  branches,  where  they  soften  and  break  up  into  fragments,  some  of 
which  may  pass  into  the  right  heart,  thence  into  the  pulmonary  artery  and 
its  branches,  until  one  is  reached  small  enough  to  resist  its  further  transit. 
Such  an  embolus,, which  is  probably  swarming  with  bacteria,  is  an  intense 
irritant,  and  inflammation  sets  in  that  invariably  terminates  in  abscess,  as 
contrasted  with  the  simple  indurative  irritation  caused  by  a  nonseptic 
embolus.  Thus  caused,  septic  pneumoniais  one  of  the  anatomical  features 
of  pyemia. 


526  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Morbid  Anatomy. — Should  it  be  our  fortune  to  see  this  form  of  pneu- 
monia in  its  first  stage,  the  same  dark-red  color  as  that  seen  in  the  hemor- 
rhagic infarct  of  nonseptic  pneumonia  may  be  noted  except  that  the  blood 
extravasation  is  more  copious.  Such  extravasation  is  a  further  irritant,  and 
soon  an  intense  inflammation  sets  in,  which  may  also  be  divided  into  two 
stages.  In  the  first  stage  the  alveolar  spaces  and  the  connective  tissue  of 
the  alveolar  and  infundibular  walls  are  infiltrated  with  pus-cells.  The 
latter  furnish  a  white-gray  ground,  on  which  may  be  seen,  with  the  naked 
eye,  delicate  red  lines  and  circles,  which  represent  infundibula  whose  vessels 
are  still  pervious  to  blood.  In  the  next  stage  abscess-formation  rapidly  suc- 
ceeds when  the  hepatized  area  melts  into  a  creamy  pus,  in  which  float  a  few 
fragments  of  elastic  tissue  representing  broken-down  alveolar  walls  and 
blood-vessels.  The  abscesses  thus  produced  may  be  multiple,  but  are 
mostly  of  small  size.  If  the  abscess  is  subpleural,  there  will  be  suppurative 
pleuritis  with  empyema,  and  possibly  perforation  of  the  lung. 

In  case  a  very  large  vessel  is  obstructed  and  a  corresponding  part  of 
lung  cut  off,  say  a  fifth  of  a  lobe,  the  area  thus  deprived  of  pulmonary 
arterial  blood  is  rapidly  filled  from  the  veins,  and  a  condition  analogous  to 
a  hemorrhagic  infarct  occurs,  to  the  border  of  which  the  inflammation  is 
confined,  where  finally  the  necrotic  mass  is  dissected  loose. 

Symptoms. — The  symptoms  are  those  of  pj'emia  (see  p.  i6i),  of  which 
the  lung  abscesses  form  a  part.  A  chill  succeeding  a  surgical  operation,  or 
occurring  during  the  lying-in  state,  followed  by  sweating  and  high  fever, 
are  significant  symptoms.  Where  there  are  symptoms  as  pain,  dyspnea, 
etc.,  referable  to  the  lung  itself,  successions  of  these  are  even  more  con- 
clusive. 

PLASTIC  OR  FIBRINOUS  BRONCHITIS. 

Definition. — This  is  a  rare  form  of  inflammation  of  a  part  of  the  bron- 
chial tree,  commonly  chronic,  but  occasionally  acute,  in  which  a  fibrinous 
mold  of  the  bronchus  and  its  branches  is  formed  and  expelled.  It  does  not 
include  those  instances  which  occur  in  croup  or  diphtheria  as  an  extension 
downward,  or  in  pneumonia  bj^  centripetal  extension. 

Etiology. — No  definite  cause  for  this  bronchitis  is  known,  though  it  is 
frequently  associated  with  tuberculosis — in  lo  out  of  21  cases  studied  bj' 
Model.  It  occurs  at  all  ages,  and  though  more  common  between  10  and  30, 
has  occurred  at  72.  It  has  happened  in  more  than  one  member  of  a  family. 
It  is  found  more  commonly  in  males  and  in  the  spring  months.  Other 
associations  named  are  probably  accidental,  as  with  skin  diseases.  In  the 
chronic  form,  which  consists  in  recurring  attacks  extending  over  many  years, 
the  same  part  of  the  bronchial  tree  is  apparently  attacked  each  time. 

Morbid  Anatomy. — As  primarily  expectorated,  the  exudate  is  a  round 
mass  mixed  with  blood  and  mucus.  This  mass,  sometimes,  quite  large, 
may  be  unrolled,  when  it  is  found  to  be  a  true  cast,  of  dendritic  shape  and 
hollow  interior,  of  the  trunk  and  branches.  The  latter  may  even  terminate 
in  bulbous  ends  corresponding  to  the  infundibula  of  the  lung.  The  mold  is 
true  fibrillated  fibrin,  in  which  are  embedded  numerous  leukocytes.  It  is 
whitish  or  yellowish-gray  in  color,  and  concentrically  laminated.     In  the 


FIBRINOUS  BRONCHITIS  527 

latter  feature  it  differs  from  the  branching  clots,  which  occasionally  form  in  a 
bronchus  and  branches  after  hemorrhage  into  the  lungs.  These  are  solid 
and  homogeneous.  A  fine  specimen  of  one  of  these  is  in  the  pathological 
museum  of  the  University  of  Pennsylvania.  The  true  fibrinous  casts  are 
usually  I  1/2  to  2  inches  (3.75  to  s  cm.)  long,  but  may  be  five  or  six  inches 
(12.5  to  IS  cm.)  long.  The  tubes  whence  the  casts  come  are  not  superficially 
changed,  but  on  minute  examination  have  been  found  bereft  of  epithelium. 
The  submucous  tissue  may  be  swollen  and  infiltrated  with  serum.  Charcot's 
crystals  and  Curschmann's  spirals  have  occasionally  been  found. 

Symptoms. — These  are  those  of  an  ordinary  bronchitis  of  severe  form. 
There  are  aggravated  cough  and  dyspnea.  Sometimes  this  is  preceded  by  a 
stage  in  which  there  is,  for  a  variable  time,  prolonged,  bronchial  catarrh  of 
ordinary  severity.  At  times  the  attack  is  ushered  in  by  rigor,  and  there  are 
high  fever,  pain  in  the  side,  and  soreness.  There  is  slight  expectoration  until 
the  cast  is  loosened  and  expelled.  The  cough  preceding  the  expulsion  does 
not  usually  last  more  than  a  few  hours,  though  it  does  sometimes  continue 
for  days.  With  the  expulsion  of  the  cast  comes  prompt  relief  for  the  time 
being.  It  is  sometimes  followed  by  slight  hemoptysis,  which  may  also  rarely 
precede  the  expulsion.  The  expectoration  of  a  single  cast  does  not,  however, 
terminate  the  attack.  After  24  to  48  hours  the  cough  and  dyspnea  return, 
and  another  cast  is  expelled.  This  may  be  kept  up  for  several  days,  after 
which  the  attacks  cease  to  recur.  Smaller  pieces  may  be  expelled.  The 
attacks  may  occur  but  once  in  a  lifetime,  or  they  may  be  repeated  at 
intervals  for  years. 

Physical  Signs. — These  are  usually  those  of  bronchitis.  There  is  no 
dullness  or  percussion,  unless  it  be  from  consolidation  due  to  collapse  of  the 
lung.  There  may  be,  according  to  Walshe,  circumscribed  pneumonia  with 
crepitant  rale  and  rusty  sputum.  The  effort  at  breathing  is  labored,  and  if 
there  is  obstruction  of  a  large  tubule,  there  may  be  retraction  of  the  lower 
ribs  during  inspiration.  The  cast  then  begins  to  be  loosened,  and  moist 
rales  make  their  appearance. 

Diagnosis. — The  rarity  of  the  disease  is  so  great  that  in  the  absence 
of  distinctive  physical  signs  the  true  condition  is  rarely  suspected.  In 
recurring  attacks  the  true  nature  of  so  severe  an  attack  of  bronchitis  may  be 
suspected. 

Prognosis. — This  is  usually  favorable,  although  the  symptoms  are 
often  alarming.  N.  S.  Davis  has  reported  two  fatal  cases  of  the  acute 
form. 

Treatment. — The  disease,  so  long  as  its  true  nature  is  undetermined,  is 
treated  as  an  ordinary  bronchitis.  If  its  true  nature  is  suspected,  the  vapor 
from  alkaline  solutions  should  be  inhaled,  or  these  should  be  sprayed 
into  the  larynx.  Lime-water  is  one  of  those  commonly  employed.  Alka- 
line solutions  may  be  of  the  strength  of  30  grains  (2  gm.)  of  sodium  bicarbon- 
ate to  the  fluidounce  (30  c.c.)  of  water.  Jaborandi  or  its  active  principle, 
pilocarpin,  may  be  tried.  Emetics  should  also  be  employed  when  the 
breathing  is  much  embarrassed.  They  sometimes  have  the  effect  of  dis- 
charging the  cast.  lodid  of  potassium  is  recommended,  and  should  certainly 
be  used  when  the  attack  is  protracted. 


528  DISEASES  OF  THE  RESPIRATORY  SYSTEM 


EMPHYSEMA  OF  THE  LUNGS. 

Synonyms. — Alveolar  Ectasia;  Increase  of  Volume  of  the  Lung. 

Definition. — There  are  three  applications  of  the  term  emphysema,  and 
they  have  very  different  significations.  In  the  first  place,  there  is  interlobular 
or  interstitial  emphysema,  in  which,  in  consequence  of  rupture  of  air  vesicles 
deep  in  the  lung  structure,  the  air  escapes  into  the  interlobular  tissue  and 
may  collect  there  like  rows  of  beads  outlining  the  lobules,  while  under  the 
pleura  larger  vesicles  may  form.  This  form  occurs  after  wounds  of  the  lung, 
and  in  severe  and  persistent  whooping-cough,  and  in  cough  of  bronchial 
asthma,  in  both  of  which  the  expiratory  strain  is  very  great.  It  is  also 
termed  acute  emphysema.  It  is  not,  however,  demonstrable  clinically, 
except  in  those  cases  in  which  it  takes  place  at  the  root  of  the  lung  and  the 
air  travels  along  the  trachea  until  it  reaches  the  .subcutaneous  tissue  of  the 
neck  and  chest-walls.  It  gives  rise  to  a  peculiar  crepitation  to  the  touch. 
A  similar  condition  of  the  subcutaneous  tissue  may  be  due  to  infiltration  of 
the  tissues,  with  gas  arising  from  decomposition.  It  is  found  in  the  neigh- 
borhood of  wounds  which  take  on  an  unhealthy  action,  and  where  decompo- 
sition leads  to  the  generation  of  gas.  This  form  of  emphj'sema  is,  of  course, 
more  circumscribed  than  that  due  to  a  wound  of  the  lung. 

The  second  form,  vesicular  emphysema,  is  an  overdistention  followed  by 
atrophy  of  air  vesicles,  either  symmetrical,  involving  both  lungs,  or  localized. 
It  occurs  in  certain  portions  of  a  lung  adjacent  to  another  which  cannot, 
from  some  cause,  expand  fully  in  inspiration.  Such  are  portions  of  the  lung 
adjoining  tuberculous  areas,  or  areas  of  collapsed  lung,  or  adjacent  to  parts 
whose  expansion  is  prevented  by  pleuritic  adhesions.  It  is  particularly  the 
anterior  parts  of  the  lung  that  are  the  seat  of  localized  emphysema  in  the 
latter  case.  When  such  complemental  dilatation  is  impossible,  as  is  often 
the  case  in  extensive  pleuritic  adhesions,  the  chest-wall  must  sink  in  to 
occupy  the  space.  Perhaps  all  emphysema  is  more  or  less  localized,  but  in 
general  or  symmetrical  emphysema  very  much  larger  areas  of  both  lungs 
are  involved.  The  distended  air  vesicles  are  useless,  whUe  many  of  them 
are  also  atrophied.  The  former  is  also  called  hypertrophic,  but  pseudo- 
hypertrophic would  be  a  much  more  suitable  term,  because  there  is  no  true 
hypertrophic  enlargement. 

The  term  "compensatory"  is  also  applied  to  localized  emphysema,  but 
this  term  should  not  be  applied  unless  the  dilatation  is  truly  compensatory — 
that  is,  is  the  result  of  an  effort  on  the  part  of  a  lung  or  portion  of  it  to  sup- 
plement the  office  of  another  more  or  less  useless  part,  when  the  condition 
is  really  developmental,  and  not  degenerate. 

A  third  form  of  emphysema  of  the  lungs  is  known  as  atrophic  emphysema; 
it  is  called  also  by  Sir  William  Jenner  small-lunged  emphysema.  In  it  the 
whole  lung  and  thorax  maj^  be  reduced  in  size,  and  even  the  respiratory 
muscles  maj'  be  atrophied.  It  is  a  disease  of  old  persons,  and  is  to  be  re- 
garded as  an  involution  process.  There  is  a  true  atrophy  of  air  vesicles,  and 
bullae  of  various  sizes  are  formed  by  the  wasting  of  intermediate  vesicles. 

The  section  is  limited  to  the  consideration  of 


EMPHYSEMA  529 

Vesicular  Emphysema — Pseudohypertrophic  Emphysema. 

Etiology. — By  far  the  larger  number  of  cases  of  emphysema  are  the 
result  of  chronic  bronchitis.  This  bronchitis  may  begin  in  childhood.  It 
may  begin  as  whooping-cough,  from  which  the  child  has  not  completely 
recovered,  or  succeeding  which  it  has  been  subject  to  constantly  recurring 
attacks  of  acute  bronchitis.  It  is  scarcely  likely,  if  the  lung-tissue  pre- 
served its  proper  integrity,  that  even  under  the  forced  inspiratory  strain  of 
coughing  the  air  vesicles  would  undergo  the  dilatation  and  destruction 
characteristic  of  emphysema.  With  chronic  bronchitis  there  is  sooner  or 
later  an  impairment  in  the  nutrition  of  the  air  vesicles,  which  makes  them 
more  yielding  and  more  likely  to  give  way  under  the  strain.  Blowing  on 
wind  instruments  and  glassblowing,  as  well  as  occupations  requiring  muscu- 
lar strain  and  the  lifting  of  heavy  weights,  are  assigned  as  causes.  Bronchial 
asthma  is  another  cause.  In  all  these  cases  both  inspiration  and  expiration 
cooperate  to  produce  the  strain,  but  it  is  probable  that  expiration  is  the 
more  potent  factor.  The  severe  cough  of  chronic  bronchitis  begins  with  a 
deep  inspiration  which,  while  harmless  to  a  healthy  air  vesicle,  may  over- 
distend  a  weak  one.  Then  follow  closure  of  the  glottis  and  a  forcible 
contraction  of  the  muscles  of  expiration — abdominal  muscles.  The  latter 
compress  especially  the  lower  part  of  the  lung,  and  as  the  air  cannot  escape, 
it  is  forced  into  the  peripheral  parts,  overdistending  the  air  vesicles  there. 
So,  also,  in  horn-blowing  and  muscular  strain  we  have  the  effect  of  deep 
inspiration,  and  especially  the  increased  pressure  during  expiration,  with 
the  glottis  closed.  We  may  admit  also  a  valve-like  effect  of  certain  plugs 
of  mucus,  which  permit  the  entrance  of  air  during  inspiration,  but  do  not 
allow  its  exit.  Thus,  the  vesicles  become  filled  with  air  which  cannot  get 
out.  Since  the  air  is  forced  in  the  direction  of  least  resistance,  it  is  the  air 
vesicles  in  the  apices  and  edges  of  the  lungs  which  dilate  first.  This  is 
probably  one  way  in  which  expiratory  strain  acts  in  producing  dilatation. 
The  valve-like  action  may  also  be  in  the  opposite  direction,  permitting  the 
air  to  get  out  of  the  vesicles,  but  preventing  it  from  getting  into  them,  and 
thus  finally  a  portion  of  the  lung  becomes  collapsed.  The  inspired  air  must 
go  somewhere  else,  and  produces  what  may  be  called  a  collateral  dilatation. 

The  vesicles  thus  overdistended  finally  lose  their  elasticity,  like  an  over- 
distended  india-rubber  air  balloon,  which,  after  repeated  distentions,  loses 
its  power  to  recoil.  Succeeding  the  overdilatation  comes  atrophy  of  the 
vesicles,  and  with  this  the  blood-vessels  surrounding  them  are  destroyed. 
Although  under  these  circumstances  the  lung  occupies  more  space,  its  blood- 
aerating  power  is  diminished.  The  circulation  is  cut  down  to  the  larger 
trunks,  and  the  blood  takes  a  short  cut,  as  it  were,  from  the  pulmonary 
arteries  to  the  pulmonary  veins.  The  aeration  of  the  blood  is  thus  rendered 
difficult  or  impossible,  accounting  in  part  for  the  dyspnea. 

There  is  also  reason  to  believe  that  heredity  plays  a  decided  role  in  the 
causation  of  emphysema,  and  that  congenital  defect  often  takes  the  place  of 
acquired  nutritive  retrogression.  This  was  first  shown  by  the  late  James 
Jackson,  of  Boston,  who  found  that  in  i8  out  of  28  cases  one  or  both  parents 
were  affected.  Accordingly,  too,  emphysema  is  surprisingly  common  in 
children,  and  in  adults  may  often  be  traced  back  to  childhood. 


530  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Morbid  Anatomy. — The  emphysematous  chest  is  often  highly  character- 
istic, in  that  the  anteroposterior  diameter  is  greatly  increased,  making  the 
two  diameters  nearly  or  quite  equal,  producing  the  "barrel  shape."  On 
opening  the  thorax  in  an  adult  the  cartilages  are  found  calcified,  and  on 
raising  the  sternum  the  greater  volume  of  the  lungs  at  once  shows  itself. 
They  are  in  a  state  of  permanent  distention,  meeting  by  their  edges  in  the 
mediastinal  space  and  almost  or  entirely  covering  the  ]3ericardium.  Nor 
do  they  collapse  when  removed  from  the  chest. 

The  individual  air  vesicles  are  not  only  dilated,  but  large  numbers  of 
them  are  atrophied,  producing  bullae  of  various  sizes,  from  the  walls  of 
which  extend  inward  partition  which  are  the  remnants  of  vesicles,  so  that 
the  large  vesicle  has  been  aptly  compared  to  a  frog's  lung  with  its  semiparti- 
tions.  The  pleura  is  pale  and  the  lungs  are  especially  so,  partly  from 
atrophy  of  the  pulmonary  capillaries  which  accompanies  the  destruction  of 
the  vesicles,  associated  with  diminution  in  the  natural  pigment.  The  lung 
surface  pits  readily  on  pressure.  The  distention  and  destruction  are  not 
limited  to  the  peripher}^  of  the  lungs,  but  are  also  found  in  the  center  and 
toward  the  root,  where  large  bulls,  two  to  three  inches  (5  to  S  cm.)  in 
diameter,  may  be  found. 

The  bronchi  exhibit  the  changes  already  described  under  Chronic 
Bronchitis  and  Bronchiectasis.  An  important  anatomical  change  is 
hypertrophy  and  dilatation  of  the  right  ventricle  of  the  heart,  due  to  the  extra 
effort  required  to  drive  the  blood  through  the  diminished  vascular  area  in 
the  lungs.  In  the  later  stages  the  hypertrophy  has  given  way  to  dilatation, 
and  there  may  be  relative  insufficiency  of  the  tricuspid  valve  with  dilatation 
also  of  the  right  auricle.  In  a  few  cases  there  is  hypertrophy  of  the  whole 
heart.  There  is  sometimes,  also,  atheroma  of  the  pulmonary  artery  and  of 
the  other  blood-vessels,  or  there  may  be  associated  pulmonar\-  tuberculosis 
of  the  fibroid  variety,  as  well  as  Bright's  disease. 

Symptoms. — The  typical  emphysematous  subject  may  often  be  recog- 
nized by  his  peculiar  round-shouldered  stoop  and  barrel-shaped  chest  and 
short  neck.  Rarely,  this  form  of  emphysema  is  an  acute  or  comparatively 
rapid  development,  succeeding  whooping-cough;  but  the  approach  of  the 
disease  is  mostly  gradual,  the  first  symptom  to  develop  and  remain  constant 
being  shortness  of  breath,  which  is  partly  due  to  the  fact  that  the  air  in  the 
vesicles  does  not  undergo  the  usual  interchange.  In  health  the  intercostal 
muscles,  the  diaphragm,  and  auxiliary  muscles  of  respiration  enlarge  the 
thoracic  box,  and  the  lungs  expand  to  fill  it  partly  by  their  own  resilienc3% 
but  chiefly  to  fill  the  vacuum,  producing  the  act  of  inspiration,  while  the 
air  is  expelled  in  expiration  partlj'  by  the  recoil  of  the  elastic  tissue  and  partly 
by  the  pressure  of  the  contracting  thorax.  This  natural  resiliency  is  absent 
in  a  large  degree,  while  the  thoracic  box  also  remains  in  a  state  of  "rigid 
dilatation."  The  lung  is  always  filled  with  air,  but  it  is  air  charged  with 
carbonic  acid  and  does  not  change.  As  a  consequence  the  patient  makes 
increased  efforts  to  draw  the  air  into  the  lungs,  but  as  the  air  vesicles  are 
already  filled,  these  efforts  are  ineffectual.  The  dyspnea,  which  is  but  slight 
at  first  and  is  brought  about  only  by  exertion,  soon  becomes  decided  and 
constant.     The  pulse-rate  is  also  accelerated,  but  the  temperature  is  usually 


EMPHYSEMA  531 

normal.  Cyanosis  is  a  characteristic  symptom  in  established  cases,  owing 
to  the  universal  presence  of  unaerated  blood. 

Aside  from  these  symptoms  are  mainly  those  of  the  associated  bronchi- 
tis— viz.,  cough,  expectoration,  and  sometimes  oppression — while  variations 
in  these  add  to  or  abate  his  discomfort.  With  failure  of  the  right  heart 
come  venoiis  engorgement,  dropsy,  and  efifusions  into  the  serous  sacs. 
Tuberculosis  of  the  fibroid  type  sometimes  develops. 

Physical  Signs. — The  physical  signs  are  not  alwaj's  distinctive.  Inspec- 
tion reveals  a  rounded  chest,  with  increased  circumference  and  wide  inter- 
costal spaces  in  the  hypochondriac  regions,  but  narrow  above.  The 
epigastric  angle  is  obtuse.  The  result  is  the  well-known  "barrel-shaped" 
chest.  More  rarely  the  emphysema  may  be  so  circumscribed  as  to  produce 
local  bulging,  by  preference  over  the  upper  lobe  of  the  right  and  lower  lobe 
of  the  left  lung.  Expansion  of  the  chest-wall  is  diminished,  while  the 
scaleni  and  stemo-cleido-mastoid  muscles  stand  out  distinctly.  The  chest 
does  not  expand,  but  is  raised  up  by  these  muscles,  which  are  hypertrophied; 
the  apex-beat  is  not  visible,  but  may  be  felt  displaced  downward  and  to  the 
right,  and  is  often  difficult  to  find,  because  covered  up  by  the  enlarged  lung. 
The  breathing  is  rapid.  There  may  be  retraction  of  the  lower  intercostal 
spaces  and  the  upper  abdomen  instead  of  swelling  out  during  inspiration, 
because  of  failure  of  the  diaphragm  to  descend.  Vocal  fremitus  is  dimin- 
ished, while  the  natural  resiliency  of  the  chest-walls  is  substituted  bj'- 
increased  resistance. 

Percussion  produces  resonance  exaggerated  in  various  degrees,  some- 
times amounting  almost  to  tympany,  the  result  of  the  overdistention  of  the 
air  vesicles,  whose  elasticity  is  spent.  To  auscultation  vocal  resonance  is 
decreased  because  of  the  diminished  vibration  in  the  air  columns .  Expiration 
is  much  prolonged  and  of  low  pitch,  being  difficult  to  hear  unless  there  are 
accompanying  rales.  Feeble  crackling  is  sometimes  heard.  StrumpeU  says 
the  vesicular  murmur  is  at  times  exaggerated  and  "shuffling,"  at  others 
"rougher  and  more  indefinite."  Roughness  and  exaggeration  seem  im- 
possible in  true  emphysematous  areas.  They  may  be  present  in  adjacent 
supplementally  acting  areas.  If  bronchitis  is  present,  its  sounds  are  asso- 
ciated, and  often  obscure  all  else.  The  pulmonary  second  sound  at  the 
second  left  interspace  is  accentuated  on  account  of  the  hypertrophy  of  the 
right  ventricle,  but  the  heart-sounds  are  usually  obscured  by  the  extra 
covering  of  the  lung.  With  dilatation  of  the  right  ventricle,  which  sooner  or 
later  succeeds,  the  increased  accentuation  disappears. 

Interlobular  emphysema,  in  which  the  connective  tissue  between  the 
lobules  is  infiltrated  with  air  as  the  restolt  of  rupture  of  air  vesicles  due  to 
violent  acts  of  coughing  or  by  wounds  of  the  lung,  affords  no  physical  signs, 
indeed  rarely  any  symptoms.  The  shape  of  the  chest  in  such  cases  is  not 
altered.  Suddenness  of  onset  is  characteristic  of  this  form  of  emphysema, 
and  it  is  apt  to  be  associated  with  a  similar  infiltration  of  the  tissues  of  the 
neck,  which  gives  rise  to  a  very  distinctive  crepitation  on  palpation. 

Diagnosis. — This  is  not  usually  difficult,  at  least  in  true  symmetrical 
emphysema.  In  pneumothorax  there  is  some  simulation  of  the  symptoms  of 
emphysema.  There  is  the  same  shortness  of  breath,  and  there  is  some  re- 
semblance in  the  physical  signs.     There  is  bulging  of  the  chest,  which  is, 


532  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

however,  more  marked  on  one  side  than  on  the  other.  Pneumothorax  is 
unilateral,  emphysema  usually  bilateral.  The  parts  of  the  chest  more  likely 
to  be  affected  with  emphysema  are  the  upper  part  of  the  right  lung  and  the 
lower  part  of  the  left.  Also  in  the  matter  of  percussion,  emphysema  gives 
hyperresonance.  Pneumothorax  gives  more  marked  tympany.  The  hy- 
perresonance,  although  often  marked,  is  not  always  so.  The  unyielding 
chest-walls  modify  it.  The  sound  in  pneumothorax  is  a  real  tympany,  com- 
parable to  that  obtained  over  the  distended  abdomen.  In  both,  the  thick- 
ness of  the  chest-walls  exerts  a  modifying  effect.  Maybe  effusion,  which 
gives  flatness  on  percussion,  and  a  line  of  separation  between  tympany  and 
flatness  is  demonstrable.  Pneumothorax  is  sudden  in  its  occurrence,  where- 
as emphysema  develops  gradually.  It  is,  however,  not  impossible  for  the 
two  affections  to  be  combined.  The  heart  is  displaced  in  pneumothorax 
and  not  in  emphysema. 

There  is  still  another  condition  with  which  emphysema  may  be  con- 
founded, though  it  is  of  rare  occurrence;  I  refer  to  diaphragmatic  hernia,  in 
which  tj'mpanitic  resonance  is  a  striking  sj'mptom. 

Prognosis. — This,  except  in  cases  of  acute  emphysema,  which  heals 
spontaneously,  is  unfavorable  as  to  cure.  The  course  is  always  a  chronic 
one,  and  much  may  be  done  for  the  comfort  of  the  patient.  No  classes 
of  cases  are  so  benefited  by  admission  into  hospitals  as  members  of  the 
laboring  class  afflicted  with  emphysema. 

Treatment. — It  is  impossible,  to  restore  destroyed  lung  texture.  If  a 
number  of  air  vesicles  have  been  converted  into  one  sac  or  bladder-like 
cavity,  there  are  no  means  by  which  these  vesicles  can  be  restored.  At  the 
same  time,  when  the  patient  is  young,  there  is  some  hope  of  cure  if  the 
structural  loss  is  not  too  great.  Effort  must  be  directed  mainly  to  avert- 
ing those  conditions  which  complicate  and  increase  the  emphysema.  As  has 
been  said,  chronic  bronchitis  is  its  most  frequent  cause,  and,  therefore,  we 
to  relieve  this  condition  by  everj^  means  in  our  power.  As  the  general  health 
ratist  tr^'  is  often  impaired,  it  is  as  important  that  this  should  be  reestab- 
lished as  that  the  bronchitis  should  be  relieved.  The  blood  is  to  be  restored 
to  a  proper  composition  by  tonic  remedies,  like  cod-liver  oil  and  iron,  and 
the  very  best  food  that  the  patient  can  procure.  To  the  cod-liver  oil  and 
iron  should  be  added  strychnin  in  full  doses,  1/30  to  1/32  grain  (0.0022  to 
0.005s  grn.),  while  arsenic  is  an  admirable  tonic  either  in  the  shape  of 
Fowler's  solution,  5  drops  at  a  dose  for  an  adult,  or  of  arsenious  acid,  1/30 
grain  (0.0022  gm.). 

While  the  bronchitis  is  treated  by  the  usual  remedies,  it  is  of  the  utmost 
importance  that  the  stomach  should  be  kept  in  good  condition,  and  that 
digestion  should  not  be  interfered  with,  while  more  than  ordinary  care  is 
required  in  the  selection  of  remedies  for  the  bronchitis. 

Strychnin  is  an  admirable  remedy,  not  only  as  a  tonic,  but  it  may  also 
be  regarded  as  an  expectorant,  and  secretions  in  the  lungs  are  often  disposed 
of  by  its  use.  It  has  also  the  effect  of  improving  the  nutrition  of  the  muscu- 
lar tissue  of  the  walls  of  the  bronchi,  as  it  has  of  imjDroving  the  muscular 
tissue  in  general.  Full  doses  should  be  given — not  less  than  i;'6o  grain 
(o.ooi  gm.),  three  times  a  day,  increased  gradually  to  1/30  grain  (0.002 
gm.) .     This  is  to  be  kept  up  for  a  long  time. 


TUMORS  OF  THE  LUNG  533 

Bronchial  asthma  is  one  of  the  most  serious  and  frequent  complications, 
and  often  overshadows  all  else.  The  treatment  recommended  on  previous 
pages  must  be  employed. 

To  relieve  the  constant  dyspnea,  the  treatment  suggested  some  years 
ago  by  Waldenburg  is  one  the  usefulness  of  which  is  only  limited  by  its 
relative  difficulty  in  application  and  the  costliness  of  the  necessary  apparatus. 
It  consists  in  the  inspiration  of  compressed  air  and  the  expiration  into 
rarefied  air.  It  is  evident  that  if  compressed  air  can  be  introduced  into  the 
vesicles,  the  aeration  of  the  blood  will  be  more  perfect,  and  that  if  the  patient 
breathe  into  rarefied  air,  the  residual  air,  which  it  is  so  difficult  to  get  rid  of, 
will  be  more  effectually  forced  out.  The  compressed-air  chamber  has  a 
similar  purpose. 

Expiration  may  also  be  aided  by  compression  of  the  chest,  intermittently 
applied  so  as  to  coincide  with  natural  breathing.  This  must  usually 
be  practised  by  a  nurse  or  an  attendant,  but  Striimpell  describes  in  his  text- 
book a  simple  contrivance  devised  by  a  patient  of  his  own  for  self -treatment. 
It  consists  of  two  boards  fastened  behind  and  allowed  to  project  forward  on 
each  side  in  front,  so  that  the  patient  himself,  taking  hold  of  the  projecting 
ends,  can  compress  his  own  chest  with  each  act  of  expiration.  Removal 
to  other  climates  suggested  in  chronic  bronchitis  should  be  carried  out  where 
possible.  As  the  heart  begins  to  fail  in  emphysema  before  the  end  in 
practically  all  cases,  great  care  must  be  taken  that  overexertion  be  not  in- 
dulged in.  All  the  care  must  be  given  to  cardiac  decompensation  in  these 
cases  as  is  advised  under  diseases  of  the  heart. 

TUMORS  OF  THE  LUNG. 

The  lungs  are  subject  to  morbid  growths  classified  as  tumors,  though, 
owing  to  their  situation,  they  rarely  present  the  macroscopic,  tumor-like 
qualities. 

They  include  carcinoma,  and  many  of  the  histoid  tumors. 

Etiology  and  Morbid  Anatomy. — Carcinoma  occurs  rarely  as  a  primarj^ 
growth,  but  is  not  infrequent  as  a  secondary  new  formation.  Primary  can- 
cer presents  itself  usually  in  the  shape  of  a  white  or  yellowish  nodule  two  to 
four  inches  (s  to  lo  cm.)  in  diameter.  It  is  found  in  the  upper  lobe  of  one 
lung,  posteriorly  and  externally;  more  seldom  in  other  parts.  It  probably 
originates  in  the  alveolar  epithelium,  and  causes  secondary  infiltration  of  the 
bronchial  glands  and  pleura.  It  may  be  represented  by  any  of  the  three 
principal  forms,  scirrhous,  encephaloid,  or  epithelioma,  also  by  the  coUoid 
and  melanotic.  It  occasions  a  reactive  pneumonia  in  the  lung  tissue  about 
it,  and  often  furnishes  the  physical  signs  of  this  affection. 

There  also  occurs  in  the  lung  ayrvmavY peribronchial  cancer,  disseminated 
in  nodules  throughout  the  lung  along  the  bronchi,  smaller  nodules  on  the 
smaller  bronchi,  and  larger,  irregular  masses  on  the  larger,  varying  in  si^e 
from  that  of  a  pea  to  a  walnut.  It  produces  also  infiltration  of  the  lymph 
glands  at  the  root  of  the  lung.  Sarcoma  is  also  a  rare  form  of  primary  tumor 
of  the  lung. 

More  frequentlj'  both  carcinoma  and  sarcoma  are  found  in  the  shape 
of  secondary  nodules  invading  both  lungs.     From  three  to   20  opaque 


534  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

white  nodules,  1/2  inch  (1.25  cm.),  more  or  less,  in  diameter,  are  found  ir- 
regularly scattered  through  each  lung.  Every  variety  of  primary  cancer 
may  be  thus  represented  secondarily  in  the  lung.  Its  origin  is  probably 
embolic,  and  it  may  be  secondary  to  cancer  elsewhere,  most  frequently  in 
the  breast. 

As  elsewhere,  these  growths  generally  present  themselves  after  middle 
life,  primary  cancer  affecting  either  sex  about  equally,  while  secondary  is 
more  common  in  women,  consistently^  with  the  more  frequent  occurrence  of 
cancer  elsewhere  in  women. 

The  histioid  tumors  are  represented  by  a  subpleural  enchondroma,  oc- 
curring, rarely,  primarily  as  large  as  a  walnut;  more  frequently,  secondary 
to  occurrence  elsewhere,  when  it  may  attain  a  large  size.  Other  histioid 
tvunors  are  myxoma,  adenosarcoma,  dermoid  cysts,  fibromata,  osteomata, 
and  gummy  tumors. 

Symptoms. — Carcinoma  and  sarcoma  may  both  be  latent,  or  at  most 
produce  such  vague  symptoms  that  it  does  not  occur  to  phj'sician  or  patient 
to  locate  them.  There  ma}^  however,  be  pain,  oppression,  cough,  expecto- 
ration, and  superficial  signs  of  vascular  obstruction,  such  as  lividity  of  the 
face  and  swelling  of  the  upper  extremities.  The  encroachment  of  the  larger 
cancerous  masses  upon  the  pleural  cavity  may  be  marked.  Pressure  on  the 
trachea  and  bronchi  may  occur  and  occasion  great  dyspnea,  while  the  heart 
may  be  dislocated.  The  pneumogastric  and  recurrent  laryngeal  nerves  are 
sometimes  involved,  occasioning  the  various  fonns  of  paralysis  of  the  vocal 
cords  and  aphonia.  The  reactive  pneumonia  referred  to  may  present  the 
physical  signs  distinctive  of  this  disease,  and  it  is  probably  thus  that  the 
prune-juice  expectoration,  though  to  be  quite  characteristic  of  cancer  of 
the  lung — 10  times  out  of  18,  as  elaborated  by  Stokes  many  years  ago — • 
originates.  This  complication,  too,  may  occasion  the  fever  which  is  some- 
times present. 

The  external  lymphatic  glands,  as  those  in  the  neighborhood  of  the 
clavicle,  may  be  involved  and  exhibit  enlargement. 

Sooner  or  later,  if  the  patient  lives  long  enough — that  is,  if  his  life  is 
not  destroyed  by  some  encroachment  on  the  breathing  or  vascular  function 
— he  emaciates,  and  becomes  cachectic  and  debilitated.  The  more  usual 
duration  of  the  disease  is  from  six  to  eight  months,  but  death  is  liable  to 
occur  suddenly  from  the  causes  named. 

Physical  Signs. — These,  of  course,  are  indefinite,  and  it  is  probably 
their  indefinite  and  irregiilar  manifestation,  with  the  symptoms  named, 
which  will  suggest  the  nature  of  their  cause.  Physical  signs  of  pneumonia 
and  pleurisy,  either  alone  or  combined,  may  be  present,  the  voice  and 
breatliing  sounds  and  percussion  note  being  affected  accordingly. 

Diagnosis. — Secondary  cancer,  where  primary  cancer  is  present  else- 
where, is  suggested  whenever  any  of  the  symptoms  named  occur  in  a  pro- 
nounced degree  and  are  sufficiently  long  continued.  In  the  case  of  primary 
growths,  the  diagnosis  must  longer  remain  doubtful,  and  we  must  study 
and  await  the  development  of  the  more  distinctive  symptoms. 

The  nonmalignant  tumors  present  no  signs  by  which  they  can  be  dis- 
tinguished from  the  malignant,  except  that  their  course  is  less  rapid  and 
the\'  develop  no  cachexia. 


ACUTE  PLEURISY  535 

Treatment. — This  consists  only  in  measures  calculated  to  relieve  symp- 
toms and  to  make  the  patient  comfortable. 

DISEASES  OF  THE  PLEURA. 

ACUTE  PLEURISY. 

Definition. — Acute  inflammation  of  the  serous  investment  of  the  lung 
or  of  its  reflection  on  the  ribs  and  diaphragm. 

Etiology. — Simple  fibrinous  pleurisy  may  be  caused  by  an  infection 
called  forth  by  simple  chilling  of  the  body  during  exposure  to  cold. 

Morbid  Anatomy. — The  morbid  anatomy  of  pleurisy  will  be  best^ under- 
stood b}'  supposing  every  pleurisy  to  begin,  as  it  probably  does,  with  a 
dry  stage,  a  pleuritis  sicca,  whatever  may  be  its  subsequent  course.  Thus 
considered,  the  earliest  stage  of  all  pleurisies  has  a  hyperemic  basis,  suc- 
ceeded immediately  by  a  roughness  of  surface  due  to  loosening  and  detach- 
ment of  the  epithelium,  a  roughness  increased  by  the  addition  of  fresh 
inflammatory  lymph  composed  of  transuded  fibrin  and  wandered-out  leuko- 
cytes from  the  subpleural  blood-vessels.  Further  progress  of  such  pleurisy 
is —   ■ 

First,  toward  resolution,  in  the  course  of  which  the  product  described 
liquefies  and  is  reabsorbed. 

Second,  toward  primary  organization  and  adhesion,  and  two  surfaces 
of  the  pleura  are  more  or  less  permanently  glued  together  over  an  area 
corresponding  to  that  of  inflammation.  This  is  the  probable  explanation 
of  the  little  patches  of  adhesion  so  frequently  found  at  autopsies,  some 
of  which  may  have  formed  without  the  consciousness  or  discomfort  of 
the  patient,  while  others  have  succeeded  upon  a  "stitch"  in  the  side  which 
has  been  passed  by  as  of  little  consequence.  Other  instances  of  this  pri- 
mary adhesive  inflammation  are  found  between  the  opposed  surfaces  of 
pleural  membrane  covering  tuberculous  deposits  in  the  lung,  or  limited 
pneumonic  areas,  or  morbid  growths,  such  as  giuxima,  cancers,  and 
sarcomata. 

Third,  toward  serous  accumulation  constituting  sero-fibrinous  exudative 
pleurisy,  in  which  varying  quantities  of  fluid  are  transuded  into  the  pleural 
cavity.  In  this  usually  clear,  straw-colored  exudate  may  be  suspended 
shreds  of  the  yellowish  plastic  lymph  already  described,  which  accumu- 
lates also  most  abundantly  where  the  movement  of  the  pleural  surfaces  is 
least,  as  in  the  chinks  and  comers  of  the  pleural  cavity.  This  effusion 
also,  in  a  large  number  of  cases,  is  absorbed,  allowing  the  pleural  surfaces 
to  approach  each  other  and  again  unite  by  what  is  known  as  secondary  ad- 
hesive inflammation,  organization  taking  place  as  before,  producing  either 
continuous  fusion  or  bands  of  new  tissue  attaching  different  parts  of  the 
pleural  surface.  The  question  as  to  how  the  process  of  exudation  is  stopped 
is  an  interesting  one,  which  cannot  be  satisfactorily  answered,  though  it 
is  probable  that  pressure  cf  accumulated  fluid  and  contraction  incident  to 
organization,  as  well  as  cessation  of  the  cause,  may  be  a  part. 

The  ordinary  serous  fluid  which  commonly  fills  the  sac  in  serofibrinous 
pleurisy  is  a  highly  albuminous  liquid,  sometimes  coagulating  sponta- 
neously, in  which  may  be  found  a  few  leukocytes,  exfoliated  endothelial 


536  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

cells,  shreds  of  fibrin,  and  sometimes  a  few  red  blood  disks.  JModificatioiis 
are  those  in  which  the  red  blood-corpuscles  are  much  more  mxmerous, 
producing  a  bloody  fluid,  or  in  which  leukocytes  are  variously  numerous, 
short  of  a  number  sufficient  to  justify  the  term  pus.  Urea,  uric  acid, 
and  sugar  are  sometimes  found  in  pleural  exudates.  The  quantity'  of  fluid 
ranges  from  half  a  liter  to  foiir  liters  (i  pint  to  4  quarts). 

Fourth,  toward  pus-formation,  in  which  either  primarily,  from  the  out- 
set, or  secondarily — that  is,  some  time  after  the  process  has  commenced — the 
microbes  of  suppuration  become  active,  and  produce  a  purulent  product 
or  an  empyema.  The  pleural  surfaces  thus  apposed  are,  however,  com- 
parable to  an  ulcer,  and  the  union  and  repair  take  place  by  formation  of 
cicatricial  tissue.  This  is  subject  to  the  contraction  usual  to  such  tissue, 
dragging  not  only  the  heart  and  lungs  out  of  place,  but  also  in  extreme 
cases  the  ribs  and  vertebrae,  producing  slight  lateral  curvature  of  the  spine. 

Various  displacements  of  adjacent  organs  are  caused  by  the  liquid 
effusion.  In  the  right-sided  pleurisies  the  liver  is  depressed.  The  heart 
is  pushed  to  the  left.  In  left-sided  pleurisies  the  heart  may  be  displaced 
so  far  that  the  apex  will  be  to  the  right  of  the  stemxmi.  The  displacements 
from  traction  after  organization  are  difficult  to  describe,  but  the  heart  may 
be  dragged  so  that  its  apex  is  much  higher  than  is  normal  or  further  to  the 
right,  whUe  the  parts  of  lung  adherent  are  drawn  in  various  directions, 
with  the  production,  at  times,  of  bronchiectatic  cavities.  If  the  patient 
die  while  large  liquid  effusions  are  present,  the  lung  is  also  found  compressed 
into  the  back  part  of  the  pleural  sac. 

Symptoms. — The  initial  symptom  of  pleurisy  is  usually  pain — at  first 
in  the  side.  It  may,  however,  be  preceded  by  a  chill,  and  at  times  there 
may  be  a  short  prodrome  of  discomfort  in  no  way  peculiar.  The  pain  in  bad 
cases  is  of  the  severest  kind,  and  among  the  pains  most  difficult  to  relieve. 
It  is  sharp  and  cutting  in  character,  aggravated  by  breathing,  so  that  the 
patient  takes  the  shortest  breath  possible,  and  the  breathing  is  made  up  of 
short,  hurried  gasps.  Cough  likewise  causes  agonizing  pain,  and  it  is  ac- 
cordingly restrained.  Nor  is  the  pain  in  these  cases  always  confined  to 
the  chest,  but  may  shoot  down  into  the  abdomen  and  back.  The  latter 
probably  implies  that  the  diaphragmatic  pleura  is  involved.  Fever  is  also 
a  constant  symptom,  but  is  not,  as  a  rule,  so  high  as  in  pneumonia.  At 
the  beginning  the  temperature  may  be  102°  or  103°  F.  (38.9°  or  39.4°  C), 
but  as  a  rule  it  subsides  early,  even  though  the  other  sjinptoms  abate  but 
partially,  and  under  any  circumstances  it  falls  much  lower  after  a  week  or 
ten  days  unless  there  is  purulent  exudate,  when  the  fever  assumes  a  hectic 
type.  The  cough  is  pecvdiar  enough  to  require  special  mention.  It  is  a 
short  cough,  attended  with  little  expectoration,  and  is  a  much  less  con- 
spicuous feature  than  in  pneumonia.  Its  characteristic  shortness  is  due  to 
the  pain  caused  by  the  act  of  coughing,  on  account  of  which  the  act  is  cut 
short.  The  decubitus  of  pleurisy  is  quite  constantly  on  the  affected  side, 
in  order  that  the  maaffected  side  may  be  free  to  expand.  This  pertains 
to  pleurisies  associated  with  copious  effusions,  as  well  as  dry  pleurisies. 

While  the  majority  of  pleurisies  begin  in  this  way,  a  certain  nimiber 
also  begin  insidiously.  For  days  and  even  weeks  the  patient,  while  feel- 
ing uncomfortable  and  doubtless  feverish  and  slightly  dyspneic,  continues 


ACUTE  PLEURISY 


537 


his  occupation,  and  even  when  the  physician  is  called,  scarcely  mentions 
symptoms  which  suggest  an  examination  of  the  thorax.  Such  pleurisies 
are  known  as  latent  pleurisies.  They  are  latent  only  to  superficial  observa- 
tion. Closer  investigation  promptly  reveals  the  physical  signs  of  a  pleural 
effusion. 

It  has  already  been  mentioned  that  purulent  pleurisies  may  be  primary 
or  secondary.  In  any  event,  they  are  most  frequently  tubercular,  and  an 
examination  of  the  pus  from  such  a  pleurisy  not  infrequently  discovers  the 
tubercle  bacillus  in  it. 

Physical  Signs. — Acute  pleurisy  is  also  resolvable  clinically  into  three 
stages,  each  of  which  is  characterized  by  phj'sical  signs  more  or  less  dis- 
tinctive. They  include  a  dry  stage,  a  stage  of  effusion,  and  a  stage  of 
resolution  or  absorption. 


Fig.  107.- 


-Grocco's  Sign.     Paravertebral  Triangle  of  Dullness  on  the  Left. 
{After  Thayer  and  Fabyan.) 


The  first  or  dry  stage  is  characterized  anatomically  by  the  presence  of 
the  so-called  lymph  or  exudate  on  the  pleural  surfaces.  During  this  is  re- 
vealed to  inspection  a  restrained  expansion  of  the  affected  side,  often  thrown 
into  jerks  or  catches  because  of  pain  suffered  in  a  continuous  inspira- 
tion. The  expansion  on  the  opposite  side  is  full  and  unhampered.  The 
patient  lies  on  the  affected  side.  Palpation  may  recognize  a  fremitus 
corresponding  to  the  friction  of  the  two  pleural  surfaces.  Percussion  in 
this  stage  is  negative,  except  that  it  may  cause  pain,  but  auscultation 
recognizes  the  friction  sound,  which  will  be  further  characterized  in  treat- 
ing diagnosis.  It  may  be  at  a  single  spot  in  the  inframammary  or  infra- 
axillary  space,  and  hence  be  overlooked.  At  other  times  it  may  be  noted 
over  a  considerable  area.  According  as  the  inflammatory  process  stops 
here  with  resolution  or  continues  into  the  second  or  stage  of  effusion,  there 
may  or  may  not  be  other  signs. 


538  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

The  signs  of  the  second  stage  vary  with  the  amount  of  Hquid  in  the  sac; 
with  a  small  amount  the  lung  is  slightly  floated  up,  and  there  may  be  no 
signs,  unless  it  be  a  vesiculotympany  above  the  line  of  the  fluid,  a  Skodaic 
resonance  by  mediate  relaxation  of  the  air  vesicles.  The  effusion,  however, 
rarely  remains  so  trifling,  but  commonly  rises  to  the  midchest.  In  the 
upright  position  of  the  patient  inspection  recognizes  in  a  spare  person  shal- 
lowness and  perhaps  obliteration  of  the  lower  intercostal  spaces,  and  bulg- 
ing of  the  chest  on  the  side  affected.  The  motion  of  the  chest-wall  is 
lessened  both  in  the  vertical  and  transverse  directions. 

To  palpation  vocal  fremitus  is  diminished  over  the  area  of  effusion,  but 
may  be  increased  in  the  lung  above  it.  To  percussion  there  is  absolute 
flatness  over  the  area  of  effusion,  but  the  line  of  demarcation  is  not  every- 
where at  the  same  level,  being  higher  behind  than  in  front.  Calvin  Ellis 
first  called  attention  to  an  S-like  curve  in  the  line  of  demarcation  which 
is  said  to  be  diagnostic.  Very  important  in  the  diagnosis  is  the  fact  that 
the  fluid  changes  its  level  when  the  position  of  the  patient  is  changed,  and 
correspondingly  the  line  of  dullness  is  altered.  This  change  of  level  does 
not  occur  when  the  chest  is  completely  full  of  liquid.  There  is  also  an  ab- 
normal sense  of  resistance  to  the  finger  in  percussing  over  the  area  of  ef- 
fusion. Above  the  effusion,  especially  anteriorly,  there  is  again  Skodaic 
resonance  by  mediate  relaxation,  and  even  rarely  a  "cracked-pot"  sound. 
Tympany  may  also  be  due  to  the  proximity  of  a  distended  stomach.  When 
the  effusion  is  in  the  left  side  the  stomach  tj'mpanj-  is  abolished  or  di- 
minished. Measurement  discovers  that  the  circumference  of  the  affected 
side  is  a  centimeter  (0.4  in.)  or  more  greater  than  that  of  the  other  side. 

To  auscultation  the  breathing  sounds  are  inaudible  or  very  feeble,  as 
compared  to  the  corresponding  portion  of  the  opposite  side,  but  vocal  reso- 
nance, though  diminished,  is  still  distinctly  heard  where  the  collection  of 
fluid  is  moderate.  BacceUi  called  attention  to  the  fact  that  the  whispered 
voice  is  transmitted  through  a  serous  but  not  through  a  purulent  exudate. 
He  advises  direct  auscultation  in  the  antero-lateral  region  of  the  chest. 
This  transmission  of  voice  and  breath  sounds  is  often  confusing,  but  where 
they  are  present  over  an  effusion  there  is  no  fremitus  and  the  heart  is  dis- 
located. Above  the  line  of  dullness  there  is  occasionally  a  friction  sound, 
and  close  to  the  root  of  the  lung  bronchial  breathing  may  be  heard.  This 
is,  however,  more  apt  to  be  the  case  when  the  effusion  is  larger  and  the 
lung  is  further  compressed.  Egophony  is  also  sometimes  heard  over  a 
thin  layer  of  eft'usion. 

When  the  eft"usion  is  larger,  filling  up  two-thirds  or  three-fourths  of 
the  pleural  sac,  the  effects  described  are  increased,  while  new  ones  are 
added.  Inspection  notes  that  respiratory  movement  is  still  more  hampered, 
that  the  intercostal  spaces  are  widened  and  even  bulging,  while  fluctuation 
may  sometimes  be  recognized  through  them.  The  heart  is  displaced  by 
the  accumulated  fluid,  and  if  the  fluid  be  in  the  left  sac,  the  apex  is  often 
found  far  over  to  the  right  of  the  median  line,  and  if  in  the  right,  the  apex 
may  be  pushed  further  to  the  left.  The  heart  sounds  arc  not,  however, 
altered.  On  the  opposite  side  the  breathing  movements  are  supplementally 
increased.  There  is  complete  absence  of  vocal  fremitus  on  the  affected 
side. 


ACUTE  PLEURISY  539 

Percussion  is  absolutely  flat  all  over  the  effusion,  and  Skodaic  resonance 
is  now  not  obtainable,  because  the  lung  is  too  thoroughly  compressed  up 
into  the  apex  of  the  sac.     Resistance  to  pressure  is  marked. 

Paravertebral  Triangle  of  Dullness  in  Pleural  Effusion  [Koranyi-Grocco's 
Sign). — In  1897,  Koranyi  of  Buda  Pesth  pointed  out  a  valuable  sign  of 
pleuritic  effusions,  a  triangular  paravertebral  area  of  dullness  on  the  side 
opposite  that  of  the  pleuritic  effusion.  In  1902  Grocco  described  the  same 
sign  as  shown  in  the  adjacent  figure.  It  is  caused  by  an  intrusion  of  the 
pleuritic  effusion  across  the  vertebral  column  pushing  the  movable  medi- 
astinal contents,  viz.,  the  aorta,  esophagus  and  azygos  vein  before  it. 

The  presence  and  significance  of  this  sign  is  variously  estimated.  It 
was  found  by  Thayer  and  Fabyan  in  30  out  of  32  cases;  by  Frankenheimer 
in  every  one  of  31;  by  Hermon  C.  Gordonier*  in  27  out  of  29,  in  all  cases 
in  which  there  was  actual  pleural  effusion.  It  is  not  found,  as  a  rule,  in 
the  paravertebral  gutter  opposite  pneumonic  consolidation  or  when  there 
is  empyema  on  the  affected  side.  The  strongest  proof  of  its  relation  to 
pleural  effusions  is  its  disappearance  after  the  fluid  is  removed  from  the 
affected  side  by  tapping.  It  is  sometimes  influenced  by  changes  of  posi- 
tion.    Thayer  gives  the  following  method  of  determining  the   triangle: 

After  determining  by  percussion  the  boundaries  of  the  supposed  ef- 
fusion, the  lower  limit  of  pulmonary  resonance  on  the  opposite  side  should  be 
marked  out.  One  should  then  percuss  downward  directly  over  the  spine, 
marking  the  spot  at  which  relative  dullness  begins.  This  will  be  found  to 
correspond  approximately  with  the  beginning  of  relative  dullness  on  the 
side  of  the  effusion  or  is  a  little  higher  than  the  limit  of  flatness.  Then 
percuss  downward  along  lines  parallel  with  the  spine  and  inward  along  lines 
parallel  to  the  lower  limit  of  pulmonary  resonance.  Thus  one  can  mark 
out  usually  the  mesial  and  inferior  angle  on  the  healthy  side  a  triangle  of 
dullness.  The  vertical  side  of  the  right-angled  triangle  corresponding  to 
the  line  of  the  spinous  processes  reaches  a  point  somewhat  higher  than  the 
upper  limit  of  flatness  on  the  affected  side,  the  base  from  the  mesial  line 
outward  on  the  unaffected  side  ranges  according  to  the  extent  of  the  effusion 
to  2  cm.  to  7  cm.  (0.8  in.  to  2.8  in.). 

The  third  side  of  the  dullness  corresponds  with  a  line  joining  the  ex- 
tremities of  these  two  lines.  Thayer^  and  Fabuyan  noted  that  this  line 
sometimes  showed  a  slight  outward  convexitj^ 

On  auscultation  over  large  pleuritic  effusions  bronchial  breathing  may 
be  heard  at  the  upper  posterior  portion  of  the  lung,  because  the  large  tubes 
are  still  pervious  to  air,  and  the  compressed  lung  intensifies  the  sound. 
Sometimes  bronchial  breathing  is  heard  in  more  peripheral  parts  of  the 
chest,  probably  conducted  hither  along  a  band  of  adhesion  or  along  a  rib. 
Elsewhere  there  is  absence  of  breath  sounds.  Vocal  resonance  and  whis- 
pering voice  are  alike  absent,  or  the  former  is  very  feeble.  In  certain 
situations,  too,  high  up,  where  there  is  but  a  thin  film  between  the  chest- 
wall  and  the  lung,  there  may  be  egophony,  but  this  is  more  likely  to  be 
present  as  the  fluid  is  being  absorbed. 

1  Albany  Medical  Journal,  Ap.,  1909. 
2  For  a  thorough  discussion  of  this  sign  based  on  a  story  of  the  literature  and  of  32  cases,  see  a  paper 
by  Thayer  and  Marshall  Fabuyan  "Paravertebral  Triangle  of  Dullness  in  Pleural  Effusion,"  Amer.  Jour. 
Med.  Sc,  vol.  cxxxiii,  p.  14.  1907. 


540  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

In  the  third  stage,  if  resolution  takes  place  with  a  gradual  retrocession 
of  the  fluid  and  the  reexpansion  of  the  lung,  we  have  a  return  to  normal 
physical  signs.  There  may  be,  too,  a  friction  redux.  A  considerable  time 
is,  however,  required  for  absorption,  and  it  is  often  many  days  before  the 
normal  breathing  sounds  are  heard  with  their  usual  intensity  or  the  natural 
fremitus  is  felt.  Often,  on  the  other  hand,  resolution  is  not  complete,  and 
the  two  surfaces  become  glued  together,  constituting  a  plastic  pleurisy,  and 
the  feebly  heard  breathing  sounds  and  diminished  fremitus  and  vocal  reso- 
nance remain  more  or  less  permanent  (chronic  pleurisy).  There  then  re- 
main the  symptoms  and  sequelae  of  a  chronic  pleurisy.  In  cases  of  punilent 
pleurisies,  if  recovery  takes  place  it  is  always  by  adhesion  of  the  apposed 
surfaces.     (See  Chronic     Pleurisy.) 

In  connection  with  the  heart,  plenropericardial  friction  may  be  heard 
if  the  pleura  covering  the  portion  of  the  lung  adjacent  to  the  pericardium  is 
involved.  The  apex-beat  may  not  be  discoverable  if  it  is  so  dislocated  as  to 
be  covered  by  the  sternum,  and  it  often  happens  that  the  heart  must  be 
located  by  its  signs.  In  many  cases  the  use  of  an  aspirating  needle  is  neces- 
sary for  a  diagnosis. 

Varieties  of  Acute  Pleurisy. — Tubercidar  pleurisy  is  a  pleurisy  due 
to  the  invasion  of  the  pleura  by  the  tubercle  bacillus,  and  has  been  con- 
sidered when  treating  of  tuberculosis. 

Diaphragmatic  pleurisy  is  a  painful  form  of  pleurisy,  in  which  the  pleural 
covering  of  the  diaphragm  is  involved,  either  alone  or  along  with  the  re- 
maining pleura.  It  is  usually  dry,  plastic,  but  maj^  also  be  exudative,  with 
a  serofibrinous  or  purulent  product.  The  pain  is  low  down  in  the  thorax 
in  the  zone  of  the  diaphragm,  and  is  often  aggravated  by  deglutition  as  well 
as  b}^  breathing  and  may  be  transmitted  to  the  appendiceal  area .  Because 
of  the  pain  in  breathing,  the  diaphragm  is  fixed  and  the  patient  breathes  by 
the  upper  thorax.  Of  diagnostic  value  is  the  fact  that  the  pain  may  be 
increased  by  pressure  at  the  insertion  of  the  diaphragm  at  the  tenth  rib. 

Hemorrhagic  pleurisy,  characterized  by  bloodj^  effusion,  is  found  in 
asthenic  states,  however  induced,  in  tubercular  pleurisy,  in  which  event 
the  hemorrhage  occurs  from  the  j^oung  blood-vessels,  and  in  cancerous 
pleurisy;  also  sometimes  in  persons  otherwise  healthy.  It  is,  of  course, 
not  to  be  confounded  with  blood-stained  serum,  caused  b}'^  wounding  a 
blood-vessel  in  the  act  of  tapping  or  with  a  hematothorax  from  rupture  of  an 
aneurysm. 

Encysted  or  circumscribed  pleurisy  is  a  form  of  purulent  pleurisy  in 
which  adhesions  form  so  as  to  produce  loculi,  or  spaces  which  are  filled  with 
pus.  They  are  quite  difficult  to  recognize  during  life — in  fact,  they  are 
commonly  found  when  exploring  the  chest  with  the  needle.  More  rarely 
they  are  revealed  to  physical  examination,  dull  percussion  areas  being 
found  in  alternation  with  clear  areas.  Such  physical  signs  should  suggest 
the  use  of  the  needle  to  clear  up  the  diagnosis.  These  collections  some- 
times pulsate  and  become  pidsating  pleurisies.  Pulsating  pleurisies  are  al- 
most invariably  on  the  left  side  and  receive  in  some  way  the  impulse  of  the 
heart,  which  in  turn  is  communicated  to  the  eye  or  hand  of  the  observer. 
The  possible  confounding  of  these  with  aneurysm  will  be  again  referred  to. 

In  interlobular  pleurisy  the  apposed  surfaces  of  two  lobes  of  the  lung 


ACUTE  PLEURISY  541 

are  agglutinated,  and  sometimes  a  sac  of  pus  is  pent  up  belween  them, 
forming  a  variety  of  encysted  pleurisy.  Such  an  abscess  may  break  into  a 
bronchus.  It  should  be  recognized  especially  when  a  hectic  fever  follows 
pneumonia. 

Diagnosis. — The  certain  diagnosis  of  pleurisy  depends  almost  entirely 
upon  the  physical  signs,  for,  however  severe  the  other  symptoms,  there  is 
nothing  in  them  by  which  the  disease  can  be  surely  recognized.  In  the 
majority  of  cases  of  pleurisy  the  diagnosis  is  made  easy  by  the  aid  of  these 
signs.  It  is  true  there  is  a  certain  resemblance  between  pleurisy  and  pneu- 
monia in  the  first  stage  of  each,  and  in  that  stage  a  diagnosis  is  often  difficult, 
especially  when  the  physical  signs  are  not  distinct.  The  resemblance  of  the 
friction  sound  to  the  crepitant  rale  is  well  recognized.  Indeed  it  is  often 
impossible  to  distinguish  between  a  pulmonary  and  a  pleural  adventitious 
sound.  Tht.  usual  distinctive  features  are  the  superficial  situation  and  the 
intermittent  character  of  the  friction  sound,  its  presence  during  expiration 
as  well  as  inspiration,  and  if  confined  to  one  of  these  acts,  rather  to  expira- 
tion, while  the  crepitant  rale  is  heard  only  during  inspiration.  The  friction 
sound  is  also  usually  rougher  and  more  circumscribed,  while  it  may  some- 
times be  heard  better  with  the  stethoscope.  Pain  is  very  apt  to  be  elicited 
in  pleurisy  if  the  stethoscope  is  pressed  hard  upon  the  ches1.  As  the 
pleurisy  becomes  dr}^  and  adhesions  form,  the  friction  sound  resembles  more 
closely  that  of  creaking  leather. 

In  the  second  stage  of  pleurisy,  too,  furnishing  as  it  does  a  dullness  on 
percussion  like  that  of  the  same  stage  of  pneumonia,  and  frequently  bron- 
chial breathing,  we  have  also  a  resemblance  in  the  physical  signs.  But  it 
is  true  of  the  bronchial  breathing  of  pleurisy  that  it  is  commonly  best  heard 
at  the  upper  border  of  the  dullness  and  least  where  the  dullness  is  most 
marked;  whereas,  in  pneumonia  the  bronchial  breathing  is  most  intense 
where  the  consolidation  is  greatest.  Above  all,  in  pleurisy  ivith  effusion  tkere 
are  diminished  vocal  fremitus  and  diminished  vocal  resonance;  in  pneumonia, 
increased  vocal  fremitus  and  increased  vocal  resonance.  There  is  commonlv, 
further,  in  pleurisy  with  effusion,  a  change  of  level  of  the  dullness  with  a 
change  of  the  position  of  the  patient,  which  is  not  the  case  in  pneumonia. 
The  egophonic  voice  is  also  often  here  present  in  pleurisy;  whereas  we  have 
only  bronchophony  in  pneumonia.  Finallj^  in  the  differential  diagnosis 
between  acute  pleurisy  and  pneumonia,  the  trifling  cough  and  absence 
of  expectoration  in  the  former  are  valuable  signs,  though  it  must  not  be 
forgotten  that  in  old  persons  there  is  sometimes  very  little  cough  in 
pneumonia. 

The  X-ray  to  be  of  service  in  the  recognition  of  pleuritic  effusion. 
The  dense  fluid  cutting  off  the  rays  about  as  much  as  an  organ  as  dense 
as  the  liver;  whereas  the  outline  of  the  ribs  may  be  obliterated  on  the 
side  of  the  effusion.  The  fluoroscope  also  enables  us  to  recognize  displace- 
ment of  the  heart  caused  by  effusions,  especially  to  the  right  of  the  sternum, 
when  sometimes  percussion  does  not  show  it.  The  effect  of  changes  of 
position  on  the  pleuritic  effusion  may  also  be  seen  by  the  fluoroscope  as 
well  as  movements  in  the  fluid  caused  by  the  movement  of  the  diaphragm. 
As  to  further  differential  diagnosis,  pleurisy  in  the  dry  stage  has  been 
mistaken  for  muscidar  rheumatism,  intercostal   neuralgia,    periostitis,    and 


542  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

caries  of  the  ribs,  and  even  gastralgia  and  nicer  of  the  stomach.  The  ab- 
sence of  fever  in  the  first  two,  the  circumscribed  situation  cf  disease  of  the 
ribs,  and  the  associated  history  of  gastralgia  and  I'lcer  of  the  stomach,  serve 
to  differentiate  them. 

The  confusion  of  mediastinal  tumors  arising  from  the  pleura  itself  with 
pleurisy  is  a  natural  error,  especially  since  such  tumors  in  their  lum  pro- 
duce pleurisy.  In  pleurisy,  the  physical  signs  are  commonly  limited  to  one 
side,  while  in  mediastinal  tumor  the  fremitus  is  less  diminished,  the  dullness 
extends  upward,  is  more  irregular,  and  more  circumscribed;  while  symp- 
toms of  compression  of  nerves  and  vessels,  and  of  encroachment  on  the 
esophagus  sooner  or  later  make  their  appearance.  Repeated  exploratory 
punctures  may  be  necessary  to  settle  the  diagnosis,  which,  may  require 
some  time. 

The  impulse  of  a  ptdsating  empyema  sometimes  very  strongly  suggests 
an  aneurysm,  but  the  empyema  furnishes  no  murmurs  or  pressure  symptoms 
while  the  location  is  usually  different  from  that  of  aneurysm. 

Prognosis. — The  prognosis  of  acute  pleurisy  depends  largely'  upon  its 
cause.  The  simple  pleurisies  which  are  the  result  of  infection  due  to  expo- 
sure always  get  well,  and  recovery  is  the  termination  in  most  cases  even 
when  there  is  large  effusion,  if  the  exudate  remains  serous.  It  has  already 
been  said  that  a  purulent  pleurisy  is  often  tubercular.  We  have  learned, 
however,  that  a  tubercular  pleurisy  is  not  necessarily  fatal,  and  it  is  more 
than  likely  that  some  of  the  cases  of  healed  empyema  with  which  we  are 
familiar  are  instances  of  such  recovery.  In  children  it  is  usually  due  to 
pneumococci  and  the  outlook  is  favorable.  The  sacculated  empyemas  are 
also  frequently  pneumococcic.  Others  are  cured  by  the  introduction  of 
drainage-tubes  and  exsection  of  ribs,  but  often  the  patient  slowly  succumbs 
to  the  exhausting  effect  of  the  illness  or  to  tuberculosis  of  the  lungs.  Not 
a  very  rare  event  in  badly  neglected  cases  is  the  spontaneous  rupture  of  such 
a  pleurisy  outward,  an  event  better  anticipated  by  paracentesis.  Very  stub- 
born, too,  are  the  somewhat  rarer  cases  in  which  perforation  takes  place 
from  the  pleural  sac  into  the  lungs,  adding  the  symptoms  of  a  pneumothorax 
to  those  of  the  pleurisy.     Yet  even  these  sometimes  heal  spontaneously. 

Though  not  a  frequent  event,  sudden  death,  when  least  expected,  is 
sufficiently  so  to  make  it  important  that  one  should  be  on  his  guard  for  it. 
It  is  not  alone  when  the  chest  is  full,  or  during  a  tapping,  that  it  occurs,  but  it 
may  happen  several  days  after  a  large  part  of  an  eiTusion  has  been  removed. 
Pulmonary  thrombosis  is  probably  the  most  frequent  cause.  A  case 
of  Tyson's  terminated  thus,  when  convalescence  was  thought  to  be  estab- 
lished, and  the  patient  expressed  himself  better  than  on  any  day  during  his 
illness.  At  the  necropsy,  a  white  "chicken-fat"  clot  was  found  in  the  right 
ventricle,  extending  as  a  red  clot  into  the  pulmonary  artery.  The  chest 
was  partly  filled  with  serofibrinous  fluid.  Edema  of  the  opposite  lung  and 
degeneration  of  the  heart  muscle  are  probably  causes,  suggested  by  Wiel. 
Obstruction  to  the  circulation  by  dislocation  of  the  heart  or  twisting  of  the 
great  vessels  has  also  been  suggested  as  a  cause. 

Treatment. — Many  simple  pleurisies  doubtless  get  well  of  themselves, 
with,  perhaps,  more  or  less  adhesion  of  the  lung,  which  may  be  the  cause 
of  certain  unexplained  restrictions  in  expanding  the  chest.     For  very  severe 


CHRONIC  PLEURISY  543 

cases  of  pleurisy,  local  blood-letting  in  the  form  of  wet  or  dry  cups  is  the 
promptest  measure  of  relief,  and  there  is  no  condition  in  which  so  delightful 
an  effect  comes  to  the  suffering  patient  gasping  for  breath  and  racked  with 
pain.  The  duration  of  many  pleurisies  is  shortened  by  such  a  treatment. 
Strapping  the  chest  after  the  manner  of  a  dressing  for  fractured  rib  is  of  the 
greatest  value.  Anodynes — morphin  hypodermically  is  the  best — are 
often  necessary  to  relieve  the  pain,  and  must  sometimes  be  repeated,  while 
We  have  even  known  repetition  to  be  inefficient  and  unsatisfactory,  when  a 
blood-letting  produced  prompt  relief. 

Even  where  the  effusion  is  considerable,  it  often  passes  away  without 
any  very  active  measures.  But  a  fairly  large  pleural  effusion  needs  tapping  to 
prevent  serious  collapse  of  the  lung.  The  salicylates  in  full  doses  sometimes 
bring  about  a  large  polyuria  and  rapid  disappearance  of  the  effusion.  If 
there  is  much  delay,  however,  in  the  absorption  of  fluid,  paracentesis  thoracis 
should  be  practiced  as  soon  as  the  fever  has  subsided.  It  is  an  operation 
every  physician  should  be  ready  to  do  without  calling  on  the  surgeon. 

This  simple  operation  should  be  done  under  the  strictest  aseptic 
precautions.  The  chest  should  be  cleansed  with  alcohol,  and  the  spot  thor- 
oughly sprayed  with  iodin.  The  instruments  should  be  sterile,  as  should 
the  hands  of  the  operator.  A  trochar  and  canula  attached  to  an  aspirating 
apparatus  should  be  used.  The  trochar  and  canula  is  better  than  the 
sharp  needle.  The  latter  may  injure  the  lung.  The  best  point  for  tap- 
ping is  the  sixth  or  seventh  interspace  in  the  midaxillary  line.  The  inter- 
spaces are  made  wider  and  the  operation  easier  if  the  arm  of  the  side  to  be 
operated  is  carried  over  to  grasp  the  opposite  shoulder.  After  a  small 
skin  incision  is  made  the  needle  should  be  introduced  close  to  the  uppe- 
margin  of  the  rib,  so  as  to  avoid  wounding  the  intercostal  artery.  Local 
anesthesia  should  be  obtained  by  the  application  of  ice  and  salt,  or  by 
chlorid  of  ethyl.  It  is  particularly  in  the  insidious  forms  of  pleurisj^  that 
the  tapping  to  the  chest  becomes  necessary,  because  they  seem  to  be  as 
slow  to  disappear  as  they  are  slow  to  make  their  presence  known.  A 
further  indication  for  paracentesis  is  aggravated  dyspnea.  The  operation 
is  usually  well  borne,  though  sometimes  faintness  results.  It  is,  therefore, 
well  to  fortify  the  patient  in  advance  with  an  ounce  of  whisky,  and  if  faint- 
ness or  cough  results,  to  desist.  Sudden  death  during  the  operation  has 
happened  in  rare  instances.  On  the  other  hand,  sudden  death  has  occurred 
more  frequently  in  cases  of  full  pleura  without  operation.  When  this 
accident  occurs,  it  is  more  than  likely  that  the  heart  was  previously 
damaged. 

Repeated  tappings   are   sometimes  necessary. 

Empyemas  almost  never  get  well  after  a  simple  tapping.  The  pus 
reaccumulates,  and  the  symptoms  and  physical  signs  are  renewed.  These 
cases  are  for  the  surgeon — resection  of  a  rib  is  best  done — though  in  children 
the  insertion  of  a  large  drainage  tube  may  be  practiced. 

CHRONIC  PLEURISY. 

Definition  and  Pathogeny. — Under  the  term  chronic  pleurisy  are  in- 
cluded   several   morbid    states,    the   result   of  inflammatory   processes   of 


544  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

longer  duration  than  a  few  weeks.     These  include  both  exudative  and  dry 
or  plastic  pleurisies. 

1.  Exudative  pleurisies,  characterized  by  liquid  product,  include — 

(a)  The  condition  already  spoken  of  as  latent  pleurisy  associated  with 
effusion. 

(6)  Suppurative  pleurisies,  all  of  which,  though  thej'  may  originate 
acutely,  are  of  long  duration,  and  may  therefore  be  appropriately  classified 
as  chronic. 

2.  Plastic  pleurisies,  characterized  by  a  dry  product.  These  originate 
in  two  ways:  First,  they  are  plastic  from  the  beginning — that  is,  the  so- 
called  lymph  first  deposited  becomes  permanently  organized  as  a  more  or 
less  thick  layer  uniting  the  pleural  surfaces.  Such  primarj^  adhesions  are 
more  usual  in  circumscribed  areas  of  pleural  surface.  Second,  the  same 
result  follows  when  the  surfaces  separated  by  the  more  copious  seropurulent 
transudate  reapproach  each  other  as  the  latter  is  absorbed,  producing 
secondary  adhesions.  Third,  we  have  a  most  distinctive  product  of 
chronic  pleurisy  in  the  cicatricial  tissue,  which  succeeds  the  healing  of  the 
extensive  suppurative  surfaces  forming  the  walls  of  an  empyema  and  which 
also  closely  cements  the  lung  to  the  costal  pleura. 

Mention  should  also  be  made  of  the  form  of  chronic  pleurisy  restating 
in  a  thick,  pleural  and  sub-pleural  deposit  slowly  formed,  tuberculous  in 
origin,  which  grows  from  the  pleura  into  the  interlobular  tissue  of  the 
lung,  dividing  it  or  dissecting  it  in  extreme  cases  into  distinct  areas,  well 
shown  upon  section,  which  has  given  rise  to  the  name  pneumonia  dissecans, 
or  pleurogenous  pneumonia.  This  form  of  pnemnonia  has  its  type  in  the 
pleuropneumonia  of  cattle.  Tyson  met  one  striking  instance  of  this  form  of 
chronic  pleurisy  of  tuberculous  origin  in  man.  Any  one  of  these  varieties 
of  chronic  pleurisy  may  originate  as  a  tuberculous  pleurisy,  and  probably 
most  of  them  are  of  this  kind. 

The  morbid  product  of  chronic  pleurisy  requires  no  further  description 
than  has  just  been  given,  and  in  the  description  of  the  morbid  anatomy  of 
acute  pleurisy,  which  necessarily  included  to  some  extent  that  of  its  frequent 
termination  in  the  chronic  form.  The  adhesion  between  the  lungs  and  the 
ribs  is  variously  close  and  the  product  variously  thick,  insomuch  that  while 
usually  the  two  surfaces  are  easilj*  dragged  apart,  sometimes  it  is  impossible 
to  do  this  without  lacerating  the  lung.  Attention  maj'  again,  however, 
be  called  to  the  displacement  of  viscera,  the  retraction  of  the  chest-wall  and 
curvature  of  the  spinal  column,  which  sometimes  take  place  as  a  con- 
sequence of  the  extreme  contraction  of  the  plastic  product  of  chronic 
pleurisy  in  its  most  aggravated  form — that  with  empj^ema. 

Treatment. — It  need  only  be  added  to  what  has  already  been  said  in 
the  treatment  of  acute  pleurisy  that,  in  chronic  pleurisy  especiall}-,  chest 
gymnastics,  consisting  in  systematic  inspiratory  efforts  and  massage  of  the 
thoracic  walls,  must  be  availed  of.  Operative  procedures  must  be  consid- 
ered in  conjunction  with  the  surgeon.  Mild  local  measures,  such  as  counter- 
irritation  by  iodin  and  counterirritating  ointments,  may  be  useful  to  relieve 
pain,  which  sometimes  annoys  the  subjects  of  chronic  pleurisy.  Blisters 
should  not  be  used. 


PNEUMOTHORAX  545 

HYDROTHORAX  AND  HEA4AT0-TH0RAX. 

Definition. — The  term  hydrothorax  is  applied  to  any  accumiilation  of 
clear  serum  in  the  pleural  sacs,  not  due  to  inflammation  of  the  pleura. 

Etiology. — It  is  the  result  mainly  of  resistance  to  the  free  circulation 
of  the  blood  through  the  vascular  basis  of  the  pleural  membrane.  It  occurs 
as  a  part  of  general  dropsy,  however  caused,  but  Bright's  disease  or  valvular 
heart  disease  are  the  most  frequent"  causes.  Hence  the  chest  should  be 
frequently  examined  in  these  diseases,  as  hydrothorax  may  be  the  first 
symptom  of  dropsy.  Hydrothorax  is  frequently  bilateral  in  both  renal 
and  heart  affections.  In  a  careful  study  of  this  subject  by  J.  Button 
Steele,'  based  upon  a  large  number  of  autopsies  with  cardiac  hydrothorax, 
in  about  83  per  cent,  of  cases  the  effusion  was  bilateral,  and  in  17  per  cent. 
unilateral.  Of  the  bilateral,  70  per  cent,  were  unequal  in  distribution,  and 
of  these,  three-fourths  were  greater  on  the  right  side.  Of  the  13  unilateral 
cases,  ten  were  right-sided  and  three  left-sided.  The  usual  explanation 
of  this  preference  of  pleural  effusion  for  the  right  side  in  cardiac  hydrothorax 
is  that  more  frequently  pressure  is  exerted  by  a  dilated  right  auricle  upon 
the  root  of  the  right  lung,  interfering  with  the  return  circulation  from  the 
pleural  sacs.  Left  unilateral  effusion  occurs  as  the  result  of  pressure  upon 
the  root  of  the  left  lung  and  left  superior  intercostal  vein.  Unequal  bilateral 
pleural  effusion  must,  therefore,  be  due  to  unequal  pressure  on  the  roots 
of  the  two  lungs.  The  serous  fluid  in  hydrothorax  is  characterized  by  the 
small  amount  of  albumin  as  compared  with  that  exuded  in  pleuris}-. 

Symptoms. — The  symptoms  are  those  of  pleuritic  effusion,  both  as  to 
subjective  symptoms  and  physical  signs.  Crepitant  rales  are  sometimes 
heard  in  the  lung  above  the  effusion,  due  to  its  retraction  and  to  partial 
atelectasis. 

Treatment. — This  is  considered  under  that  of  the  diseases  causing  the 
hydrothorax. 

Hemato-ihorax  is  a  term  applied  to  any  accumulation  of  blood  in  the 
thorax,  however  caused.  It  may  be  due  to  the  wounding  of  vessels,  malig- 
nant disease,  or  aneurysmal  rupture.  The  symptoms  and  physical  signs 
and  treatment  are  those  of  pleural  effusion. 

PNEUMOTHORAX. 

Synonyms. — Hydropneumothorax;  Pyopneumothorax. 

Definition. — Pneumothorax  means  air  in  the  thorax,  but  the  term  is 
limited  to  the  condition  in  which  there  is  air  in  a  pleural  sac.  It  is  almost 
always  accompanied  by  a  liquid  inflammatory  exudate,  usually  purulent 
or  seropurulent,  whence  the  terms  pyopneumothorax  and  seropneumo- 
thorax, though  a  form  of  spontaneous  pneumothorax  occurs  when  there 
is  no -formation  of  liquid.  The  effects  of  pneumothorax  are  compression 
of  the  lung,  almost  always  dislocation  of  the  heart  toward  the  opposite 
side,  and  in  some  instances  displacement  of  the  liver  and  spleen.  Pneumo- 
thorax is  almost  without  exception  one-sided,  though  it  is  not  impossible 
for  it  to  be  double. 


546  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Etiology. — The  most  frequent  cause  is  perforation  of  the  pleura  over 
a  phthisical  cavity  or  a  hemorrhagic  infarct,  or  over  a  septic  bronchopneu- 
monic  focus,  or  gangrene  of  the  lung.  Other  causes  are  perforating  wounds 
of  the  lung,  perforation  of  the  diaphragm  due  to  malignant  disease  in  the 
abdomen,  especially  cancer  of  the  stomach  or  colon,  or  of  the  esophagus. 
Perforation  into  the  lung  from  the  pleural  side  may  occur  in  empyema. 
Rupture  of  the  lung  due  to  straining  has  caused  it.  The  opening  may  be 
valvular,  so  as  to  admit  air  intermittently.  Rupture  of  emphysematous 
blebs  gives  rise  to  the  so-called  spontaneous  pneumothorax. 

Symptoms. — Sudden  pain  and  increased  dyspnea  usually  usher  in  a 
perforation  causing  pneumothorax,  though  the  efifect  may  be  more  gradual. 
Sometimes  the  symptoms  are  more  severe,  constituting  those  of  collapse — 
faintness,  frequent  pulse,  and  lowered  temperature .  Later,  at  least  slight 
fever,  corresponding  acceleration  of  pulse  and  breathing  rate,  continue  while 
the  condition  lasts.  Pneumothoraces  have  also  been  found  postmortem 
when  unsuspected  before  death,  having  occurred  without  producing  symp- 
toms. The  patient  may  be  orthopneic,  or  ma)'  lie  upon  the  affected  side, 
for  the  same  reason  as  in  pleuris3^  Pleurisy  is  a  frequent,  but  not  invari- 
able, consequence,  and  superadds  its  own  symptoms,  most  palpably'  effusion. 

Physical  Signs. — These  are  the  most  distinctive  symptoms.  Inspection 
recognizes  commonly  a  bulging  half-chest,  with  the  intercostal  spaces  ob- 
literated or  prominent  as  compared  with  the  opposite  side,  the  apex 
of  the  heart  displaced.  The  breathing  is  frequent  and  short.  Palpation 
recognizes  absent  or  very  indistinct  vocal  fremitus,  the  lungs  being  no  longer 
in  contact  with  the  chest-wall,  which  is  also  in  a  state  of  tension  interfer- 
ing with  vibration.  The  percussion  note  is  resonant,  often  ringing  and 
amphoric  over  the  upper  part  of  the  side.  If  a  liquid  is  present  over  the 
area  below,  containing  the  fluid,  there  is  absolute  dullness.  On  the  other 
hand,  there  may  be  dullness  over  the  air-containing  space,  instead  of  tym- 
pany, on  account  of  the  extreme  high  tension  checking  all  vibration.  We 
may  also  meet  here  that  interesting  modification  of  tympany  known  as 
Biemer's  change  of  note,  based  upon  the  fact  that  with  a  given  tension  the 
larger  an  air-containing  cavity,  the  lower  the  pitch  of  the  percussion  note. 
If  the  patient  with  pyopneumothorax  sits,  or  especially  stands,  in  the  upright 
position,  the  pleural  air-containing  space  is  enlarged,  because  the  weight 
of  the  fluid  pushes  the  diaphragm  downward,  whereas  in  the  horizontal 
position  the  fluid  flows  into  the  gutter  between  the  ribs  and  spinal  column, 
the  diaphragm  rises,  the  cavity  becomes  smaller,  and  the  pitch  of  the  per- 
cussion note  is  raised.  There  is  also  the  usual  change  of  level  of  the  dull- 
ness corresponding  with  change  of  position,  as  in  pleurisy  ^^'ith  eflusion. 

Auscultation  recognizes  feeble  or  absent  vesicular  murmur  in  the  situa- 
tion where  it  is  present  in  health,  while  amphoric  breathing  may  be  sub- 
stituted— bronchial  breathing  of  a  metallic  character.  Ringing  amphoric 
bronchophony  is  also  heard  when  the  patient  speaks.  An  interesting 
auscultation  sign  is  the  so-called  "metallic  tinkling,"  a  sound  ascribed  to 
the  dropping  of  liquid  from  the  seat  of  perforation  into  the  fluid  below. 
Here  also  is  produced  in  its  typical  expression  the  "coin-clinking"  sound 
conveyed  to  the  ear  of  the  auscultator  listening  at  the  back  of  the  chest, 
while  a  coin  placed  upon  the  chest  in  front  is  tapped  by  another  coin. 


MORBID  GROWTHS  OF  THE  PLEURA  547 

This  is  a  sign  usually  limited  to  pyo-  or  hydro-pneumothorax,  though  it 
may  also  be  produced  over  bronchiectatic  cavities.  Here,  too,  may  be 
produced  the  well-known  Hippocratic  succussion  sound  by  shaking  the 
body  of  the  patient,  the  splashing  being  intensified  in  the  air-distended 
cavity.  It  should  be  remembered  that  tinkling,  splashing  and  coin  sound 
occur  only  when  there  are  both  air  and  liquid  in  the  chest. 

Diagnosis. — Almost  the  only  condition  with  which  pneumothorax  may 
be  confounded  is  diaphragmatic  hernia,  the  physical  signs  of  which  very 
closely  resemble  those  of  pneumothorax.  The  causes  of  diaphragmatic 
hernia  are  usually  severe  traumatic  agencies,  such  as  compression  between 
cars  or  under  masses  of  earth,  yet  occasionally  more  trifling  causes  produce 
it,  as  in  the  case  of  severe  cough.  A  distended  stomach  itself  is  named 
as  a  source  of  confusion  with  pneumothorax,  and  it  is  true  that  succes- 
sion and  metallic  tinkling  can  be  elicited  in  it  in  great  perfection.  The 
absence  of  distention  of  the  thorax  itself,  the  limitation  of  the  physical 
signs  to  the  neighborhood  of  the  stomach,  their  association  with  move- 
ments of  the  stomach  quite  independently  of  breathing,  point  to  the  proper 
source.  Pneumothorax  is  scarcely  likely  to  be  confounded  with  large 
tubercular  cavities,  for  while  the  latter  furnish  amphoric  signs  over  them, 
vocal  fremitus  is  increased,  or  at  least  remains  distinct,  while  with  pneu- 
mothorax vocal  fremitus  is  diminished  or  absent.  Further,  there  is  at 
least  no  prominence  over  cavities,  while  there  is  often  depression,  and  suc- 
cussion signs  cannot  be  elicited.  Finally,  cavities  are  circumscribed. 
Bronchiectatic  cavities  furnish  signs  behind  and  below  the  scapula,  and 
therefore  more  in  the  situation  of  those  of  pneumothorax,  but  there  is 
dullness  instead  of  tympany,  no  bulging,  and  vocal  fremitus  probably 
remains  distinct,  while  there  is  often  pectoriloquy,  never  present  in  pneu- 
mothorax.    X-ray  gives  excellent  diagnostic  results. 

Treatment. — This  is  mainly  symptomatic.  Sudden  pain  and  extreme 
dyspnea  must  be  treated  by  morphin,  preferably  subcutaneously ;  em- 
barrassing accumulation  of  fluid,  by  thoracentesis  and  draining  of  the  sac, 
and  in  extreme  cases  the  air  may  be  liberated  in  a  similar  manner.  Often 
pneumothorax  gives  surprisingly  little  inconvenience,  and  it  is  by  no  means 
impossible  for  spontaneous  healing  to  take  place.  Potain  suggested  re- 
placing the  air  and  fluid  by  sterilized  air,  but  such  air  would  soon  be  sub- 
stituted by  impure  air.  Operative  interference  has  been  carried  out  with 
more  or  less  success.  ^  The  cases  of  spontaneous  pneumothorax  got  well 
by  simple  rest.  If,  however,  there  is  prolonged  dyspnea  the  air  may  be 
with  drawn  by  an  aspirator  with  no  untoward  results  following. 

MORBID  GROWTHS  OF  THE  PLEURA 

These  are  rare  and  will  be  considered  to  some  extent  in  treating  medi- 
astinal disease.  The  pleura  is  subject  to  carcinoma  and  to  sarcoma,  the 
clinical  phenomena  of  which  are  identical.  Most  cases  of  carcinoma  of 
the  pleura  arise  by  contiguous  growth  from  primary  cancer  of  the  lung. 
Secondary  cancer  of  the  pleura  occasionally  arises  by  metastasis  from  the 
mammary  gland  or  lungs. 

'See  a  paper  on  the  "Operative  Treatment  of  Pneumothorax,"  by  Samuel  West,  "British  Medical 
Journal,"  November  27,  1897,  p.  1568. 


548  DISEASES  OF  THE  RESPIRATURV  SYSTEM 

Sarcoma  occurs  as  a  primar)-  growth  in  the  shape  of  the  so-called  en- 
dothelial carcinoma  of  Wagner,  which  starts  from  the  endothelial  cells  of 
the  lymphatics  and  connective  tissue.  It  also  gives  rise  to  secondary  de- 
posits in  the  lungs,  lymphatic  glands,  the  liver,  and  muscles. 

The  symptoms  of  any  one  of  these  forms  of  growth  are  those  of  chronic 
pleurisy,  varying  in  intensity  with  the  extent  of  the  growth,  single  second- 
ary nodules  often  giving  rise  to  no  symptoms,  while  the  diffuse  forms, 
spreading  from  the  lungs,  cause  all  the  symptoms  described  as  belonging 
to  chronic  pleurisj',  the  lung  symptoms  being  relatively  insignificant.  In 
the  meantime  the  true  nature  of  the  disease  may  long  remain  unknown,  its 
real  nature  being  determined  with  the  development  of  cachexia  toward 
the  end,  the  decline  of  strength,  and  probably  secondary  deposits  in  dis- 
coverable localities.  The  bloody  character  of  the  effusion  is  a  sign  point- 
ing to  malignant  disease  of  the  sarcomatous  or  carcinomatous  type.  Oc- 
casionally a  sarcoma  of  the  pleura  gives  rise  to  signs  identical  with  pleural 
effusion. 

The  prognosis  is  altogether  unfavorable,  and  treatment  is  palliative 
only. 

There  are  also  sometimes  found  in  connection  with  the  pleura  chon- 
droma and  lipoma,  while  calcification  sometimes  takes  place  in  chronic 
inflammatory  products. 

Echinococcus  or  hydatid  disease  is  occasionally  found  in  the  pleural 
cavity.  Of  this,  the  first  clinical  symptom  is  hydrothorax,  the  fluid  from 
which  is  nonalbuminous,  differing  in  this  respect  from  that  of  pleurisy  and 
to  a  less  degree  from  that  of  ordinary  hydrothorax.  The  only  unmistakable 
evidence  of  hydatid  disease  is  the  presence  of  hooklets  and  fragments  of 
the  hydatid  cysts  in  the  aspirated  fluid.  Here,  also,  the  product  may  be 
purvdent. 

MEDIASTINAL  DISEASE. 

Definition. — Under  mediastinal  disease  are  included  all  anatomically 
morbid  conditions  situated  in  the  mediastinal  space,  except  diseases  of 
the  heart,  aorta,  trachea,  and  esophagus.  By  far  the  greater  number  of 
these  are  tumors,  but  simple  lymphadenitis,  abscess,  and  hemorrhage  and 
fibrinous  mediastinitis  are  also  included. 

Anatomical.— In  consequence  of  the  difficulty  attending  the  concep- 
tion of  the  mediastinum  and  its  contents,  the  consideration  of  mediastinal 
disease  is  preceded  by  a  brief  anatomical  description  of  the  mediastinum 
and  its  spaces. 

The  mediastinum  is  bounded  in  front  by  the  sternum,  posteriorly  by 
the  vertebral  colimm  from  the  lower  edge  of  the  fourth  dorsal  vertebra 
downward,  and  laterally  by  the  two  pleurse.  Clinicians  are  in  the  habit 
of  subdividing  this  space  into  the  superior,  anterior,  middle,  and  posterior 
mediastinum  or  mediastinal  spaces. 

The  superior  mediastinum  is  that  portion  of  the  interpleural  space 
above  the  upper  level  of  the  pericardium,  between  the  manubrium  stemi 
in  front  and  the  upper  dorsal  vertebras  behind,  and  bounded  below  by  a 
plane  passing  from  the  junction  of  the  manubriiun  with  the  body  of  the 


MEDIASTINAL  DISEASE 


549 


sternum  backward  to  the  lower  border  of  the  fourth  dorsal  vertebra.  It 
contains  the  origins  of  the  sternohyoid  and  sternothyroid  muscles,  and  the 
lower  end  of  the  longus  colli;  the  transverse  portion  of  the  arch  of  the  aorta; 
the  innominate,  the  left  carotid,  and  left  subclavian  arteries;  the  superior 
vena  cava  and  the  innominate  veins,  and  the  left  superior  intercostal  vein; 


Left  bronchus. 


Superior  cava. 


Right  bronchus 


Descending  aorta. 


Dorsal  vertebra. 


Fig.  io8.  —  Section  through  Frozen  Thorax  at  Second  Interspace  in  Front,  Looking  from  above 
downward,  Showing  Mediastinal  Space. 

the  pneumogastric,  cardiac,  phrenic,  and  left  recurrent  laryngeal  nerves; 
the  trachea,  esophagus,  and  thoracic  duct,  and  the  remains  of  the  thymus 
gland  with  lymphatics. 

The  anterior  space  of  the  lower  or  clinical  mediastinum  is  bounded  in 
front  by  the  sternum,   posteriorly  by  the  pericardium,  and  laterally  by 


Left  bronchus 


Esophag' 


Dorsal  vertebr; 


Fig.  log.  — Section  through  Frozen  Thorax  at  Second  Interspace  in  Front,  Looking  from  below 
upward,  Showing  Mediastinal  Spaces. 

the  pleurae.  It  is  wider  below  than  above,  and  is  narrowest  in  the  middle, 
since  at  this  point  the  two  pleural  edges  approach  each  other,  while  in 
some  instances  they  are  actually  in  contact.  The  anterior  mediastinum 
contains  the  origins  of  the  triangularis  sterni  muscles;  the  intearnl  mam- 


550  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

mary  vessels  of  the  left  side;  a  quantity  of  loose  areolar  tissue ;  a  few  lymph 
atic  glands,  with  lymphatics  from  the  upper  surface  of  the  liver  and  two 
or  three  lymphatic  glands  called  anterior  mediastinal  glands. 

The  middle  space  contains  the  heart  in  its  pericardial  sac,  the  ascending 
aorta,  the  superior  vena  cava,  the  pulmonary  artery  and  veins,  the  phrenic 
nerves,  the  bifurcation  of  the  trachea,  and  the  roots  of  the  lungs,  with 
numerous  lymphatic  glands.  It  is  broader  than  the  anterior  or  posterior 
mediastinal  space. 

The  posterior  space  is  triangular  in  form,  and  is  bounded  behind  by  the 
vertebral  column.  Its  anterior  boundary  is  the  pericardial  sac  and  the 
roots  of  the  lungs ;  its  lateral  walls,  the  pleurae.  It  contains  the  de- 
scending portion  of  the  arch  and  the  descending  thoracic  aorta;  the  greater 
and  less  azygos  veins,  the  thoracic  duct,  the  pneumogastric  and  sympathetic 
nerves,  the  esophagus,  and  some  lymphatics. 

MEDIASTINAL  TUMORS. 

Pathology  and  Morbid  Anatomy. — The  varieties  of  growth  consist 
mainly  of  sarcoma,  including  lymphosarcoma,  carcinoma,  simple  lymph  ad- 
enoid tumors;  more  rarely  cysts,  dermoid  and  hydatid,  fibroma,  lipoma, 
gumma,  and  chondroma;  also  the  teratoma  myomatoids  of  Virchow. 
Sarcoma  and  carcinoma  and  h'mphadenoid  tumors  make  up  the  larger 
number.  Most  observers  have  found  more  carcinomata  than  sarcomata, 
but  in  the  light  of  the  fact  that  many  tumors  formerly  described  as  can- 
cerous are  at  the  present  day  acknowledged  to  be  sarcomata,  it  is  more 
than  likely  that  the  latter  have  always  predominated.  Hilton  Fagge 
and  Douglas  Powell  were  the  first  to  announce  this,  and  William  Pepper 
and  Alfred  Stengel,  in  their  monograph  published  in  1895,  came  to  the 
same  conclusion. 

The  majority  of  tumors  in  the  anterior  mediastinum  start  from  the 
remnant  of  the  thymus  gland  and  are  Ijonphosarcomata.  The  lymphatic 
structures  in  the  anterior  mediastinum  furnish  a  few.  In  the  middle 
mediastinum  the  lymphatic  glands  are  the  principal  starting-points  of 
the  relatively  frequent  lymphosarcomata.  The  carcinomata  are  usually 
primary,  but  secondary  carcinoma  is  not  infrequent.  The  breasts,  lungs, 
and  stomach  are  among  the  primary  seats  named.  The  secondary  cancers 
do  not  usually  attain  a  large  size.  Cancer  may  extend  from  the  abdomen 
to  the  lymphatic  glands  of  the  chest  bj^  vascular  embolism,  by  direct 
spread  of  the  disease  to  the  under  surface  of  the  diaphragm,  through 
which  it  may  penetrate  along  the  lymphatics  into  the  chest  and  glands, 
or  by  embolism  through  the  thoracic  duct  to  the  chest  and  then  by  retro- 
grade embolism  to  the  mediastinal  glands. 

The  pleura  is  also  a  frequent  starting-point  of  mediastinal  growths. 
Among  these  are  the  so-called  endotheliomata  of  Wagner  and  Schulz, 
starting  in  the  endothelium  of  lymphatic  vessels  and  sometimes  the  surface 
endothelium.  They  are  sarcomata  or  carcinomata  according  as  the 
endothelium  is  counted  mesoblastic  or  endodermic  in  origin.  The  cases 
of  primary  cancer  of  the  pleura  are  probably  endothelioma.  Fibrous, 
fatty,  and  calcareous  tumors  of  the  pleura  are  of  rare  occurrence.     The 


MEDIASTINAL  TUMOR  551 

lungs  also  contribute  tumors  to  this  locality — carcinoma,  primary  and 
secondary,  and  sarcoma,  primary  and  secondary.  Of  the  primary  tumors, 
carcinoma  is  the  more  common,  but  primary  sarcoma  of  the  lymphatic 
glands,  surrounding  the  bronchi  and  within  the  lungs  near  the  root  is  not 
very  rare.  The  clinical  symptoms  are  the  same  as  when  the  glands  around 
the  bronchi  outside  of  the  mediastinum  are  affected.  The  cancers  may 
start  from  the  surface  epithelium  of  the  bronchi,  from  the  mucous  glands, 
or  from  the  alveolar  epithelium  of  the  lung.  Finally,  from  the  esophagus, 
also,  start  cancerous  tumors  invading  the  mediastinum,  usually  small, 
though  not  always.  From  these  the  posterior  mediastinum  and  lungs 
may  also  be  invaded. 

Symptoms. — Mediastinal  tumors  may  be  latent.  Their  symptoms 
when  present  are,  in  a  word,  those  of  pressure.  Such  pressure  may  involve 
the  lungs,  the  trachea,  the  bronchi,  the  esophagus,  the  heart,  the  vessels, 
and  the  nerves  of  this  locality.  They  include  symptoms,  subjective  and 
objective,  of  the  usual  kind,  and  also  physical  signs.  It  will  be  remem- 
bered that  the  symptoms  of  aneurysm  are  also  largely  those  of  pressure, 
and  it  is  chiefly  from  aneurysm  that  mediastinal  tumor  is  to  be  distin- 
guished, often  a  matter  of  some  difficulty.  The  division  by  Pepper  and 
Stengel  into  three  groups  affords  the  most  convenient  mode  of  studying 
these  symptoms.     These  groups  are: 

1.  Those  in  which  the  anterior  mediastinum  is  the  seat  of  the  growth. 

2.  Those  involving  the  middle  and  posterior  spaces. 

3.  Those  in  which  the  pleura  or  superficial  portion  of  the  lung  is 
involved. 

I.  Intrathoracic  Tumors  Situated  in  the  Anterior  Mediastinum,  and 
in  which  the  Physical  Signs  are  easily  Observed. — The  symptoms  are  mainly 
those  arising  from  pressure  exerted  on  the  venous  trunks,  the  superior 
vena  cava,  and  the  right  and  left  innominate  veins.  The  jdelding  walls 
of  these  vessels  as  contrasted  with  the  firmer  adjacent  arteries  easily  siiffer 
compression,  and  may  even  be  penetrated  by  the  growths  which  may 
proliferate  within  them,  sometimes  causing  occlusion  by  thrombosis. 
The  consequence  is  distention  of  the  veins  of  the  upper  part  of  the  body — 
the  head,  neck  and  upper  chest,  sometimes  the  arms.  Coldness,  lividity, 
edema,  and  clubbing  of  the  ends  of  the  fingers  result,  while  the  superficial 
venous  channels  may  be  dilated  and  tortuous.  - 

From  pressure  on  the  arteries  may  resiilt  inequality  of  the  radial 
pulses.  Of  the  nerves,  the  inferior  laryngeal  is  especially  liable  to  com- 
pression, with  resulting  hoarseness  and  aphonia.  The  sympathetic  is 
also  sometimes  compressed,  with  consequent  inequality  of  pupils,  the 
pneumogastric  being  less  frequently  involved  than  when  the  timior  occupies 
a  more  posterior  situation.  As  the  tumor  enlarges  and  the  air-passages 
are  intruded  upon,  dyspnea  makes  its  appearance.  Dyspnea  is  usually 
of  the  inspiratory  kind.  Pericarditis  and  pleurisy,  with  pain,  hydro- 
pericardium,  and  pleural  effusion  may  be  present.  With  the  prolongation 
of  the  disease  the  patient  wastes,  but  it  is  said  that  cachexia  is  less  apt  to 
develop  than  in  malignant  growths  of  the  posterior  mediastinum.  Pain 
is  not  always  present — indeed,  it  is  said  to  be  less  marked  than  in  aneurysm. 

Physical  Signs  of  Growths  in  the   Anterior   Mediastinum. — To   inspec- 


552  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Hon  the  sternum  is  frequently  pushed  forward,  and  in  a  few  instances  eroded. 
Vocal  fremitus  may  be  either  increased  or  diminished.  Percussion  elicits 
abnormal  dullness,  characterized  by  more  or  less  irregular  shape.  Pulsation 
may  occur,  but  is  rare,  while  the  sharp  diastolic  shock  of  aneurysm  is 
wanting.  If  the  tumor  extends  upward  sufficiently,  it  may  be  felt  in  the 
suprasternal  notch.  Auscultation  over  the  area  of  dullness  may  be  nega- 
tive, but  sometimes  the  breath-sounds  and  heart-sounds  are  well  transmitted, 
while  a  distinct  systolic  bruit  may  be  produced  by  pressure  on  the  aorta 
or  the  pulmonary  artery.  Eustice  Smith's  sign  may  be  elicited.  It  is 
a  murmur  heard  over  the  upper  part  of  the  sternum  when  the  head  is 
bent  far  backward,  caused  by  pressure  of  enlarged  bronchial  glands  on 
the  aorta.  Secondary  enlargement  in  the  cervical  lymphatic  glands 
sometimes  makes  its  appearance. 

Intrathoracic  Tumors  in  the  Middle  and  Posterior  Portions  of  the  Spaces 
around  the  Bronchi,  Esophagus,  Aorta,  and  Nerves,  and  in  which  the  symp- 
toms predominate  over  the  physical  signs. — The  first  effect  is  likely  to 
be  pressure  on  the  trachea  and  bronchi.  Hence  dyspnea  is  an  important 
and  early  symptom  of  tumors  in  this  situation,  and  the  inspiratory  effort 
is  extreme.  Pressure  here  is  also  exerted  upon  the  vena  cava  ascendens, 
whence  result  edema  of  the  abdominal  walls  and  lower  extremities.  The 
effect  of  pressure  on  the  arteries  is  not  serious.  From  pressure  on  the 
vagus  nerve  arises  peculiar  cough,  paroxysmal  and  whooping.  Sometimes 
it  is  loud  and  ringing,  at  other  times  constant  and  hacking.  This  cough 
is  said  to  be  due  to  the  joint  involvement  of  one  vagus  and  the  pulmonary 
plexus;  whereas  experimentally  two  pneumogastrics  are  required  to  be  cut  to 
produce  it.  The  explanation  is  in  the  involvement  of  the  pulmonary  plexus. 
Mucopurulent  and  even  blood-stained  sputa  may  attend  the  cough. 
The  latter  is  sometimes  a  sign  of  perforation  of  the  bronchial  wall.  Dys- 
phagia from  pressure  on  the  esophagus  is  a  symptom  in  this  group,  some- 
times, indeed,  the  only  one.  It  is  not,  however,  invariably  present.  Vomit- 
ing, cardiac  palpitation  with  irregularity,  and  syncope,  when  present, 
are  also  ascribed  to  the  pneumogastric  involvement.  Pressure  upon 
the  azygos  veins  may  cause  edema  of  the  upper  part  of  the  abdomen  and 
serous  effusion  in  the  chest,  while  pleural  effusions  are  also  due  to  com- 
plicating inflammations  or  neoplasms  of  the  pleura.  Fever  may  be  a 
symptom  of  tumor  of  the  posterior  mediastinum.  It  is  usually  moderate 
but  is  sometimes  high  and  irregular,  followed  by  sweating.  On  the  other 
hand,  there  may  be  lowered  temperature,  as  in  tumor  of  the  anterior 
mediastinum  from  impeded  circulation. 

Cachexia  is  much  more  frequent  with  this  group  of  symptoms,  as  might 
be  expected  from  the  greater  severity  and  disturbing  effect  of  the  disease, 
including,  as  it  docs,  destructive  process  involving  bone  and  lung  structure, 
as  well  as  severe  and  deep-seated  pain. 

Physical  Signs  of  Growth  in  the  Middle  and  Posterior  Mediastinal  Space. 
— It  is  evident  that  in  this  group  the  physicial  signs  plaj-  a  secondary  r61e, 
and  except  as  a  result  of  modified  breathing  by  pressure  and  impairment 
of  resonance  to  percussion,  have  little  significance. 

3.  Tumors  Originating  in  the  Pleura  and  Lung,  and  in  which  the  symp- 
toms and  physical  signs  are  of  equal  prominence.     The  former  is  the 


MEDIASTINAL  TUMOR  553 

more  frequent  starting-point,  but  the  underlying  lung  is  usually  soon 
invaded  and  may  be  more  frequently  the  actual  starting-point  than  is 
commonly  supposed.  Naturally,  the  symptoms  first  produced  are  those 
of  pleurisy,  and  the  disease  is  generally  so  regarded  at  first,  being  charac- 
terized by  the  comparatively  sudden  onset,  sharp  pain,  cough,  embarrassed 
breathing,  and  pleuritic  effusion.  Instead  of  abating  ultimately,  as  is 
the  course  in  pleurisy,  these  symptoms  grow  worse,  especially  the  pain, 
which  extends  along  the  intercostal  nerves  and  their  distribution  and  to 
the  neck  and  arms.  The  cough  also  persists,  while  the  expectoration 
may  become  bloody  and  include  sometimes  cells  from  the  morbid  gro\\i;h. 

Paracentesis,  too,  is  successful,  and  often  furnishes  in  the  peculiarity 
of  its  product  valuable  aid  in  the  diagnosis,  because,  instead  of  being  clear 
or  nearly  so,  it  is  apt  to  be  bloody  or  slightly  chyliform  from  the  presence 
of  fatty  matter.  This  fatty  character  has  been  found  where  there  were 
cancer  and  sarcoma.  The  diagnostic  importance  of  certain  large,  swollen 
cells  of  endothelial  nature,  which  seem  to  become  detached  and  trans- 
formed only  in  case  of  pleuritic  disease  of  malignant  character,  is  insisted 
upon  by  Fraenkel.  To  the  information  gained  from  the  fluid  obtained 
by  tapping  are  added  also  unusual  resistance  to  the  trocar  and  imperfect 
relief  to  the  dyspnea.  Rapid  emaciation,  anemia,  and  cachexia  complete 
the  picture,  while  all  doubt  is  removed  if  secondary  growths  make  their 
appearance  in  the  lungs,  as  not  infrequently  happens. 

Physical  Signs  oj  Mediastinal  Growths  Originating  in  the  Pleura  and 
Lung. — These  are  those  caused  by  pleurisy,  pleuritic  effusion  and  consoli- 
dation of  the  lung  plus  the  signs  of  a  growth  in  one  or  the  other  part  of  the 
mediastinum. 

Diagnosis. — In  view  of  the  similarity  of  symptoms  to  aneurysm,  the 
history  of  the  case  in  mediastinal  disease  becomes  of  the  utmost  impor- 
tance, but  shortness  of  breath,  the  bulging  of  the  thorax,  irregular  outline 
of  percussion  dullness,  the  feebleness  of  breathing  sounds,  the  dislocation 
of  the  heart  and  sometimes  of  the  abdominal  organs,  the  symptoms  of 
venous  engorgement,  which  are  usually  more  marked  in  mediastinal 
disease,  the  more  rapid  course,  and  secondary  metastatic  deposits  are 
strong  points  in  favor  of  the  latter  as  contrasted  with  aneurj^sm.  Laryn- 
goscopic  examination  with  a  view  to  discovering  any  constriction  of  the 
trachea  from  pressure  by  the  tumor  may  be  availed  of.  The  subjects 
of  mediastinal  disease  are  usually  younger  than  those  of  aneurysm.  Bony 
erosion  and  pain  are  less  frequent.  Constitutional  disturbance  and  ema- 
ciation are  more  marked.  Diastolic  shock  is  never  present  in  mediastinal 
disease,  while  pulsation,  if  present,  is  not  expansile. 

Confusion  with  pleurisy  and  pericarditis  is  a  natural  error  when  the 
symptoms  involving  the  pleura  and  pericardium  are  recalled,  and  here 
the  slower  development  of  the  symptoms  associated  with  those  of  compres- 
sion of  the  various  mediastinal  tissues  and  absence  of  tendency  to  improve 
should  lead  to  suspicion  of  the  true  nature  of  the  disease. 

The  nature  of  the  tumor  may  even  be  suspected  from  certain  features. 
Thus,  rapid  growth,  metastatic  deposits  in  the  glands  of  the  neck  and 
apices  of  the  lungs,  cachexia,  tumors  and  in  other  situations  point  to 
malignancy.     Especially  may  sarcoma  be  suspected  if  the  subject  be  a 


554  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

youthful  one.  Abscess  may  be  suspected  if  there  is  a  history  of  injury, 
caries,  or  p\'emia,  or  if  there  is  abscess  of  the  lung  or  empyema  attended 
by  the  supervention  of  pressure  symptoms.  Hemorrhage  may  be  suspected 
also  when  there  is  trauma  and  the  s\Tnptoms  develop  very  rapidly. 

Treatment. — There  is  no  treatment  for  mediastinal  disease,  except 
such  as  may  suggest  itself  for  the  palliation  of  symptoms. 

Mediastinal  Abscess. — Separate  mention  should  be  made  of  mediastinal 
abscess,  since  it  is  relatively  not  a  very  rare  disease.  Out  of  Hare's  520 
cases  of  disease  of  the  mediastintmi  115  were  abscesses,  as  contrasted 
with  134  case's  of  cancer  and  98  of  sarcoma,  21  cases  of  lymphoma,  7  of 
fibroma,  11  of  dermoid  cyst,  8  of  hydatid  cyst,  with  isolated  cases  of  gumma, 
chondroma,  and  lipoma. 

The  abscesses  were  found  in  the  majority  of  instances  in  males,  most 
often  in  the  anterior  mediastinum,  and  most  could  be  traced  to  traumatic 
causes.  Other  causes  were  tuberculosis,  the  eruptive  fevers,  and  erysipe- 
las. A  few  cases  of  mediastinal  abscess  also  originate  in  the  bronchial 
and  tracheal  lymphatic  glands,  as  tubercular  lymphadenitis.  In  54  cases 
the  abscess  was  acute. 

Of  symptoms,  substernal  pain,  sometimes  throbbing,  was  the  most 
conspicuous.  To  this  was  added  fever  in  acute  cases;  sometimes  chills 
and  sweats.  Erosion  of  the  sternum  and  burrowing  along  a  rib  into  the 
abdomen  were  noted,  also  rupture  into  the  trachea  and  esophagus.  In 
chronic  abscess  the  pus  may  become  inspissated — cheesy.  Supptirative 
lymphadenitis  has  been  known  to  terminate  thus,  previous  symptoms 
having  been  masked  by  the  lung  affection.  Rarely  are  we  able  to  detect 
fluctuation  at  the  edge  of  the  sternum  and  in  the  suprasternal  notch, 
where  there  may  be  pulsation.  Only  as  the  abscess  becomes  large  enough 
to  encroach  upon  the  air-passages  does  it  cause  dyspnea. 

The  physical  signs  are  not  distinctive.  They  are  essentially  those 
described  in  the  general  description  of  mediastinal  disease.  Fever,  throb- 
bing pain,  fluctuation,  and  the  history  of  trauma  are  symptoms  which, 
if  added,  aid  the  diagnosis. 

As  to  treatment,  given  a  correct  diagnosis,  operative  interference 
is  justified,  and  likely  to  afford  relief  if  the  pus  is  reached. 

Simple  Lymphadenitis. — This  probably  occurs  to  a  degree,  in  all  in- 
flammatory affections  of  the  bronchi  and  of  the  lungs,  but  is  rarely  recog- 
nizable. The  glands  are  mostly  in  the  posterior  mediastinimi,  and 
their  enlargement  may  be  appreciable  to  percussion  in  the  upper  inter- 
scapular region  behind,  though  lymphatic  enlargement  may  contribute 
also  to  dullness  in  the  region  of  the  manubritmi.  Tuberculosis  may  effect 
these  glands,  and  great  masses  form  both  from  tuberculosis  and  from  leu- 
kemia and  pseudo-leukemia. 


SECTION  IV. 

DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS. 

GENERAL  SYMPTOMATOLOGY  OF  CARDIAC  DISEASE. 

Serious  cardiac  disease  may  be  present  without  gi\'ing  rise  to  any  symp- 
toms though  the  physical  signs  are  unmistakable.  Under  these  circumstances 
the  heart  is  capable  of  normal  action  and  is  said  to  be  fully  compensated. 
When  the  heart's  force  is  no  longer  sufficient  for  efficient  work  the  follow- 
ing symptoms  occur  as  this  result  of  failure  and  there  is  said  to  be  loss  of 
compensation,  or  decompensation  of  the  heart.  Whatever  the  original  lesion 
causing  the  weakness  of  the  heart  the  symptoms  are  practically  the  same. 
If  the  cardiac  muscle  is  weakened  as  the  result  of  some  condition  outside 
the  heart  itself,  eraphysema,  high  a^erialten^^i,  etc,,  the  sj'^^^toms  may 
be  identical  with  those  arisi^|[£^|ima0SE^iHHHifesaitt^^g^3r  its  valves. 

1.  Shortness  of  Breath,  Cardiac  Asthma. — D^^^^^IFwortness  of 
breath  is  commonly  the  first  symptom  of  cardiac  disease,  .fl^  first  it  is 
very  slight,  being  felt  only  on  exertion.  As  the  disease -advances  it  is  in- 
duced by  slighter  effort,  and  finally  it  is  more  or  less  permanent.  The 
higher  degrees  are  commonlj^  characterized  as  cardiac  asthma. 

2.  Palpitation. — The  second  symptom  characteristic  of  -heart  disease 
and  commonly  concurrent  with  shortness  of  breath  is  palpitation.  Bj^ 
palpitation  is  meant  undue  frequency  of  the  heart's  action,  with,  or  without 
irregularit3^  It  succeeds  very  early  upon  shortness  of  breath,  or  is  coitici- 
dent  with  it,  and  is  more  common  in  mitral  disease  than  in  aortic  disease.  It 
varies  greatly  in  degree,  being  at  times  scarcely  noticeable  by  the  patient, 
and  at  others  exceedingly  distressing.  The  rate  attained  by  the  heart 
under  these  circumstances  is  sometimes  as  great  as  200  in  a  minute,  more 
frequently  120  to  150. 

3.  Slow-pulse. — Unnaturally  slow  action  of  the  heart  as  a  symptom  of 
organic  heart  disease  is  not  infrequent.  The  number  of  heart-beats  is 
reduced  to  40,  20,  or  even  less.  It  is  more  frequentlj^  associated  with  degen- 
erative, fatty  or  fibroid  disease  of  the  muscular  substance  of  the  heart  and 
of  the  coronary  arteries.  Such  diseased  state  of  the  muscle,  often  due  to 
scleroses  of  the  coronaries,  may  interfere  with  prompt  contractile  response 
to  the  stimiolus  of  the  endocardial  blood  on  the  ventricles. 

Slow  pulse  may  also  be  caused  b}'  resistance  (scleroses  and  high  tension) 
in  the  peripheral  vessels,  to  overcome  which  the  diastole  is  prolonged  and 
the  pulse  thus  slowed.     In  other  cases  there  is  deranged  innervation. 

4.  Pain. — Pain  is  not  so  frequent  in  heart  disease  as  is  palpitation  or 
dyspnea.  It  is  of  two  kinds — a  dull,  aching  pain  and  a  sharp  pain  of  great 
severity,  radiating  through  the  heart  and  do^vn  the  arms,  especially  the  left 
arm.  Sometimes  the  patient  complains  of  a  sensation  as  if  the  heart  was' 
being  compressed,  or  grasped  in  a  vise.  This  pain  is  associated  with  an 
anxious  expression  and  feeling,  including  a  sense  of  impending  death,  which 

55.5 


556  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

is  characteristic  of  the  severer  forms  of  angina  pectoris.  Pain  of  this  kind 
is  apt  to  be  associated  with  disease  of  the  muscular  substance  of  the  heart, 
of  its  blood-vessels,  and  of  the  aortic  valves.  Pain  is  less  common  in 
mitral-valve  disease,  and  when  present  is  more  likely  to  be  of  a  dull,  aching 
character. 

5.  Dropsy. — Dropsy  is  another  symptom  of  heart  disease.  It  does  not 
occur  with  every  form,  being  for  the  most  part  absent  in  disease  of  the  aortic 
valves  and  is  most  common  in  mitral  disease.  Not  every  case  of  mitral  dis- 
ease is  associated  with  dropsy,  but  it  occurs  sooner  or  later  in  the  vast 
majority  of  cases.  It  is  sometimes  the  earliest  symptom  noticed,  and 
makes  its  appearance  first  almost  invariably  in  the  lower  extremities.  It  is 
the  direct  consequence  of  backing  of  the  blood  into  the  venous  side  of  the 
circulation,  and  is  due  to  the  transudation  or  filtration  of  its  water}^  element. 
The  serum  is,  as  it  were,  strained  out.  When  unchecked,  the  swelling 
extends  from  the  feet  to  the  legs,  thighs,  the  trunk,  abdominal  walls,  and, 
last  of  all,  serous  cavities  and  especially  the  peritoneal  cavity,  producing 
ascites.  The  pleural  sacs  may,  in  rare  instances,  be  the  first  seats  of  transu- 
dation in  heart  disease.  (See  remarks  on  Hydrothorax,  page  545.)  These 
simple  transudates  are  usually  free  of  albumin,  as  contrasted  with  inflam- 
matory exudates. 

6.  Hypertrophy  and  Dilatation  of  the  Heart. — These  conditions  will  be 
frequently  mentioned  in  the  following  pages  and  will  be  considered  at  greater 
length  on  pp.  600,  601,  at  present  briefly,  that  a  correct  application  of  the 
terms  may  be  learned.  By  hypertrophy  is  meant  enlargement  of  the  heart 
associated  with  physiological  thickening  of  the  muscular  wall  with  or  with- 
out enlargement  of  the  cavities.  When  the  cardiac  cavity  remains  un- 
changed in  size  the  hypertrophy  is  called  simple;  when  there  is  enlargement 
of  the  cavity  it  is  called  eccentric  hypertrophy  or  hypertrophy  with  dilatation . 

When  the  left  or  right  ventricle  alone  is  affected,  the  hypertrophy  may 
be  simple  or  eccentric;  when  there  is  general  hypertrophy,  it  is  always 
eccentric.  All  true  hypertrophies  are  numerical — that  is,  there  is  an  actual 
increase  in  the  number  of  muscular  fasciculi,  due  partly  to  a  fission  of  pre- 
viously existing  fibers  and  partly  to  a  new  formation  of  fibers. 

The  word  dilatation  is  applied  to  conditions  in  which  the  cavities  are 
enlarged  without  corresponding  thickening  of  the  walls.  Usually  there  is 
attenuation  of  the  walls.  The  latter  is  the  typical  condition.  Dilatation 
implies  degeneration,  for  it  is  through  intermediate  degeneration  that  the 
muscular  fasciculi  waste  and  ultimatelj-  disappear,  producing  thinning. 

Hypertrophy  more  frequently  affects  the  left  ventricle,  dilatation  the 
left  and  right  ventricles,  but  the  whole  heart  ma}-  be  involved  by  one  or  the 
other  condition. 

Morbid  Anatomy. — The  hypertrophied  and  dilated  heart  is  altered  in 
its  weight,  dimensions,  and  shape.  The  adiilt  heart  weighs  in  health,  in  the 
male  50  to  60  years  old,  about  335  grams  (11. 8  ounces);  in  the  female,  295 
grams  (10.44  ounces).  The  average  thickness  of  the  wall  of  the  left  ven- 
tricle in  health  is  from  5/8  to  2/3  inch  (1.6  to  1.7  cm.) ;  of  the  right  ventricle, 
•1/6  to  1/4  inch  (0.4  to  0.6  cm.);  of  the  left  auricle,  1/8  inch  (3  mm.);  the 
right  auricle,  1/12  inch  (2  mm.). 

Hearts    exceeding   these    weights   and    measurements    are,    therefore. 


ACUTE  PERICARDITIS  bbl 

hypertrophied.  Measurements  should  be  made  before  rigor  mortis  sets  in  or 
after  it  has  passed  away.  Relaxations  may  be  favored  by  soaking  the  heart 
in  water.  Commonly,  the  hj'pertrophied  heart  does  not  exceed  25  ounces 
(750  gm.),  though  hearts  weighing  48  and  53  ounces  (144  to  1590  gm.)  have 
been  found. 

The  shape  of  the  heart  varies ;  in  left  ventricular  hypertrophy  it  is  elon- 
gated to  the  left  and  lies  more  horizontall}-,  while  the  conical  shape  is  less 
marked;  when  both  ventricles  are  hypertrophied,  the  heart  is  round.  In 
mitral  stenosis  with  hypertrophy  of  the  left  auricle  and  right  ventricle  it  is 
also  quadrate,  the  right  ventricle  occupying  the  chief  bulk  of  the  organ, 
while  the  left  ventricle  recedes  behind  it. 


DISEASES  OF  THE  PERICARDIUM. 

ACUTE  PERICARDITIS. 

Definition. — An  inflammation  of  the  serous  covering  of  the  heart  and  of 
its  reflection  on  the  inner  surface  of  the  pericardial  sac. 

Etiology. — 'By  far  the  larger  number  of  cases  of  pericarditis  are  due  to 
some  toxic  substance  in  the  blood,  such  as  is  developed  in  the  infectious  dis- 
eases, or  to  some  excrementitious  matters  which  accumulate  in  the  blood 
because  of  deficient  elimination.  Pathogenic  organisms  may  be  the  direct 
cause  in  certain  cases.  Other  cases  arise  per  contigtiuni,  a  few  cases  are  trau- 
matic, and  those  that  cannot  be  accounted  for  are  called  idiopathic.  Acute 
articular  rheumatism  or  its  cause  is  b}-  far  the  most  frequent  etiological  factor, 
from  30  to  70  per  cent,  of  aU  cases  being  ascribed  to  it.  The  greater  the 
severity  of  the  primary  disease,  the  more  likely  is  it  that  the  complication, 
pericarditis,  will  occur;  j^et  it  arises  also  in  the  mildest  cases,  and  has  some- 
times even  preceded  the  rheumatic  attack.  It  may  be  that  certain  seeming 
idiopathic  cases  are  due  to  the  toxin  of  rheumatism  spending  itself  on  the 
pericardium  instead  of  on  the  joints.  Other  infectious  diseases  causing  it 
are  pyemia,  scarlet  fever,  typhoid  fever,  diphtheria,  and  even  measles. 
Bright's  disease  is  one  of  the  best  recognized  causes  of  pericarditis,  thoughnot 
a  very  frequent  one,  and  it  may  be  the  toxic  matters  which  acciunvdate  in 
the  blood  in  this  disease  which  are  responsible  for  it.  Such  dj'scrasic  states 
of  the  blood  as  are  represented  by  scurvy  and  purpura  hemorrhagica  may 
cause  it.  Tuberculosis  of  the  pericardium  is  a  common  cause  of  pericarditis. 
Tubercular  pericarditis  ma}'  be  part  of  a  general  tubercvdosis  or  a  secondary 
infection  from  the  lungs. 

Diseases  of  adjacent  organs  which  cause  pericarditis  are  pneumonia, 
pleurisy,  especially  tubercular  pleuris}^  morbid  growths  in  the  vicinity, 
ulcerative  disease  of  the  esophagus,  disease  of  the  bronchial  glands  and 
bronchi,  disease  of  the  vertebrse,  ruptured  aneurysm,  abscess  of  the  heart, 
or  invasion  of  the  pericardium  by  suppuration  through  the  diaphragm. 

Morbid  Anatomy. — The  appearances  vary  with  the  stage  of  the  disease. 
Ordinary'  acute  pericarditis  is  met  with  in  one  of  three  stages.  The  first 
stage  is  represented  by  hyperemia  and  its  consequences.  The  initial  events 
are  hyperemia  followed  by  roughness  due  first  to  loosening  and  detachment 
of  the  epithelium,  and  further  increased  by  deposits  of  fresh  inflammatory 


558  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

lymph.  This  lymph  is  spread  at  first  in  yellow  flakes  over  the  surface  ot"  the 
pericardium. 

From  this  point  onward  morbid  appearances  vary  with  the  mode  of  ter- 
mination. This  may  be  by  resolution,  when  the  products  described  undergo 
fatty  degeneration  and  are  absorbed,  restoring  the  normal  state.  Or  there 
may  be  organization  and  union  between  the  visceral  and  reflected  peri- 
cardium (primary  adhesive  inflammation) . 

Frequently  there  supervenes  the  second  stage,  in  which  the  liquid  transu- 
date increases,  separating  the  two  surfaces  of  the  pericardium  and  distending 
the  sac.  This  transudate  is  a  clear,  straw-colored  fluid  in  which  may  be 
found  floating  flakes  of  lymph  above  described.  The  quantity  of  fluid 
varies  greatly,  amounting  sometimes  to  a  liter  (2  pints)  or  more.  In 
favorable  cases  it,  too,  is  reabsorbed,  and  the  two  pericardial  .surfaces  are 
reapposed  with  or  without  union  of  the  apposing  surfaces.  Sometimes  this 
union  is  complete  and  firm,  so  that  the  two  surfaces  are  separated  with  diffi- 
culty, or  it  may  be  partial,  by  bands  of  varying  length. 

The  term  third  stage  is  usually  applied  to  the  phenomena  succeeding 
the  transudation  described.  They  include  organization  or  suppuration. 
The  former  may  be  adhesive  in  various  degrees  or  villous.  The  latter 
occurs  when,  union  being  prevented  by  the  constant  motion  to  which  the 
two  surfaces  are  subjected,  organization  takes  place  without  attachment  of 
the  opposing  surfaces,  and  a  peculiar  villous  product  resalts,  characterized 
by  numerous  projections,  uniform  in  size  and  shape,  resembling  closely  the 
papillae  on  a  sheep's  tongue.  These  papillae,  composed  of  vascular  con- 
nective tissue,  originate  in  the  usual  way  by  an  outgrowth  and  vasctdari- 
zation  of  the  connective  tissue  of  the  serous  membrane,  and  not  by  organi- 
zation of  the  exuded  lymph,  as  was  formerly  supposed.  This  lymph 
undergoes  fatty  degeneration  and  absorption. 

The  more  tmfavorable  cases  terminate  in  suppuration,  which  may  also 
be  primary  or  secondary.  In  the  former  instances  there  is  at  once  a  rapid 
outwandering  of  leukocytes  and  the  formation  of  a  purulent  fluid  in  the  peri- 
cardium— pyo-pericardium.  In  the  secondary  form  the  clear,  serous  trans- 
udate is  substituted  by  pus,  an  event  which  is  usually  ushered  in  by  a 
chill  and  is  followed  by  hectic  fever.  The  cause  of  the  suppuration  in  either 
case  is  the  access  of  the  usual  pus  organisms,  the  streptococci,  the  staphy- 
lococci and  pneumococci.  It  may  also  be  caused  by  the  pneumococcus. 
The  contents  of  the  pericardium  may  become  cheesy,  especially  if  the 
inflammation  is  tubercular. 

Symptoms. — Clinically,  as  well  as  anatomically,  we  seek  to  separate  the 
stages,  first  of  roughening,  second  of  effusion,  and  third  of  absorption  or 
organization,  chieflj'  by  aid  of  the  physical  signs. 

Pericarditis  is  sometimes  ushered  in  by  a  chiU.  More  frequenth'  a  sharp 
pain  in  the  region  of  the  heart  initiates  the  attack,  previous  to  which  there 
may,  however,  have  been  a  sense  of  discomfort  or  distress  about  the  organ, 
which  may,  indeed,  be  the  only  subjective  symptom.  The  pain  and  dis- 
comfort may  be  referred  to  the  epigastrium  and  to  the  appendiceal  region. 
Attacks  of  pain  in  the  region  of  the  appendix  are  most  confusing  when  they 
are  due  to  a  pericarditis.  MacKenzie  says  the  pain  is  always  indicative  of 
some  myocardial  involvement.     To  these  symptoms  may  be  added  dyspnea 


ACUTE  PERICARDITIS  559 

or  orthopnea.  There  is  also  fever,  which  is  not  very  high — temperature  102° 
F'  (39-9°  C.) — unless  there  be  previous  disease  with  fever,  when  the  pericar- 
dial complication  adds  an  increment.  The  pulse  is  frequent  and  the  patient 
restless  and  uncomfortable.  There  is  often  tenderness  over  the  region  of  the 
heart,  which  may  be  brought  out  by  percussion  or  pressure  with  the  stetho- 
scope. The  position  assumed  by  the  patient  varies ;  sometimes  he  may  pre- 
fer to  lie  on  the  left  side,  at  other  times  on  his  back  or  on  the  right  side,  or  he 
may  prefer  to  sit  up.  Finally,  there  may  be  no  subjective  symptoms  added 
to  those  of  the  primary  disease,  in  which  case  the  pericarditis  can  be  dis- 
covered only  by  the  physical  examination,  or  it  may  escape  detection  alto- 
gether until  the  necropsy  reveals  it. 

As  the  effusion  distends  the  pericardiiun  and  encroaches  on  the  lung, 
the  difficulty  in  breathing  increases,  dyspnea  becomes  more  marked,  the 
action  of  the  heart  more  disturbed,  frequent,  and  irregular.  When  large  it 
may  press  upon  the  left  lung  producing  changes  in  the  percussion  note  which 
will  be  discussed  when  considering  the  physical  signs  of  the  disease. 

Still  larger  effusions  produce  dysphagia  in  consequence  of  encroachment 
on  the  esophagus.  Aphonia  may  occur  from  pressure  on  the  recurrent 
laryngeal  nerve.  The  pulsus  paradoxus  of  Griesinger  and  Kussmaul,  in 
which  the  pulse  beat  is  weakened  and  accelerated  during  inspiration, 
is  common.     (Fig.  no.) 

A  certain  degree  of  prominence  oj  the  epigastrium  may  result  from  the 
encroachment  of  distended  pericardium,  while  the  excursion  of  breathing 
movement  may  be  noticeably  greater  on  the  right  side. 


Fig.  no. — Pulsus  Parado.xus. 
Influence  of  Respiration  upon  the  sphygmogram  (after  Riegel);  I,  During  inspiration; 
During  expiration. 


Physical  Signs. — In  the  first  stage  there  may  be  pain  in  response  to  pres- 
stire,  but  the  physical  sign  characteristic  of  the  stage  is  the  friction  sound. 
It  may  be  associated  with  an  impulse  stronger  than  natural.  The  friction 
sound,  is  of  the  greatest  importance  in  diagnosis.  It  is  a  superficial  to-and-f  ro 
sound  synchronous  with  the  heart  beat,  heard  directly  under  the  ear,  com- 
monly loud  and  rasping,  never  blowing,  sometimes  creaking.  It  is  loudest 
over  the  middle  of  the  heart.  It  is  not  conducted  as  are  the  murmurs  at  the 
valves  in  the  direction  of  the  blood  current.  It  is  often  influenced  by  changes 
of  position  or  by  breathing.  The  rub  may  sometimes  be  felt  by  the  hand 
placed  over  the  heart.  In  the  first  stage,  at  least,  it  lasts  a  short  time — a 
day  or  two  at  most  and  sometimes  only  a  few  hours — and  disappears  with 
the  filling  of  the  pericardium  by  effusion.  It  may  sometimes  be  brought 
out  or  intensified  by  pressure  with  the  stethoscope.  It  may  occur  suddenly 
long  after  the  beginning  of  the  inflammation,  and  disappear  almost  as 
suddenly. 


560  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

The  second  stage,  or  that  of  effusion,  exhibits  usually,  but  not  always,  signs 
discoverable  to  inspection,  or  palpation,  or  to  both.  They  depend  on  the 
amount  of  effusion.  If  large,  the  precordium  may  be  bulging,  the  interspaces 
obliterated,  and  the  impulse  undulating,  tumultuous,  and  indistinct.  As 
the  effusion  increases  the  heart  is  pushed  further  and  further  away  from 
the  chest-wall  and  assumes  a  more  horizontal  position,  while  the  impulse, 
feebler  and  feebler  to  vision  and  touch,  may  disappear  altogether.  The 
friction  sound  so  characteristic  of  the  first  stage  is  found  high  up  and  becomes 
less  marked.  The  site  of  the  apex  beat  is  raised.  Percussion  fimiishes  the 
most  striliing  change.  The  area  of  dullness  is  enlarged — peculiarly  en- 
larged. It  becomes  rudely  triangular  or  truncated  pyramidal  with  the 
apex  toward  the  inner  end  of  the  left  cla\dcle  and  the  base  as  low  as  the 
seventh  rib,  and  extending  in  extreme  cases  from  nipple  to  nipple,  even 
pushing  the  diaphragm  and  liver  downward.  The  absence  of  resonance 
in  the  fifth  intercostal  space,  to  the  right  of  the  sternum,  is  known  as  Rotch's 
sign  in  pericarditis,  and  has  been  assigned  considerable  value  in  the  early 
diagnosis  of  pericardial  effusion. 


Fig.  III. — E,  Ewart's  posterior  pericardial  patch.     P,  Pins'  sign.     B,  Broadbent's  sign  within 
dotted   lines. — [After  Ewarl   modified.) 

It  is  not  impossible,  however,  that  a  similar  dullness  may  be  caused  by  a 
circtunscribed  pleuritic  effusion  or  even  great  enlargement  of  the  heart 
The  cardiohepatic  angle  as  determined  by  percussion,  normally  an  acute  or 
a  right  angle,  may  become  obtuse. 

Auscultation  confirms  palpation.  The  conditions  of  the  friction  sound 
are  removed  more  or  less  by  separation  of  the  opposed  pericardial  surfaces. 
Yet  the  sound  does  not  always  disappear.  The  heart-sounds  are  indistinct 
and  best  heard  at  the  top  of  the  sternum.  Sometimes  there  is  a  basic 
systolic  murmur. 

The  third  stage  represents  a  return  to  the  normal  state  of  affairs,  which 
may  come  about  with  the  intermediation  of  a  friction  redux  or  not ;  or  adhe- 
sions may  form  between  the  heart  and  the  sac,  embarrassing  its  movements 
permanently,  and  producing  retraction  of  the  chest-waU  with  systole.  On 
the  other  hand,  necropsj^  has  often  revealed  close  adhesions  between  the 
heart  and  the  pericardium  which  were  not  suspected  during  life.  Permanent 
roughening,  represented  by  the  "sheep's  tongue"  surface  or  other  roughen- 


ADHESIVE  PERICARDITIS  561 

ing  or  adhesions,  ma}^  produce  permanent  friction  sound,  and  the  pericarditis 
is  chronic. 

Secondary  Physical  Signs  in  the  Lungs. — The  enlarged  distended  peri- 
cardium protruding  upward  toward  the  left  clavicle  may  produce  there 
Skodaic>  resonance  to  percussion  in  the  adjacent  lung  by  indirect  relaxation, 
or  it  may  compress  the  lung  producing  dull  percussion.  More  frequently 
the  lower  lobe  is  encroached  upon,  sometimes  completely  emptied  of  air, 
whence  the  percussion  note  over  the  lung  in  the  lower  axilla  and  about  the 
angle  of  the  scapula  may  be  Skodaic  or  even  dull  if  the  lung  is  completely 
emptied  of  air.  Correspondinglj'  the  breathing  sounds  may  be  feeble, 
broncho-vesicular  and  rarely  bronchial,  and  there  may  be  egophony. 
These  sounds  are  not  to  be  confounded  with  those  due  to  a  possible  asso- 
ciated pleuritic  effusion  which  gives  diminished  or  absent  tactile  fremitus  as 
contrasted  with  increased  fremitus  of  the  compressed  lung.  Attention 
was  called  to  these  sjinptoms  as  far  back  as  1857  by  Bamberger'  whence 
they  are  known  as  Bamberger's  sign,  though  the  names  of  Ewart  and  San- 
som  have  also  become  associated  with  his.  The  normal  state  of  the  lung 
may  be  in  part  restored  by  changing  the  position  of  the  patient,  causing  him 
to  lean  forward,  to  lie  on  his  right  side,  or  assume  the  knee-elbow  position. 
To  this  attention  was  especially  called  by  Pins. 

Ewart  has  also  called  attention  to  an  area  of  dullness  below  the  ninth  rib, 
on  the  left  side  between  the  spine  and  a  line  dra-mi  through  the  posterior 
edge  of  the  scapula,  and  to  a  less  degree  to  the  right  of  the  spine.  In  this 
area  known  as  " Ewart 's  posterior  pericardial  patch  of  dullness"  the  res- 
piratory sounds  are  also  absent  and  the  voice  sovmds  are  feeble.  He  as- 
cribes this  sign  to  an  altered  dorsal  relation  of  the  liver  due  to  pressure  of  the 
pericardial  effusion.  Ewart  has  also  called  attention  to  what  he  calls  the 
"first  rib  sign,"  also  recognized  by  palpation.  The  upper  edge  of  the  first 
rib  may  be  followed  round  by  the  finger  tip  because  the  cla\T.cle  is  apparently 
raised  above  its  normal  position  by  the  effusion  which  must  of  covirse  be 
large. 

Physical  Signs  of  Chronic  Adhesive  Pericarditis  or  Adherent  Pericardium. 
— These  differ  materially.  They  are  most  easily  studied  in  children,  in 
whom  the  condition  is  especially  apt  to  occvu"  after  rheumatism.  Their 
study  is  further  facilitated  by  dividing  the  condition  into  two  groups : 

1.  Simple  adhesion  of  the  pericardial  and  epicardial  layers.  These  are 
the  cases  more  frequently  overlooked,  sometimes  giving  rise  to  no  sjonptoms 
and  first  found  at  necrops}'.  There  may,  however,  be  friction  and  creaking 
sounds  with  indistinct  apex  beat  on  the  one  hand,  or  retraction  of  the  chest- 
waU  below  described. 

2.  Adherent  pericardium,  with  chronic  mediastinitis  and  fusion  of  the 
outer  layer  of  the  pericardium  with  the  pleura  and  to  the  chest-walls,  a  serious 
form,  leading  to  marked  hypertrophy  and  dilatation,  especially  in  children. 
To  inspection  and  palpation  the  precordiun  is  bulging,  the  impulse  is  more 
diffuse,  extending  sometimes  from  the  third  to  the  sixth  interspace,  and  from 
the  right  parasternal  line  to  outside  the  left  nipple.  The  apex  may  be 
displaced  in  various  degrees  from  its  natural  site ;  it  may  be  to  the  right  of  its 
normal  position  and  above  it  or  down  toward  the  epigastrium.     It  is  some- 

'  "Lehrbuch  der  Krankheiten  des  Herzens,"  von  H.  Bamberger,  Wien,  1857. 


562  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

times  multiple,  or  spreads  in  a  wave-like  manner  over  the  area  named.  At 
other  times  the  systole  is  associated  with  a  tugging  retraction  of  the  chest-wall, 
which  is  especially  evident  in  thin  persons  and  is  regarded  by  some  as  the 
most  valuable  sign  of  adhesion  of  the  pericardium.  It  is  most  frequently 
noted  between  the  seventh  and  eighth  ribs  in  the  left  parasternal  line.  This 
may  be  followed  by  a  rapid  rebound  of  the  chest-wall,  known  as  the  diastolic 
shock.  It  may  be  associated  with  a  coincident  collapse — the  diastolic 
collapse  of  the  cervical  veins,  due  to  a  sudden  emptying  of  these  vessels 
consequent  on  the  expansion  of  the  chest-wall,  a  sign  first  described  by 
Friedreich. 

Broadbent's  diaphragm  sign  has  attracted  much  attention — a  systolic 
tug  which  is  communicated  through  the  adherent  diaphragm  to  its  points 
of  attachment,  especially  on  the  left  side  behind,  between  the  eleventh  and 
twelfth  ribs.  It  is  distinct  and  apart  from  the  tugging  in  the  left  parasternal 
line,  between  the  seventh  and  eighth  ribs,  to  which  attention  had  been  pre- 
viously called.  Furthermore,  owing  to  the  attachment  of  the  pericardium 
to  the  central  tendon  of  the  diaphragm  this  muscle  does  not  descend  with 
inspiration,  and  consequently  the  usually  visible  movement  of  the  epigastrium 
during  this  act  does  not  take  place. 

It  is  in-  adhesive  pericarditis,  too,  that  we  sometimes  have  the  pulsus 
paradoxus,  referred  to  on  page  559.  First,  Griesinger,  and  later  Kussmaul, 
called  attention  to  it  as  a  constant  symptom  of  cicatricial  mediastinitis, 
due  to  the  dragging  of  the  cicatricial  tissue  on  the  great  vessels  during 
inspiration.  It  happens,  too,  when  the  ^reat  vessels,  already  compressed 
by  the  exudate,  are  further  encroached  upon  by  the  expanding  lung,  making 
the  ptdse  smaller  and  more  frequent.  This  is  more  frequently  demonstrable 
by  the  sphj'gmograph,  but  in  extreme  cases  may  be  appreciated  by  the 
finger.  It  is  not  a  pathognomonic  sign  of  either  event,  but  if  associated 
with  an  inspiratory  distention  of  the  cervical  veins,  it  points  strongly  to 
adhesive  pericarditis. 

To  percussion  there  is  usually  a  large  increase  in  the  normal  area  of  car- 
diac dullness,  commonly  upward  and  to  the  left,  sometimes  as  high  as  the 
first  interspace.  Adherent  pericarditis  may  give  rise  to  extremely  large 
hearts.  Often  the  pericardium  is  adherent  to  the  adjacent  pleura,  in 
which  event  the  area  of  cardiac  dullness  is  not  influenced  by  deep  breathing, 
a  sign  pointed  out  by  C.  J.  B.  Williams  as  of  great  value  in  diagnosis. 

Auscultation  may  be  entirely  negative,  or  there  may  be  a  modification 
of  the  usual  friction  sound  which  closely  resembles  the  creaking  of  leather. 
A  galloping  or  fetal  rhythm  may  be  present,  or  there  may  be  a  loud  systolic 
murmur  at  the  apex  due  to  relative  insufficiency  which  has  often  given  rise 
to  the  erroneous  diagnosis  of  mitral  valve  disease.  Endocardial  disease 
may,  however,  coexist,  especially  in  children. 

The  possible  association  of  chronic  adhesive  pericarditis  and  medias- 
tinitis with  proliferating  peritonitis,  perihepatitis,  and  splenitis  should  be 
remembered.  Rarely  ascitis  may  be  one  of  the  earl 3^  signs  of  this  condition 
and  lead  to  the  mistaken  diagnosis  of  cirrhosis  of  the  liver.  This  condition 
has  been  described  as  multiple  serositis. 

Diagnosis. — In  all  cases  of  acute  articular  rheumatism  the  heart  should 
be  frequently  examined,  because  pericarditis  often  supervenes  with  feebly 


ADHESIVE  PERICARDITIS  5G3 

pronounced  subjective  symptoms.  At  the  outset  the  distinction  is  to  be 
made  between  pericarditis  and  acute  endocarditis,  which  as  frequently  suc- 
ceeds rheumatism  with  subjective  symptoms  no  more  distinctive.  There 
is  usually  not  much  difficulty  in  acute  cases.  The  to-and-fro  rhythm, 
heard  directly  under  the  ear,  usually  most  distinct  over  the  center  of  the 
heart,  and  the  absence  of  sounds  transmitted  in  accordance  with  the  laws  of 
transmission  of  the  valvular  abnormal  sounds,  are  distinctive  features  of 
the  cardiac  friction.  If,  however,  one  of  the  to-and-fro  elements  is  wanting, 
the  difficulty  is  greater  and  errors  do  occur.  Close  study  must  be  made  as 
to  transmission.  It  is  further  characteristic  of  the  friction  sound  that  it 
is  increased  in  loudness  by  pressing  the  chest-wall  with  the  stethoscope, 
while  this  is  not  the  case  in  endocardial  murmurs.  Such  pressure  is,  how- 
ever, often  painful  to  the  patient.  In  chronic  valvular  defects  there  are 
changes  in  the  size  and  position  of  the  heart  which  are  not  present  in  the 
first  stage  of  acute  pericarditis.  When  both  acute  endocarditis  and  peri- 
carditis are  present,  the  difficulty  is  greatly  increased  and  one  or  the  other 
condition  is  likely  to  be  overlooked. 

The  "  pleuropericardial "  friction  sound  or  "  extrapericardial "  friction 
sound  is  to  be  distinguished  from  pericardial  friction  sound.  It  is  a  soimd 
similar  in  rhythm  to  the  pericardial  sound,  but  the  primary  condition  of  its 
causation  is  a  pleuritis  involving  the  opposed  surface  of  the  mediastino- 
costal  sinus  of  the  left  side.  It  is  more  commonly  heard,  therefore,  over  the 
left  border  of  the  heart.  It  is  the  combined  product  of  the  respiratory 
and  cardiac  action,  being  usually  louder  during  expiration.  It  generally 
ceases  during  a  deep  inspiration,  because  at  this  time  the  cardiac  action 
cannot  produce  the  required  rubbing.  On  the  other  hand,  this  is  some- 
times the  very  condition  under  which  the  friction  sound  is  loudest.  Simply 
holding  the  breath  may  also  stop  it,  though  not  necessarily,  because  the 
heart  motion  produces  it.  This  influence  of  the  breathing  one  way  or  the 
other  is,  however,  of  importance  in  diagnosis,  while  other  symptoms  must 
also  be  taken  into  consideration.  Thus,  if  it  be  a  pleurisy,  the  pleural 
friction  sound  is  probably  heard  elsewhere,  and  there  are  the  other  symp- 
toms of  a  pleurisy  present,  while  those  of  a  pericarditis  are  absent.  Unlike 
the  true  pericardial  friction  sound  the  pleuropericardial  friction  sound  is 
uninfluenced  by  bending  the  body  forward,  but  is  heard  with  equal  dis- 
tinctness with  the  body  in  any  position.  Difficulties  again  increase  when  it 
is  associated,  as  it  sometimes  is  in  a  pleuropneumonia,  with  endocarditis. 
It  also  occurs  in  tuberculosis,  where  it  is  sometimes  associated  with  a 
systolic  click  due  to  the  simultaneous  expulsion  of  a  bubble  of  air  from  a 
portion  of  softened  lung. 

For  diagnosis  between  pericarditis  with  effusion  and  dilatation  of  the 
heart  see  page  604.  It  is  in  this  differential  diagnosis  particularly  that 
Rotch's  sign  and  the  difference  as  determined  by  percussion  of  the  car- 
diohepatic  angle  become  valuable.  It  must  be  remembered,  however, 
that  Rotch's  sign  is  not  always  present,  even  when  there  is  considerable 
effusion.  The  possibility  of  a  circumscribed  pleuritic  effusion  must  also 
not  be  overlooked.  Bamberger's  sign — Skodaic  resonance  and  dullness  in 
the  lower  axilla  and  region  of  the  angle  of  the  left  scapula — should  be  sought ; 
also  Ewart's  posterior  pericardial  patch. 


564  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

Prognosis. — The  course  of  pericarditis  varies  with  different  cases.  In 
an  ordinary  uncompHcated  case  passing  to  recovery,  the  duration  is  one  to 
three  weeks,  even  when  there  is  considerable  eflusion,  which  is  often  ab- 
sorbed with  surprising  rapidity.  In  other  cases,  especially  in  cachectic 
subjects,  the  duration  is  longer.  Relapses  occur.  When  adhesion  results, 
convalescence  is  greatly  prolonged,  and  in  the  majority  of  cases  the  heart 
is  permanently  crippled.  On  the  other  hand,  extensive  adhesions  are  some- 
times found  at  necropsy  where  no  lesion  was  suspected.  The  pyo-peri- 
cardial  cases  are  usually  fatal. 

Treatment. — Prompt  treatment  is  of  the  greatest  importance  in  peri- 
carditis. Rest  is  an  absolutely  essential  condition.  Measures  to  relieve 
pain  are  indicated.  Nothing  is  so  satisfactory  as  moderate  doses  of  morphin 
administered  hypodermically,  associated  with  atropin  in  the  proportion 
of  1/150  grain  (0.00044  gm-)  of  the  latter  to  1/4  grain  (0.0165  gm.)  of  the 
former.  Cold  applications  to  the  pericardium  by  Leiter's  coil  or  the  ice-bag 
are  sometimes  useful.  At  other  times  hot  applications  are  more  comforting. 
Blisters  of  i  to  2  inches  in  diameter  may  be  useful  in  the  stage  of  effusion. 

Digitalis  may  be  used  when  one  is  certain  that  the  strength  of  the  heart 
muscle  is  failing.  It  should  not  be  used  as  a  routine  measure.  The  aro- 
matic spirit  of  ammonia  is  indicated.  Strychnin  is  a  valuable  heart  tonic. 
Liquid  food,  including  milk  and  broths,  should  be  adhered  to  until  con- 
valescence is  established.     Eggs  may,  however,  be  early  allowed. 

If  the  effusion  is  very  large,  tapping  the  pericardium  may  be  necessary 
to  relieve  the  patient,  although  practically  the  relief  which  first  follows  a 
successful  operation  is  rarely  followed  by  complete  recovery.  The  aid  of 
the  surgeon  should  be  secured  if  possible,  but  if  not,  puncture  may  be 
made  in  the  fourth  interspace,  an  inch  (2.5  cm.)  to  the  left  of  the  edge  of  the 
sternum.  If  made  in  the  fifth  interspace,  the  puncture  should  be  made 
a  little  further  out — say  i  1/2  inches  (3.5  cm.).  A  safe  point  which  may  be 
used  in  large  effusions  is  the  left  xiphocostal  angle,  at  which  the  needle 
shoidd  be  pushed  upward  and  backward.  Still  another  site  is  the  left  fifth 
interspace  between  the  apex  impulse  and  the  outer  margin  of  dullness. 
When  the  pericardial  fluid  is  pus,  a  simple  tapping  is  insufficient.  Free 
incision  should  be  made,  and  free  drainage  should  be  established  ^\ath 
aseptic  precautions.  John  B.  Roberts'  collected  35  cases  of  suppurative 
pericarditis  treated  by  incision,  of  which  15  recovered  and  20  died.  It  is 
not  impossible  that  if  operation  were  done  earlier,  better  results  would 
follow. 

The  treatment  of  chronic  adhesive  pericarditis  is  mainly  symptomatic, 
and  when  a  condition  of  dilatation  arises  is  that  of  dilatation  of  the  heart 
from  any  other  reason. 

OTHER  PERICARDIAL  AFFECTIONS. 

Other  affections  of  the  pericardium  are  hydropericardium,  hemoperi- 
cardium,  pneumopericardium,  and  tuberculous  pericarditis,  rarely  morbid 
growths. 

Hydropericardium. — This  term  is  applied  to  a  large  accumulation 

1  "American  Journal  of  the  Medical  Sciences,"  December,  1897. 


ACUTE  ENDOCARDITIS  565 

of  serous  fluid  in  the  pericardium.  In  health  the  pericardium  is  simply 
lubricated  by  this  fluid.  It  occurs  sometimes  as  a  part  of  a  general  dropsy, 
most  frequently  cardiac  dropsy,  more  rarely  in  renal  dropsy.  The  accumu- 
lation is  seldom  large  in  these  cases.  It  is  not  common,  but  is  suflSciently 
so  to  demand  frequent  examination  of  the  heart,  as  it  is  often  overlooked. 
Its  signs  are  the  same  as  those  of  the  inflammatory  effusion. 

Hemopericardium,  or  blood  in  the  pericardium,  occurs  only  as  a  result 
of  rupture  of  an  aneurysm  in  the  first  part  of  the  aorta  into  the  pericardial 
sac,  from  rupture  of  the  heart  itself  or  a  wound  of  the  heart.  It  is  rapidly 
followed  by  shock  and  death.  The  physical  signs  are  those  of  effusion. 
It  may  also  be  caused  by  tuberculosis  of  the  pericardium.  Cancer  of  the 
pericardium  may  be  associated  with  blood  effusion. 

Pneumopericardium  is  a  rare  condition  in  which  gas  is  present  in  the 
pericardial  sac.  It  is  analogous  to  the  much  more  common  one  of  pneu- 
mothorax. As  in  pneumothorax,  the  presence  of  air  implies  also  the 
presence  of  liquid  and  that,  usually,  pus.  It  is  produced  by  similar  causes, 
such  as  perforation  into  an  air-containing  space  like  the  lungs  or  esophagus. 
Such  perforation  is  usually  traumatic.  Decomposition  of  pericardial  exu- 
date or  morbid  growth,  it  is  said,  may  also  produce  it. 

Symptoms. — Its  symptoms  are  pain  and  pericardial  embarrassment, 
but  the  phj'sical  signs  are  most  distinctive,  especially  those  of  auscultation. 
To  inspection  there  is  prominence  of  the  precordium,  with  indistinctness  or 
obliteration  of  apex-beat,  restored  by  the  patient's  bending  forward.  Per- 
cussion furnishes  dullness  over  the  lower  portion  of  the  cardiac  area  and 
tympany  above  it,  the  position  of  both  being  altered  by  change  in  position 
of  the  body.  To  auscultation  the  heart-sounds  assume  a  striking  metallic 
character,  being '  audible  even  at  a  distance  from  the  bodj^.  A  similar 
metallic  character  is  given  even  to  a  friction  sound,  if  it  is  present,  as  it 
often  is. 

Diagnosis. — The  diagnosis  of  this  condition  requires  differentiation 
from  the  effect  of  an  air-dilated  stomach  on  the  heart-sounds,  or  rarely  of  a 
phthisical  cavity  or  pneumothorax.  All  doubt  in  the  case  of  the  stomach  is 
removed  by  filling  it  with  water.  The  associated  symptoms  of  the  other 
conditions  make  a  mistake  unlikely. 

Treatment  is  scarcely  available,  except  in  case  of  external  injury,  when 
operation  may  be  of  service. 

Tuberculous  Pericarditis  presents  nothing  peculiar  in  its  symptoms 
or  signs  as  already  described. 

Morbid  Growths  of  the  Pericardium  are  rarely  diagnosticated  before 
death. 

DISEASES  OF  THE  ENDOCARDIUM. 

ACUTE  ENDOCARDITIS. 

Synonym. — Valvulitis. 

Definition. — Endocarditis  in  both  its  acute  and  chronic  forms  is  an 
inflammation  for  the  most  part  confined  to  the  valves ;  for  such  inflammation, 
therefore,  valvulitis  is  a  more  correct  term.     The  lining  of  the  cavity  of 


566  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

the  heart  is,  however,  sometimes  affected  in  acute  endocarditis,  especially 
in  the  more  severe  cases,  when  it  is  known  as  mural  endocarditis.  It  is 
usually  in  the  apex  of  the  left  ventricle  that  such  inflammation  occurs. 
It  is,  in  reality,  only  a  complication  of  some  infectious  disease. 

There  is,  however,  a  great  difference  in  the  severity  of  different  cases 
of  acute  endocarditis,  and  the  disease  varies  from  those  in  which  recovery 
almost  always  takes  place  up  to  a  certain  point,  leaving  often  a  degree  of 
valvular  defect  known  as  chronic  endocarditis,  to  those  which  are  fatal. 
It  is  impossible,  however,  in  the  beginning  to  definitely  state  when  a  case 
will  be  mild  and  when  severe. 

In  attempting  to  explain  why  at  one  time  the  simple  form  and  at  another 
the  virulent  form  of  endocarditis  arises,  it  may  be  stated  that  the  toxins 
generated  by  the  less  virulent  bacteria  maj'  pave  the  way  for  the  operation  of 
the  virulent  streptococcus  and  staphylococcus  pyogenes,  the  pneumococcus, 
the  gonococcus,  and  other  organisms  which  are  found  in  the  morbid  products 
of  malignant  endocarditis.  It  is  not  unreasonable  to  suppose  that  the 
former  produce  the  simple  form  of  endocarditis,  while  the  cooperation 
of  the  septic  bacteria  named  is  necessary  to  produce  the  malignant  variety. 
On  the  other  hand,  it  may  be  not  so  much  the  specific  organism  as  the 
constitutional  or  local  peculiarities  of  the  individual  on  whom  the  disease 
is  engrafted — the  nature  of  the  soil,  as  it  were. 

Etiology. — Almost  any  one  of  the  recognized  infectious  diseases  may 
become  a  cause  of  simple  endocarditis.  Acute  articular  rheumatism  is, 
however,  the  most  frequent  cause,  about  30  per  cent,  of  all  cases  being 
ascribed  to  it.  After  this  comes  chorea.  Indeed,  William  Osier,  who  has 
made  the  subject  a  special  study,  says:  There  is  no  disease  in  which,  at 
necropsy,  acute  endocarditis  has  been  so  frequently  found,  ^''egetations 
were  found  on  the  valves  in  62  out  of  73  fatal  cases  of  chorea  collected  by 
him,  chorea  probably  being  a  form  of  rheumatism.  The  complications 
may  accompany  a  very  mild  form  of  rheumatism,  the  "growing  pains"  of 
the  laity.  Tonsillitis,  gonorrhea,  scarlet  fever,  pneumonia  and  tuberculo- 
sis, are  not  infrequent  predisposing  causes;  less  frequently  are  diphtheria, 
erysipelas,  smallpox,  and  typhoid  fever.  Endocarditis  also  supervenes  as 
a  complication  of  Bright's  disease.  Even  in  these  cases  bacteria  are  found 
in  the  vegetations.  Cachectic  states,  such  as  are  caused  by  tuberculosis 
and  cancer,  also  seem  to  favor  the  development  of  acute  endocarditis. 
Finally,  chronic  valvtilitis  is  a  predisposing  condition  of  both  mild  and 
severe  forms  of  endocarditis,  whence  the  term  "recurring"  endocarditis. 
This  latter  form  has  been  fairly  well  proven  to  be  due  to  a  special 
organism. 

Morbid  Anatomy. — The  left  side  of  the  heart  is  more  frequently  involved, 
and^lin  this  the  mitral  leaflets  first,  in  at  least  half  of  aU  cases;  next  the 
aortic  cusps;  then,  in  the  right  heart,  the  tricuspid  valve,  and  finally  the  pul- 
monary valve.  In  embryonic  life,  in  which  acute  endocarditis  also  occurs, 
the  right  side  of  the  heart  and  the  tricuspid  valve  are  most  frequently  affected, 
accounting  thus  for  certain  congenital  valvular  defects. 

The  type  of  the  morbid  change  on  the  \'alves  in  simple  endocarditis  is  so 
constantly  a  product  warty  or  fimgous  in  appearance  that  the  term  warty 
or  verrucose  endocarditis  is  often  applied  to  this  form.     On  the  auricular  sur- 


ACUTE  ENDOCARDITIS  567 

face  of  the  mitral,  and  the  ventricular  surface  of  the  aortic  valves,  at  the  line 
of  their  contact  during  closure — i.  e.,  1/25  to  1/12  inch  (i  to  2  mm.)  back  of 
the  valve  edge — granular  and  warty  excrescences  make  their  appearance. 
These  rise  1/12  to  1/8  inch  (2  to  3  mm.)  above  the  surface  and  extend  a 
variable  extend  along  the  valve.  They  soon  become  capped  with  fibrin, 
often  abundantly,  and  thus  a  vegetation  is  formed.  The  vegetation  begins 
in  a  proliferation  of  the  cells  of  the  adventitia  and  of  the  connective  tissue  of 
the  external  laminae  of  the  endocardium.  Thus  formed,  it  is  a  friable  prod- 
uct, liable  to  be  broken  off  at  any  time  and  carried  into  the  general  circu- 
lation to  a  point  of  lodgment,  where  it  plays  the  role  of  an  embolus.  In 
point  of  fact,  this  accident  does  not  often  happen  in  the  simple  acute  endo- 
carditis succeeding  febrile  diseases.  It  occurs  more  frequently  in  the  acute 
endocarditis  engrafted  on  chronic  valvular  disease,  and  in  the  malignant 
form.  More  frequently  the  vegetation  undergoes  organization  and  con- 
traction, and  the  valve  is  restored  partially  to  its  natural  condition,  leaving 
a  simple  sclerotic  thickening,  which  is  especially  prone  to  become  the  start- 
ing-point of  new  processes.  Unless  there  has  been  previous  valvular  disease, 
or  unless  a  myocarditis  accompanies  the  condition,  there  is  no  enlargement 
of  the  heart  in  the  beginning  of  acute  endocarditis.  In  the  severe  and 
malignant  forms  the  vegetations  vary  in  size  from  that  of  a  pin's  head  to 
that  of  a  pea,  and  are  reddish-yellow  in  color.  The  seat  of  this  vegetation 
becomes  rapidly  necrotic  and  breaks  down  into  an  ulcer  which  may  perforate 
the  valve,  mth  or  without  previous  protrusion — the  so-called  valvular 
aneurysm. 

Symptoms. — These  are  often  masked  by  those  of  the  previous  disease, 
and  sometimes  overlooked,  the  autopsy  first  disclosing  the  lesion.  There 
is  frequently  noticed,  however,  greater  or  less  embarrassment  of  breathing, 
orthopnea  being  not  infrequent;  the  pulse  is  much  more  rapid  and  vciay  be 
irregular,  the  patient  is  restless,  the  countenance  dusky,  while  the  temperature 
is  a  degree  or  two  higher  than  normal.  Altogether,  it  is  plain  that  he  is  sicker. 
Yet  there  is  rarely  actual  pain,  as  in  pericarditis.  Leukocytosis  is  present. 
A  blood  culture  will  frequentl}^  show  the  infecting  organism  in  the  blood 
stream.     Fever  and  leucj'tosis  may  be  the  first  to  attract  attention. 

Physical  Signs. — As  already  stated,  in  the  first  attack  of  endocarditis 
there  is  no  notable  enlargement  of  the  cardiac  area  as  determined  by  per- 
cussion or  inspection  of  the  seat  of  apex-beat.  Auscultation  may  recognize 
a  murmur,  the  situation  varying  with  the  valve  involved.  If  the  mitral, 
a  murmur  is  heard  in  this  area,  usually  systolic,  soft,  and  blowing,  at  times 
quite  harsh.  Very  rarely  is  there  a  presystolic  murmur,  though  its  more 
frequent  occurrence  might  be  expected  from  the  nature  and  situation  of  the 
lesions  described.  When  the  lesion  is  at  the  aortic  orifice,  the  murmur  is 
heard  in  the  aortic  area  at  the  second  interspace  at  the  right  edge  of  the  ster- 
num. It  is  usually  also  systolic,  but  may  be  diastolic.  But  not  every 
aortic  murmur  heard  in  acute  endocarditis  is  due  to  a  valvular  lesion,  as  the 
condition  of  the  blood  predisposes  to  a  hemic  murmur.  Basic  murmurs  also 
occur  in  the  pulmonary  area  to  the  left  of  the  sternum,  which  are  functional 
in  nature. 

.  Nor  is  a  systolic  murmur  in  the  mitral  area  always  due  to  organic  change 
in  the  valves  because  the  state  of  the  muscle  predisposes  to  imperfect 


568  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

closure  of  the  auriculovcntricular  orifice.  Mitral  regurgitation  may  also 
occur  in  rheumatism  and  in  other  acute  febrile  diseases  from  myocardial 
changes,  as  the  result  of  which  the  basal  part  of  the  cardiac  muscle  is  enfeebled 
and  unable  to  do  its  part  of  the  work  of  closing  the  mitral  orifice,  and  the  valve 
leaflets  are  insufficient  to  complete  it.  Some  of  the  cases  of  murmur  which 
disappear  with  recovery  may  belong  to  this  category.  The  same  excres- 
cences which  form  on  the  valve  leaflets  may  also  attach  to  the  papillary 
muscles  and  chorda  tendinecE  as  well.  It  is  characteristic  of  endocardial  mur- 
murs to  come  and  go.  In  the  severe  forms  there  are  chills,  followed  by  fever 
and  sweats.  In  this  form,  particularly,  the  resemblance  to  intermittent  fever 
seems  at  first  close,  but  a  careful  study  of  the  temperature  chart  from  day  to 
day,  and,  above  all,  the  leucocytosis  show  that  the  malarial  disease  is  not 
present.  The  absence  of  the  Plasmodium  malarioe  serv'es,  however,  to  dis- 
tinguish it  from  malarial  disease. 

It  always  greatly  aids  the  diagnosis  when  to  chills  and  fever  are  added 
other  symptoms  suggesting  embolism,  which  so  frequently  occurs.  The 
occurrence  of  a  hemiplegia,  pain  in  the  region  of  the  spleen,  with  increased 
dullness  on  percussion,  pain  in  the  region  of  the  kidney  with  hematuria,  or 
a  sudden  blotch  in  the  skin,  of  the  kind  described,  is  of  inestimable  value. 
Unfortunately  for  diagnosis,  thege  symptoms  are  not  often  present.  Rarer 
symptoms  of  similar  origin  are  impaired  vision  from  retinal  hemorrhage, 
parotitis,  and  abscess  of  the  parotid  gland.  The  symptoms  are  not  always  so 
pointed  as  detailed,  while  they  may  include  others  not  mentioned.  The 
fever  may  not  be  so  high,  but  it  is  always  present;  again,  it  maj-  not  be 
remittent,  but  continuous.  There  may  be  jaundice,  precordial  oppression, 
shortness  of  breath,  while  heart  symptoms  may  be  altogether  absent,  when  it 
is  almost  impossible  to  distinguish  the  disease  from  a  septic  fever  of  the 
ordinary  kind.  The  pulse  and  respirations  are  invariably  accelerated. 
Extreme  embarrassment  of  breathing  is  very  characteristic.  Albuminuria 
and  casts  occur  in  all  forms,  either  as  the  result  of  acute  nephritis  or  of 
renal  embolism. 

A  further  study  of  the  symptoms  of  malignant  endocarditis  permits 
their  classifications  into  three  groups,  known  as  the  septic  or  pyemic,  the 
typhoid,  and  the  cerebral. 

The  septic  type  occurs  in  connection  with  such  septic  processes  as 
external  wounds,  the  puerperal  process,  or  acute  bone  disease  with  necrosis. 
The  symptoms  added  are  rigor,  irregular  fever,  sweats,  and  exhaustion. 
Yet  these  are  only  the  sj-mptoms  characteristic  of  pyemia.  In  fact,  it  is  a 
pyemia;  and  the  term  arterial  pyemia,  suggested  by  Wilks,  is  a  good  one, 
because  the  pyemic  abscesses  result  from  emboli,  starting  in  the  left  heart 
and  lodging  in  arteries.  The  endocarditis  constitutes  the  distinctive 
feature  of  the  disease.  The  resemblance  to  intermittent  fever  here  exists 
also,  and  a  quotidian  or  double  tertian  type  may  be  simulated. 

The  symptoms  of  the  typhoid  type  are  even  more  characteristic.  We 
meet  here,  too,  the  same  prostration,  irregular  temperature,  and  sweating; 
rigor  is  less  frequent,  and  the  onset  is  more  gradual.  There  are  delirium, 
drowsiness,  often  diarrhea,  with  distention  of  the  abdomen  and  tenderness 
in  the  right  iliac  region,  to  which  a  rash  may  also  be  added,  which,  though 
not  identical  with  that  of  typhoid  fever,  is,  nevertheless,  similar  to  it.     The 


ACUTE  ENDOCARDITIS 


569 


tongue  is  dry  and  brown,  and  sordes  collects  about  the  teeth.  The  tempera- 
ture is  remittent,  Hkethat  of  typhoid,  reaching  103°  to  104°  F.  (39.4°  to  40° 
C.)  and  even  higher.  Here  again  the  heart  symptoms  may  be  overlooked. 
Still  another  group  is  the  cerebral,  in  which  the  symptoms  simulate  men- 
ingitis, basilar  or  cerebrospinal,  with  acute  delirium  as  the  distinctive 
feature. 


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II 

Fig.  112. — Temperature  Chart,  Malignant  Endocarditis. 


Diagnosis. — This  is  based  almost  entirely  on  the  physical  signs,  as  no 
one  of  the  symptoms  is  pathognomonic.  Nor  are  the  murmurs  always 
to  be  relied  upon,  for  the  reasons  assigned. 

The  distinction  of  the  endocardial  from  the  pericardial  murmur  was 
considered  in  treating  of  pericarditis.  The  more  superficial  situation  of  the 
latter  over  the  body  of  the  heart,  its  to-and-fro  rhythm,  not  connected  with 
the  heart-sounds,  its  failure  to  follow  the  usual  laws  of  conduction,  and  the 
fact  that  it  is  made  more  pronounced  by  pressure — all  serve  to  distingtaishit. 
A.  E.  Sansom  calls  attention  to  a  possible  source  of  error  in  a  pericardial 
roughening  at  or  about  the  apex,  especially  in  children,  which  causes  a  sys- 


570  DISEASES  OE  HEART  AND  BLOOD-VESSELS 

tolic  apical  murmur.  This  should  be  remembered  as  a  possible,  but  rare, 
occurrence.     In  the  malignant  forms  this  is  difficult. 

Prognosis. — The  subject  of  the  simple  form  of  acute  endocarditis  rarely 
dies,  but  he  is  likely  to  recover  with  a  damaged  heart — in  other  words, 
chronic  valvular  disease  results,  while  the  severer  forms  are  rapidly  fatal. 
This  is  not,  however,  always  the  case,  for  complete  recovery  is  not  impos- 
sible. On  the  other  hand,  some  of  the  instances  of  complete  recovery  after 
mitral  regurgitant  murmur  belong  doubtless  to  the  category  described  of 
insufficiency  due  to  myocardial  defect  without  mitral  lesion.  It  should  not 
be  concluded,  however,  that  because  a  murmur  has  disappeared  the  patient 
has  certainly  recovered,  since  a  murmur  due  to  myocarditis  may  be  succeeded 
by  another  true  valvular  murmur.  Finally,  one  acute  attack  from  which 
recovery  has  taken  place  is  liable  to  be  succeeded  by  another  and  another,  so 
that,  sooner  or  later,  chronic  valvular  defects  are  produced. 

Treatment. — The  keynote  of  the  proper  treatment  of  acute  endocarditis 
is  absolute  quiet  rest  in  bed.  It  is  not  often  that  much  else  is  required. 
Ice  applied  over  the  heart  often  is  of  value.  Digitalis  is  not  indicated 
unless  there  is  distinct  dilatation  with  decomyjensation,  when  the  dose 
should  be  moderate — only  enough  to  steady  the  heart.  Dy,spnea  is  best 
treated  by  sufficientdoses  of  opium  or  morphin,  which  should  not  be  put  off 
too  long.  The  diet  should  be  easily  assimilable  and  liquid  until  convales- 
cence is  established.     Salicylates  are  probably  of  value. 

The  Severe  or  Malignant  Form  of  Acute  Endocarditis. 
Synonyms. — Ulcerative,    Infectious,    Mycotitic,    or  Diphtheric  Endocarditis. 

Diagnosis. — This  is  not  always  easy  at  first.  A  few  days'  study  of  the 
temperature,  with  its  extreme  fluctuations,  the  rigors,  and  the  supervening 
sweats,  should  at  once  lead  to  suspicion,  and  these,  if  continued,  point 
to  this  disease.  If  one  would  always  remember  the  possibility  of  the 
occurrence  of  malignant  endocarditis  in  connection  with  the  diseases  named, 
it  woidd  be  less  frequently  overlooked.  The  fever  is  a  septic  one  in  all 
cases,  the  heart  symptoms  adding  the  peculiarity.  In  true  typhoid  fever 
there  is  always  splenic  enlargement  and  often  parotitis,  so  that  the  presence 
of  these  symptoms  naturally  suggests  that  disease,  and  an  erroneous  diag- 
nosis is  not  inexcusable.  It  is  said  that  splenic  enlargement  is  not  so 
marked  as  in  typhoid  fever,  and  that  there  is  commonlj^  more  tenderness  in 
ulcerative  endocarditis.  This  may  be  true  in  some  cases,  and  not  in  others. 
At  the  present  day  the  Widal  test  should,  of  course,  be  made  in  all  doubt- 
ful cases  of  fever  and  may  afford  important  assistance  in  diagnosis.  The 
blood  culture  furnishes  the  most  conclusive  evidence  of  the  presence  of  the 
disease. 

Rheumatic  fever  often  more  closely  resembles  malignant  endocarditis, 
with  its  high,  irregular  fever,  and  copious  sweats,  while  confusion  is  further 
contributed  to  by  the  fact  that  endocarditis  is  one  of  the  most  frequent 
complications  of  rheumatism,  the  malignant  form  being,  however,  more  in- 
frequent than  the  simple.  But  recurring  rigors  are  not  usual  in  rheumatism. 
The  joint  symptoms  of  rheumatism  are  conspicuous  at  an  early  stage  of  the 
disease;  there  is  no  enlargement  of  the  spleen,  nor  symptom  ascribable  to 


CHRONIC  VALVULAR  DISEASE  571 

embolism,  unless  secondary  to  endocarditis.  The  essential  identity  of 
ordinary  pyemia  and  malignant  endocarditis  has  been  mentioned,  and  only 
the  endocarditis  and  its  consequences  distinguish  the  disease  from  ordinarj'- 
septic  fever.     The  presence  of  leukocytosis  in  endocarditis. 

It  must  not  be  forgotten  that  the  simple  and  severe  forms  are  not  sepa- 
rated by  any  sharp  line. 

CHRONIC  VALVULAR  DEFECTS. 

Synonyms. — Chronic    Endocarditis;    Chronic    Valvular    Disease. 

Definition. — Permanent  alterations  in  the  structures  about  the  cardiac 
orifices,  producing  incompetency,  narrowing,  or  other  deviations  from  the 
normal . 

Etiology. — The  majority  of  chronic  valvular  defects  are  the  consequence 
of  endocarditis,  acute  or  chronic.  It  may  be  that  the  very  first  attack  of 
acute  inflammation  has  left  the  valve  leaflets  in  so  sclerotic  a  condition 
that  they  readily  become  the  seat  of  the  subsequent  changes  which  consti- 
tute the  chronic  disease,  or  it  may  be  that  several  attacks  are  necessary 
before  a  permanent  effect  is  produced.  On  the  other  hand,  we  must 
acknowledge,  too,  a  chronic  valvulitis,  in  which  valvular  defect  is  brought 
about  gradually  without  the  intervention  of  acute  inflammation.  This 
process  is  analogous  to  chronic  endarteritis,  consisting  in  hj^perplasia  with 
fatty  (atheromatous)  and  calcareous  degeneration  of  the  new  tissue.  In 
fact,  a  chronic  endarteritis  may  spread  from  the  aorta  to  the  aortic  valves. 
These  slowly  induced  inflammations  are  variously  caused.  The  rheumatic 
poison  may  cause  them,  as  it  does  the  acute  forms.  Alcoholic  indiilgence 
and  intemperate  eating,  whether  by  the  direct  irritation  of  the  substances 
taken  into  the  blood  or  through  the  poison  of  gout  engendered  by  them, 
are  frequent  causes.  Another  cause  is  prolonged  muscular  strain,  producing 
overtension  of  the  valve  leaflets.  This  operates  in  laborers  who  do  much 
heav^"  lifting,  and  sometimes  in  athletes.  Especially  potent  is  it  when, 
as  is  often  the  case,  hard  muscular  work  is  associated  with  overeating  and 
drinking.  To  these,  syphilis  also  often  contributes.  Under  all  of  these 
latter  circumstances  it  is  the  aortic  cusps  which  suffer  most. 

Morbid  Anatomy. — The  anatomical  condition  of  the  defective  valves 
is  made  up  of  five  separate  factors,  each  of  which  may  enter  more  or  less 
into  the  lesion.  This  is  true  both  of  the  auriculo-ventricular  and  semi- 
lunar valves.     These  conditions  are: 

(i)  Thickening.  (2)  Retraction.  (3)  Adhesion.  (4)  Atheroma,  either 
alone  or  associated  with  calcification.     (5)   Calcification. 

1 .  Thickening  is  the  immediate  restalt  of  an  overgrowth  of  connective 
tissue.  The  slighter  degrees  are  seen  along  the  bases  of  the  aortic  cusps 
and  at  the  line  of  contact  in  closure  of  the  mitral  leaflets.  Such  degrees 
do  not  necessarily  impair  the  function  of  the  valves.  More  advanced 
stages  produce  a  distinct  thickening  and  sclerosis  of  the  whole  of  each 
aortic  cusp  and  mitral  leaflet. 

2.  Retraction  or  curling  is  the  result  of  shrinkage  of  this  hyperplastic 
tissue.     The  three  aortic  cusps  are  often  reefed  back  and  fixed,  although 


572  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

the  very  edge  of  the  valve  may  still  remain  movable.  In  the  case  of  the 
mitral  valve,  the  tendinous  attachments  of  the  papillary  muscles  often 
contract  and  draw  the  valves  into  the  left  ventricle,  producing  a  permanent 
funnel-like  extension  analogous  to  that  which  takes  place  in  physiological 
closure  of  the  mitral  orifice. 

3.  Adhesions  unite  the  valve  leaflets,  increasing  their  immobility  and 
rigidity,  interfering  with  complete  opening  and  closure.  The  right  and 
posterior  aortic  cusps  are  most  frequently  tmited.  Most  serious  is  the 
effect  of  union  of  the  mitral  leaflets,  which  sometimes  results  in  a  reduction 
of  the  orifice  to  a  mere  slit  or  buttonhole-like  opening — the  buttonhole 
mitral  orifice. 

4.  Atheroma,  or  fatty  degeneration,  is  also  often  found  in  the  shape  of 
yellow  spots  on  the  surface  of  the  valves  and  at  the  marginal  attachments  of 
the  aortic  cusp,  without  producing  insufficiency. 

5.  Calcification  or  limy  infiltration  of  the  valves  thus  united  may  succeed 
in  various  degrees,  producing  in  extreme  cases  firm,  calcareous  rings  which 
further  diminish  the  mobility  of  the  valves.  In  less  degrees  there  are 
splinter-like  projections  into  the  substance  of  the  valve  which  also  interfere 
with  complete  closure  and  opening;  at  other  times  there  may  be  simple 
marginal  deposits  which  impede  the  function  of  the  valves  only  slightly 
or  not  at  all. 

Still  another  form  of  lesion  found  at  necropsy  is  riipture  of  a  leaflet,  the 
result  of  strain.  This  is  perhaps  not  possible  with  a  sound  valve,  while  one 
weakened  by  the  morbid  states  described  may  give  way.  The  physiological 
result  is  insufficiency,  while  the  lumen  of  the  orifice  during  sj^stole  is  not 
encroached  upon.  Such  an  accident  is  not  infrequent  in  acute  ulcerative 
endocarditis  in  consequence  of  erosion  and  partial  destruction  of  the  valve. 

Congenital  defects  are  relatively  common  in  the  right  side  of  the  heart, 
which  is  the  subject  also  of  inflammation  during  intra-uterine  life.  The 
changes  resulting  from  the  latter  are  of  the  nature  of  fusions.  Such  defects 
also  occur  on  the  left  side ;  most  rarely  in  the  mitral  valve. 

The  term  relative  insufficiency  is  applied  when  a  valve  is  insufficient  or 
incompetent  because  of  dilatation  of  the  ventricular  cavities  or  vessels 
which  it  guards.     (See  below.) 

Mitral  Insufficiency  or  Incompetency. 

Occurrence  and  Mechanism. — This  is  the  most  frequent  of  the  uncom- 
bined  forms  of  valvular  disease.  The  valve  leaks.  The  blood  flows  back- 
ward during  systole  from  the  left  ventricle  to  the  left  auricle.  The  dis- 
tended avuicle,  first  attempting  to  resist  the  backward  flow,  hypertrophies 
but  eventually  dilates,  and  the  blood  is  crowded  backward  into  the  lungs, 
which  become  engorged.  The  right  ventricle,  in  its  efforts  to  push  the  blood 
through  the  engorged  lungs,  hj'pertrophies,  and  the  pulmonary'  factor  of  the 
second  sound  becomes  louder  and  sharpl}^  accentuated.  The  compensating 
effect  of  the  hypertrophied  right  ventricle  for  a  time  arrests  the  mischief. 
At  this  stage,  perhaps,  begins  the  hypertrophy  of  the  left  ventricle,  wliich  in 
all  cases  of  mitral  insufficiency  presents  itself  sooner  or  later,  although  at 
first  the  double  outlet  for  the  blood  from  the  ventricle  would  seem  to  demand 


MITRAL  INSUFFICIENCY  573 

less  strength  of  the  left  ventricle.  The  right  ventricle,  however,-  in  its 
hypertrophied  state,  delivers  more  blood  through  the  lungs  to  the  left 
ventricle,  which  demands  more  power  to  drive  it  on,  hypertrophy  results, 
and  thus  compensation  is  for  a  time  longer  maintained.  Sooner  or  later  the 
right  ventricle  dilates,  the  tricuspid  valve  becomes  insufficient,  the  blood 
regurgitates  into  the  right  auricle  and  thence  into  the  great  veins  of  the  neck. 
The  valves  of  these  ultimately  yield,  the  jugular  vein  dilates  with  each 
systole  of  the  right  ventricle  producing  the  so-called  jugular  puJse  and  the 
general  venous  system  is  engorged. 

Incompetency  of  the  cardiac  valves  is  often  brought  about  by  dilatation 
of  the  ventricles  and  the  great  vessels  leading  from  the  heart,  the  valve 
leaflets  themselves  remaining  intact.  Such  relative  insufficiency  affects 
most  frequently  the  auriculo-ventricuJar  valves,  and,  as  a  consequence,  the 
latter  are  not  "sufficient"  to  stretch  across  their  respective  orifices  and 
close  them.  Less  commonly  the  semilunar  valves  are  similarly  deficient; 
more  frequently  the  aortic  in  dilatation  of  the  aorta ;  and  more  rarely  also  the 
pulmonary  valve  when  that  vessel  is  dilated. 

Etiology. —  Endocarditis,  acute  or  chronic,  is  the  most  frequent  initial 
cause  of  mitral  insufficiency. 

Symptoms. — Often  there  are  no  symptoms,  because  for  a  considerable 
length  of  time  compensation  keeps  pace  with  the  development  of  the  disease 
unless  the  latter  be  sudden,  as  by  rupture  of  a  valve  leaflet.  The  first 
thing  noticeable  is  usually  shortness  of  breath  on  exertion,  followed  by  severe 
attacks  of  dyspnea,  the  so-called  cardiac  asthma.  With  this  is  soon  associated 
palpitation,  or  "beating"  of  the  heart,  which  increases  and  abates  pari  passu 
with  the  dyspnea.  Next  is  irregularity  of  the  heart's  action.  This  is  the  be- 
ginning of  waning  compensation,  of  which  the  immediate  result  is  conges- 
tion of  the  lungs.  Dyspnea  is  now  permanent.  Thence  the  engorgement 
extends  to  the  right  ventricle  and  venous  side  of  the  circulation,  the  pressure 
in  the  arteries  being  proportionately  less.  The  lung  engorgement  invites 
frequent  attacks  of  bronchitis,  excites  cough  and  increases  dyspnea.  Or- 
thopnea is  frequent  at  this  stage,  and  the  patient  can  only  rest  sitting  in  a 
chair.  There  is  sometimes  blood-stained  expectoration,  in  which  may  be 
found  alveolar  epithelium  dotted  with  pigment  granules. 

Along  with  this,  or  before  it,  the  liver  becomes  congested,  enlarged,  and 
tender;  the  mucous  membrane  of  the  stomach  also  becomes  congested, 
causing  nausea  and  indigestion.  The  hepatic  enlargement  is  sometimes  very 
great,  and  it  has  been  mistaken  for  cancer  of  the  organ.  The  liver  is  often 
the  seat  of  pulsation,  and  as  often  a  jugular  pulse  is  seen.  Both  signs  are 
pathognomonic  of  tricuspid  regurgitation  usually  the  result  of  mitral 
regurgitation'.  Later,  this  enlarged  liver  may  return  to  its  normal  state 
or  contract  still  further,  constituting  the  so-called  red  atrophy.  Jaundice 
is  sometimes  present  due  to  compression  on  biliary  capillaries  by  engorged 
blood-vessels.  In  advanced  stages  the  kidneys  also  become  passively  con- 
gested, the  urine  is  scanty  and  its  specific  gravity  high,  while  there  are  copi- 
ous deposits  of  urates.  It  contains  a  small  quantity  of  albxunin  and  there 
may  be  hyaline  tube-casts,  rarely  even  a  few  blood-disks.  As  a  secondarj' 
result  of  hepatic  engorgement  only  there  may  also  be  enlargement  of  the 
spleen. 


574  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

Concurrent,  or  succeeding  on  failing  compensation,  comes  edema  or 
dropsy,  the  direct  result  of  venous  engorgement  and  the  filtration  of  the 
liquid  elements  of  the  blood  into  the  subcutaneous  connective  tissue  of  the 
body — first  of  the  feet  and  legs,  then  of  the  trunk,  face,  and  upper  extremi- 
ties, and,  finally,  into  the  pleural  and  peritoneal  cavities,  causing  various 
degrees  of  inconvenience.  Effusion  into  the  pleural  sacs  may  occur  before 
there  is  any  tendency  to  dropsy  elsewhere.  This  can  be  observed  by  care- 
ful and  repeated  examination  of  the  chest. 

Nose-bleed  is  a  s\Tnptom  sometimes  seen  in  this  disease.  It  is  a  natural 
result  of  the  venous  congestion.  Among  the  later  and  rarer  symptoms  in 
children  especially,  is  clubbing  of  the  finger-ends. 

Physical  Signs. — In  the  early  stage  before  compensation  is  broken  the 
systolic  murmur  may  be  the  only  physical  sign,  later  inspection  discovers 
increased  frequency  of  breathing  movements.  The  impulse  is  to  the  left  of 
its  normal  position  in  the  fifth  interspace,  or  perhaps  a  little  lower  down. 
It  may  be  in  the  line  of  the  nipple  or  even  beyond  it,  more  forcible  and  diffuse 
than  in  health.  The  outward  dislocation  of  the  apex  is  due  to  the  enlarge- 
ment of  the  two  ventricles.  In  thin  persons  an  auricular  impulse  may  be 
seen  to  the  left  of  the  ptilmonic  area  in  the  second  interspace,  and  may  be 
presystolic  and  active  for  the  auricle — that  is,  produced  when  the  auricle 
contracts;  or  systolic  and  passive  for  the  atuicle — that  is,  caused  by  a  filling 
of  the  auricle  by  regurgitation  from  the  ventricle  during  the  latter's  systole. 
In  young  persons  a  bulging  precordiimi  may  be  looked  for  in  the  second 
and  third  interspaces  to  the  left  of  the  sternum;  also  to  the  left  of  the  lower 
part  of  the  stemima  from  hypertrophy  of  the  right  ventricle.  In  advanced 
stages  there  is  a  jugular  pulse,  which  is  also  pathognomonic  of  tricuspid 
regurgitation.  The  jugular  pulse  must  be  distinguished  from  the  false 
jugular  pulse  which  occurs  when  the  venous  system  becomes  replete  with 
blood  from  any  cause  like  overexertion.  It  is  commonly  more  superficial. 
It  is  presystolic  in  time,  while  the  jugular  pulse  is  systolic.  Moreover,  the 
false  jugular  pulse  is  obliterated  by  pressure  on  the  vein  above  the  clavicle, 
while  the  true  jugular  remains  distinct  below  the  point  of  pressure.  The 
liver  may  pulsate  with  each  systole. 

On  palpation  the  apex-beat  is  found  more  forcible  than  normal,  at  least 
while  compensation  is  maintained,  and  there  may  be  a  pulsation  near  the 
ensiform  cartilage,  caused  by  the  systole  oj  the  enlarged  right  ventricle.  As 
compensation  wanes  the  impulse  becomes  weaker  and  irregular.  Some- 
times an  intermittent  systolic  thrill  is  felt  in  the  fourth  interspace  in  the  left 
mammillary  line.     Very  rarely  is  there  a  systolic  thrill  at  the  apex. 

The  radial  pulse  in  the  early  stage  is  comparatively  unaltered.  Later, 
it  becomes  frequent  and  irregidar  in  volume.  Appended  (Fig.  113)  is' a 
sphygmogram  of  the  pulse  in  advanced  mitral  insufficiency.  It  is  of  the 
type  of  the  pulsus  parvus  irregularis. 

Percussion  generally  finds  enlargement  of  both  the  relative  and  absolute 
areas  of  dullness,  upward  in  the  direction  of  the  left  auricle,  downward  to 
the  left  and  also  to  the  right,  the  right  border  of  the  heart  extending  at  times 
beyond  the  right  border  of  the  stemtun.  The  impaired  resonance  thus  pro- 
duced rather  by  the  right  auricle  than  by  the  ventricle  which  in  its  enlarge- 
ment pushes  the  auricle  to  the  right. 


MITRAL  STENOSIS  ?>lb 

Auscultation  recognizes  a  systolic  murmur  in  the  mitral  area,  conducted 
with  various  degrees  of  loudness  into  the  left  axilla  and  under  the  angle  of 
the  scapula.  This  direction  of  its  conduction  is  the  distinctive  feature  of  this 
murmur.  It  is  usually  soft,  but  occasionally  rough,  more  rarely  musical. 
Richard  C.  Cabot  says  that  musical  murmurs  are  heard  more  frequently 
at  the  mitral  valve  in  regurgitation  than  at  any  other  valve.  A  fading 
mitral  systolic  murmur  generally  means  further  failing  compensation,  and 
when  compensation  is  completely  gone  it  is  substituted  by  incomplete  valvu- 
lar sounds,  great  irregularity,  gallop  rhythm,  labored  breathing,  and  all  the 
signs  of  pulmonary  congestion.  The  mitral  systolic  murmur  is  also  some- 
times heard  distinctly  to  the  left  of  the  pulmonic  cartilage,  and  rarely  over 
the  entire  precordium.  Not  always  loud  enough  to  be  easily  heard,  it  may 
be  brought  out  by  exertion  on  the  part  of  the  patient. 


Fig.  113. — Tracing  of  Pulse  of  Mitral  Insufficiency. 

The  second  sound  of  the  heart  is  heard  sharply  accentuated  at  the  pul- 
monary area  until  the  tricuspid  valve  fails,  when  the  accentuation  fades 
away.  The  aortic  second  sound  is  less  strong,  corresponding  with  the 
smaller  degree  of  hypertrophy  of  the  left  ventricle. 

Differential  Diagnosis. — The  murmur  of  mitral  regurgitation  is  not 
usually  difficult  of  recognition  through  the  features  which  have  been  de- 
scribed. A  functional  murmur  is  rarely  heard  at  the  apex.  Should  it 
happen  that  it  is,  it  will  not  be  conducted  as  is  the  organic  mitral  systolic 
murmur,  and  it  is  not  heard  behind  and  below  the  angle  of  the  scapula. 
Aortic  roughening  produces  a  murmur  heard  at  the  same  time  as  the  mitral 
systolic,  and  may  also  be  propagated  to  the  apex,  but  the  position  of  greatest 
intensity  is  the  second  interspace  to  the  right  of  the  sternum  and  the  murmur 
is  transmitted  loudly  into  the  great  vessels  of  the  neck,  which  is  never  the 
case  with  the  mitral  systolic  murmur.  The  tricuspid  systolic  murmur 
occurs  at  the  same  time,  but  its  point  of  greatest  intensity  is  at  the  ensiform 
cartilage. 

R-IiTRAL  Stenosis. 

Occurrence  and  Mechanism. — This  lesion  occurs  as  an  uncombined  or 
simple  form  of  valvular  disease  in  young  persons,  especially  women,  but  is 
usually  combined  with  mitral  insufficiency.  Seventy-six  per  cent,  of  all 
cases  are  said  to  occur  in  the  female  sex.  In  the  simple  form  the  orifice 
is  stenosed,  and  the  blood  is  restrained  from  passing  freely  into  the  left  ven- 
tricle. It  is  backed  into  the  left  auricle,  the  lungs,  right  ventricle,  and 
general  venous  circulation,  but  the  left  ventricle  is  not  hypertrophied  in 
simple  mitral  obstruction  because  no  extra  muscular  demand  is  made  on  it, 
while  hypertrophy  of  the  left  auricle  is  one  of  its  most  characteristic  signs. 
Theoretically,  the  left  ventricle  should  even  atrophy  from  diminished 
function.     Practically  this  does  not  occur,  but  the  absence  of  the  enlarge- 


576  DISEASES  OF  HEART  A\D  BLOOD-VESSELS 

ment  is  of  great  diagnostic  value.  Excellent  compensation  is  often  main- 
tained in  mitral  stenosis  for  many  years. 

The  enlargement  and  dilatation  of  the  left  auricle  is  in  rare  instances 
enormous,  especially  in  the  form  known  as  horizontal  dilatation  which  has 
been  especially  studied  by  Owen,  Fenton  and  Ewart.'  The  enlargement 
with  corresponding  dullness  to  percussion  extends  both  to  the  left  and  right 
of  the  stemtun  and  the  auricle  has  been  tapped  under  the  impression  that 
it  was  a  circumscribed  collection  of  fluid  in  the  pleural  sac. 

Pure  stenosis  without  regurgitation  is  possible  if  the  mitral  valve  leaflets 
are  fused  without  retraction,  so  as  to  form  the  funnel-shaped  opening 
already  described.  In  these  cases  a  postmortem  demonstration  of  insuffi- 
ciency by  means  of  the  hydrostatic  test  is  scarcely  possible.  Less  fre- 
quently the  mitral  orifice  viewed  from  above  is  a  mere  slit — Corrigan's 
buttonhole  contraction — straight  or  slightly  crescentic,  in  a  smooth  septum 
formed  by  fusion  and  contraction  of  the  valve  leaflets  and  tendinous  cords. 
In  some  cases  calcareous  infiltration  is  added,  and  in  a  few  rare  instances 
deposits  of  urates  are  found.  The  ratio  of  buttonhole  mitral  stenosis  to 
the  funnel-shaped  orifice  varies  with  different  observers — i  to  lo  by  A. 
E.  Sansom,  i  to  13  by  Hayden,  i  to  46  by  Hilton  Fagge. 

Etiology. — Most  frequently  mitral  stenosis  is  the  result  of  endocarditis, 
acute  or  chronic,  but  it  may  in  rare  cases  be  congenital.  In  these  cases,  of 
which  a  number  have  been  collected  by  Bedford  Fenwick,  the  stenosis  is 
secondary  to  narrowing  of  the  tricuspid  orifice,  thus  explained: — a  small 
quantity  only  of  blood  being  allowed  to  pass  into  the  right  ventricle  and 
lungs,  a  diminished  supply  is  sent  to  the  left  heart,  whence  both  its  cavities 
and  orifices  are  reduced  in  size.  Attention  has  been  called  by  Teissier  to  the 
possible  origin  of  mitral  stenosis  in  tuberculosis  and  Robert  H.  Babcock  has 
reported  some  cases  which  tend  to  confirm  this  view.^  No  functional  dis- 
order can  cause  mitral  stenosis. 

Symptoms. — These,  often  delayed  by  compensation,  as  in  mitral  insuf- 
ficiency, are  the  same  as  in  that  lesion  though  palpitation  and  dyspnoea 
seem  to  be  more  prominent.  In  consequence  of  this  similaritj^  of  s^'mptoms 
the  diagnosis  of  mitral  stenosis  is  based  largely  on  the  physical  signs.  As 
in  mitral  insufficiency,  in  long  cases  and  especially  in  children,  clubbing 
of  the  finger-ends  may  be  present. 

Physical  Signs. — Mitral  stenosis  may  exist  for  many  years  without 
giving  rise  to  physical  signs  except  the  murmur.  Inspection  consistently 
with  what  would  be  expected  in  absence  of  hypertrophy  of  the  left  ventricle, 
recognizes  little  or  no  displacement  of  the  apex  in  pure  stenosis.  If  there 
is  any,  it  is  due  to  the  hypertrophy  of  the  right  ventricle  which  pushes  the 
apex  toward  the  left  rather  than  downward  and  to  the  left.  Nor  is  the  true 
apex-beat  increased  in  force,  though  there  may  be  strong  epigastric  pulsation 
because  of  hypertrophy  of  the  right  ventricle,  and  in  persons  with  thin 
chest-walls  there  may  be  an  impulse  in  the  third  and  fourth  interspaces,  to 
the  left  of  the  sterniim,  due  to  right-auricle  hypertrophy.     A  left  auricular 


'  Owen  and  Fenton,  "A  Case  of  Extreme  Dilatation  of  the  Left  Auricle  of  the  Heart,"  "  Clinical  Society's 
Transactions,"  vol.  xxxiv.,  ipox,  p.  183. 

Ewart  and  Owen.  "A  Case  Illustrating  some  of  the  Clinical  Features  of  Horizontal  Dilatation  of  the 
Left  Auricle."  "Ibid.,"  vol.  xxxiv..  1902,  p.  142. 

Owen.  "Horizontal  Dilatation  of  the  Left  Auricle,"  "Ibid.,"  p.  147. 

-  Diseases  of  Heart  and  Arterial  System.  1903,  p.  252. 


MITRAL  STENOSIS  577 

impulse,  presystolic,  may  be  noted  in  the  second  interspace  to  the  left  of 
the  stemvun,  for  the  same  reason  as  in  mitral  regurgitation.  A  jugular 
pulse  may  also  be  present  if  there  is  tricuspid  regurgitation.  A  bulging 
precordium  is  possible  only  from  great  enlargement  of  the  right  ventricle 
and  is  not  often  seen.  In  children  the  lower  sternum  and  fifth  and  sixth 
left  costal  cartilages  may  be  prominent  from  this  cause.  There  may  be 
prominence  of  the  right  upper  quadrant  of  the  abdomen  from  enlarge- 
ment of  the  liver. 

Palpation  shows  that  the  apex-beat  is  without  undue  force,  but  it  may 
be  diffuse,  and  an  impulse  may  be  felt  in  the  epigastrium,  the  situation  of 
the  apex  of  the  right  ventricle.  The  most  marked  feature  recognized  by 
palpation  is  the  presystolic  thrill  at  the  apex,  differing  in  this  respect  from 
the  rare  systolic  thrill  of  mitral  insufficiency.  It  is  usually  best  felt  in  the 
fourth  or  fifth  interspace,  within  the  nipple-line.  It  is  similar  in  rhythm  to 
the  presystolic  murmur,  but  may  be  present  wdthout  it.  It  is  often  absent. 
It  is  pathognomonic  of  mitral  stenosis.  Palpation  may  recognize  tenderness 
in  the  region  of  the  liver. 

In  moderate  degrees  of  stenosis  the  pulse  is  not  altered;  in  high  degrees 
it  is  small,  from  want  of  blood  and  left  ventricular  power.  Irregularity, 
like  that  of  mitral  regurgitation,  is  characteristic  of  advanced  stages.  Two 
tracings  from  cases  of  mitral  stenosis  are  introduced  in  the  text. 

Percussion  recognizes  cardiac  enlargement  in  the  direction  of  the  left 
auricle  and  right  ventricle,  but  not  of  the  left  ventricle  in  pure  mitral 
stenosis,  that  is,  the  area  of  cardiac  dullness  extends  to  the  right  of  the  ster- 
num, and  upward  often  to  the  top  of  the  second  rib. 

Auscultation. — The  most  characteristic  auscultatory-  sign  is  the  pistol- 
like first  sound,  short,  sharp  and  loud.-  A  murmur  does  not  occur  in  every 
case  of  mitral  stpnosis  because  of  the  feebleness  of  the  auricular  contraction, 
especially  toward  the  end  of  life,  when  compensation  has  failed  and  there 
is  not  the  force  of  contraction  sufficient  to  throw  the  blood  stream  into 
audible  vibration.  Most  characteristic  is  the  abruptly  terminating  pre- 
systolic murmur,  confined  for  the  most  part  to  the  mitral  area  to  the  inner 
side  of  the  apex-beat,  though  it  may  be  conveyed  upward,  and  it  is  even 
heard  posteriorly,  though  rarely. '  It  is  true  that  the  presystoUc  murmur 
is  heard  in  atypical  situations,  especially  in  the  axilla  and  below  the  angle  of 
the  scapula,  more  frequently  than  has  commonly  been  supposed.^ 

The  presystolic  tnurrnur  of  mitral  stenosis  is  a  diastolic  murmur  occur- 
ring at  the  end  of  diastole  of  the  ventricle,  because  it  is  at  this  time  that  the 
auricular  systole  takes  place,  giving  the  propulsive  force  necessary-  to  pro- 
duce the  audible  -^nbration.  It  is  a  loud,  rough,  \ibrator\-  murmur  termi- 
nating suddenly  with  the  first  sound,  sharp  and  ringing  and  coincident  with 
the  presvstolic  thrill.  The  murmur  terminates  with  the  impulse,  and  as 
the,  two  are  not  alwaj^s  easily  separable,  the  former  is  commonly  more 
readily  distinguished  by  its  qualities  than  by  its  time.  It  is  often  followed 
by  a  "sharp"  first  sound,  which,  in  consequence  of  this  character,  is 
sometimes  mistaken  for  a  second  sound.  As  the  disease  advances  the- 
presystolic  element  disappears  and  a  murmur  develops  which  may  occupy 


1  this  subject  by  J.  P.  C.  GrifEth  in  the  "Transactions  of  the 


578  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

the  entire  peroid  of  diastole.  In  such  cases  there  is  sometimes  a  short  pause 
between  the  beginning  or  diastolic  part  and  the  terminal  or  presystolic 
part  of  the  murmur.  In  the  last  stage  the  murmur  may  disappear  alto- 
gether ,  leaving  only  the  snapping  first  sound. 

Differential  Diagnosis. — The  murmur  of  mitral  stenosis  ought  not  to 
be  confounded  with  the  murmur  of  aortic  regurgitation,  for  the  latter  is 
heard  loudest  in  a  different  situation,  but  moreover  there  is  enormous 
hypertrophy  of  the  left  ventricle,  which  is  wanting  in  mitral  stenosis.  The 
time  of  tricuspid  stenosis  is  identical  with  that  of  mitral  stenosis,  but  it  is 
heard  in  a  different  part  of  the  precordium — in  the  epigastrium.  Tricuspid 
stenosis  is,  however,  a  very  rare  lesion.  Much  more  reasonably  might  the 
murmur  of  mitral  stenosis  be  confounded  with  the  so-called  Flint  murmur. 
This  murmur  is  heard  at  the  apex,  at  the  same  site  as  the  presystolic,  and 
may  be  similar  in  quality.     It  occurs  in  high  degrees  of  dilatation  of  the 


Fig.  115. — Tracing  of  Pulse  in  Mitral  Stenosis. 

ventricle,  occtirring  in  aortic  regurgitation,  and  is  due  to  the  fact,  according 
to  the  late  Austin  Flint,  St.,  that  in  such  dilatation  the  mitral  leaflets  cannot, 
during  diastole,  be  kept  back  against  the  ventricular  wall,  but  remain  in 
the  blood  current,  throwing  the  latter  into  audible  vibration.  It  may  be 
said  of  the  Flint  murmur  that  it  is  never  as  intense  as  mitral  presystolic 
murmur  and  that  it  never  occurs  except  in  the  presence  of  aortie  regurgi- 
tation. Otherwise  the  acoustic  qualities  are  similiar.  The  snapping  first 
sound  and  systolic  shock  are  also  apt  to  be  modified  or  absent.  Accentua- 
tion of  the  pulmonic  second  sound  is  wanting  in  marked  aortic  insufficiency, 
and  the  other  signs  of  aortic  regurgitation  are  most  hopeful  to  a  .diagnosis. 

A  rumbling  sound  succeeding  a  pericarditis  in  children,  referred  to 
especially  by  Broadbent  and  Rosenbach,  has  occasioned  error,  but  this,  too, 
is  said  to  tmaccompanied  by  accentuation  of  the  first  sound  at  the  apex. 
It  is  a  transient  murmur  often  followed  by  recovery. 

These  sources  of  error  are  well  illustrated  by  observations  of  Phear,' 
who  investigated  46  cases  of  presystolic  murmur  in  which  no  mitral  lesion 
was  found  at  autopsy.  In  17  of  these  there  was  aortic  regurgitation;  in  20 
there  was  adherent  pericardium;  in  nine  nothing  more  than  dilatation  of 
the  left  ventricle  was  found.  In  none  was  the  snapping  first  sound,  so 
common  in  mitral  stenosis,  recorded  during  life. 

Very  frequently  the  presystolic  murmur  is  associated  with  a  mitral 
systolic  or  regurgitant  murmur,  usually  soft  and  not  very  loud,  though 
sometimes  it  is  distinct  and' is  well  transmitted  into  the  axilla. 

Accentuation  of  the  second  sound  is  marked,  but  confined  to  the  pul- 
monary area,  because  there  is  no  hypertrophy  of  the  left  ventricle.     The 

1  "Lancet,"  September  21,  1S95, 


MITRAL  INSUFFICIENCY  AND  STENOSIS  579 

second  sound  may  also  be  duplicated,  because  of  the  lack  of  synchrony  in 
the  closure  of  the  aortic  and  the  pulmonary  valves.  A.  E.  Sansom  regards 
this  reduplication  as  only  a  seeming  one  of  the  second  sound.  He  regards  it 
rather  as  the  normal  second  sound  followed  by  another  soixnd  due  to  a  sud- 
den tension  of  the  mitral  valve  itself.  He  also  says  it  occurs  in  at  least  one- 
third  of  all  cases  of  mitral  stenosis,  and  is  rare  in  other  cardiac  conditions. 
The  accentuation  of  the  pulmonary  second  sound  also  disappears  with  the 
enfeebling  of  the  contraction  of  the  right  ventricle. 

The  pulse  is  small,  as  would  be  expected  from  the  small  volume  of  blood 
ejected  from  the  ventricle,  but  may  be  quite  regular,  as  seen  in  the  sphygmo- 
grams.  More  frequently  it  is  irregular.  Sometimes  there  is  a  rhythmical 
failure  of  an  alternate  heart-beat  to  reach  the  wrist,  while  the  sphygmogram 
will  show  a  small  rise  between  two  higher  ones  constituting  the  pulsus 
bigeminus. 

On  account  of  the  difficulties  mentioned,  while  the  presystolic  murmur  is 
a  valuable  sign  of  mitral  stenosis,  it  should  not  be  alone  relied  upon  for 
diagnosis,  but  should  be  taken  in  connection  with  other  signs.  Tricuspid 
stenosis  may  be  associated  with  mitral  stenosis  or  insufficiency,  or  both. 
With  the  loss  of  compensation  the  presystolic  murmur  disappears  together 
with  the  thrill,  and  there  remains  only  the  sharp,  ringing  first  sound. 

In  slight  degrees  of  mitral  stenosis  the  second  sound  is  heard  at  the  apex, 
but  as  the  lesion  becomes  more  serious  it  becomes  fainter  and  eventually 
inaudible  in  this  situation,  though  markedly  accentuated  in  the  pulmonic 
area.  In  advanced  cases  of  mitral  stenosis  with  much  dilatation  of  the  right 
cardiac  cavities,  the  entire  anterior  surface  of  the  heart  may  be  made  up  of 
the  right  side  of  the  heart.  The  right  border  of  dullness  being  made  up  of 
the  border  of  the  right  auricle,  the  left  of  the  right  ventricle,  the  apex  of 
the  heart  being  right  ventricle.  In  the  secases  there  is  usually  a  loud  sys- 
tolic murmur  at  the  xyphoid  due  to  tricuspid  regiu-gitation. 

The  physical  signs  of  mitral  stenosis  are  more  changeable  and  fleeting 
than  those  of  any  other  valvular  disease  of  the  heart. 

Sansom  lays  great  stress  on  the  evidence  of  the  cardiograph  in  the  diag- 
nosis of  mitral  stenosis,  which  enables  one  to  judge  of  the  relative  length  of 
systole  and  diastole.  In  stenosis  the  diastole  may  be  greatly  prolonged, 
or  the  diastolic  intervals  vary  greatly  in  duration.  In  mitral  regurgitation, 
on  the  other  hand,  a  short  interval  only  separates  the  systoles. 

Complications. — Patients  with  mitral  stenosis  are  subject  to  attacks  of 
recurring  valvulitis,  with  consequent  embolism  in  different  parts  of  the  body. 
Embolism  is  a  frequent  complication  of  mitral  stenosis.  Pulmonary 
tuberculosis  is  found  more  often  in  association  with  mitral  stenosis  than 
any  other  form. 

Mitral  Insufficiency  and  Stenosis. 

Occurrence.— More  common  than  mitral  stenosis  as  an  un  combined  lesion 
is  stenosis  associated  with  insufficiency,  in  which  case  we  have  the  double 
mitral  murmur  of  mitral  insufficiency  and  mitral  stenosis,  sometimes 
with  difficulty  divisible  into  its  two  parts.  Extreme  irregularity  of  rhythm 
and  pulse,  with  frequency  and  smallness  of  the  latter,  conspicuous  thrill. 


580  DISEASES  OE  HEART  AXD  BLOOD-VESSELS 

marked  right-sided  hypertrophy,  and  sharply  accentuated  pulmonic  sound 
are  characteristic  of  advanced  stages.  The  presence  of  hypertrophy  of  the 
left  ventricle  points  to  associated  mitral  insufficiency  and  stenosis.  When 
this  combined  lesion  exists,  mitral  insufficiency  is  said  to  usually  precede. 

Aortic  Insufficiency  or  Inco.mpetency. 

Occurrence  and  Mechanism. — By  aortic  insufficiency  is  meant  an  in- 
ability of  the  aortic  valve  to  close  the  orifice  of  the  aorta.  This  is  the 
most  serious  of  the  valvular  diseases  of  the  heart  commonly  met.  Next 
in  frequency  to  mitral  incompetency,  much  more  frequent  than  aortic  steno- 
sis, with  which  it  more  often  coexists,  it  is  a  disease  of  men  rather  than 
women,  commonly  adults  at  or  before  middle  life.  It  includes  30  to  50  per 
cent,  of  all  cases  of  chronic  valvular  disease.  The  width  of  the  aortic  orifice 
increases  from  birth  to  old  age,  while  the  valve  cusps  tend  to  shrivel,  so  that 
conditions  favorable  to  incompetency  coexist.  It  is  more  frequently  asso- 
ciated with  arterial  sclerosis  and  less  frequently  the  result  of  rheumatic  en- 
docarditis, though  it  may  be  thus  caused.  It  is  the  lesion  most  frequently 
followed  by  sudden  death. 

When  it  exists,  the  aortic  valves  are  incompetent  to  close  the  aortic 
orifice,  either  on  account  of  the  large  size  of  the  latter  or  of  disease  of  the 


Fig.   iisa. — Tracings  of  Pulse  of  Aortic  Regurgitation. 


valve  segments,  and  the  blood  flows  backward  into  the  left  ventricle  during 
diastole.  The  ventricle,  seeking  to  restore  the  balance,  redoubles  its  energy 
and  hypertrophies.  The  blood  is  thus  driven  into  th»  aorta  with  great 
force,  distending  the  arteries  to  an  extreme  fullness,  which,  however,  falls 
promptly  away,  because  of  the  backward  flow  into  the  ventricle  at  the  same 
time  with  the  forward  movement  into  arteries  and  capillaries.  This  sudden 
falling  away  of  the  pulse,  from  extreme  distention  to  collapse,  is  verj^  char- 
acteristic of  this  form  of  valviolar  disease,  and  is  called  the  "trip-hammer" 
or  "water-hammer"  pulse,  also  Corrigan  pulse.  To  the  careful  observer  it 
may  even  be  visible  in  the  exposed  arteries,  such  as  the  corotid,  temporal, 
and  radial,  while  the  aortic  beat,  ordinarily  beyond  reach  in  the  suprasternal 
notch,  may  be  felt  in  this  situation. 

The  abrupt  jerking  impulse  vnth.  sudden  recoil  is  easily  recognized  by 
the  finger  on  the  pulse,  which,  however,  fails  to  find  the  pulse  as  strong  and 


AORTIC  INSUFFICIENCY  581 

hard  as  would  be  expected  from  its  appearance.  On  the  other  hand,  it  is 
soft  and  receding.  It  is  commonly  regular.  A  tracing  of  this  pulse  is  seen 
in  Fig.  1 1  sa.  It  is  the  typical  pulsus  celer  et  altus.  A  frequent  and  irregular 
pulse  is  much  more  serious  in  aortic  valve  disease  than  in  mitral  disease. 
Sclerotic  changes  in  the  arterial  walls  are  not  uncommonly  associated  with 
aortic  incompetency.  The  systolic  blood  pressure  is  relatively  high,  while 
the  third  phase  is  frequently  lost,  and  therefore  the  diastolic  pressure  cannot 
be  estimated. 

The  product  of  this  defect  is  the  largest  heart  met  in  morbid  anatomj', 
the  left  auricle  and  right  ventricle  often  sharing  in  the  enlargement.  From 
its  size  the  heart  is  called  the  boinne  heart.  It  may  weigh  as  much  as  35 
ounces  (1050  gm.),  and  even  50  ounces  (1500  gm.)  or  more.  The  cavities 
are  enlarged  and  the  walls  are  thickened,  so  that  it  furnishes  an  instance  of 
eccentric  hypertrophy.  There  may  be  ultimate  dilatation  of  the  arch  of 
the  aorta  from  the  constant  pounding  of  the  blood  against  it  in  systole, 
while  all  the  superficial  arteries  can  be  seen  and  pulsate  forcibly. 

The  gradual  enlargement  of  the  ventricle  may  ultimately  cause  the  mitral 
valve  to  yield.  Compensation  is  still  maintained  for  a  time  by  hypertrophy 
of  the  left  auricle,  which  also  yields  after  a  time,  becoming  dilated  and 
allowing  the  blood  to  engorge  the  lung.  Hypertrophy  of  the  right  ventricle 
then  comes  to  the  rescue  for  a  time.  Sooner  or  later  it,  too,  yields,  dilates, 
the  tricuspid  valve  weakens,  and  finally  gives  way,  allowing  the  blood  to  flow 
back  into  the  venous  side  of  the  circulation,  producing  engorgement  of  the 
liver,  stomach,  kidneys,  general  dropsy — the  train  of  symptoms  described 
under  mitral  regurgitation. 

Etiology. — Causes  of  insufficiencj^  in  addition  to  those  considered  under 
the  general  etiology  of  valvular  disease  are  congenital  malformations,  includ- 
ing fusion  of  two  leaflets,  commonly  those  behind  which  the  coronary  arter- 
ies come  off.  Such  fused  leaflets  are  especialh^  prone  to  vahoilitis  and  its 
consequences.  Aortic  insufficiency  is  quite  often  caused  by  dilatation  and 
aneurysm  of  the  ascending  aorta,  giving  rise  to  relative  insufficiency. 

Symptoms.— Like  all  other  forms  of  valvular  heart  disease,  aortic  in- 
competency may  be  compensated  for  a  long  time,  and  elude  detection  for  a 
corresponding  time.  Indeed,  full  compensation  is  said  by  some  to  be  most 
usual  in  this  form  of  valvular  disease.  Both  dropsy  and  dyspnea  are  char- 
acteristically absent  until  compensation  ceases,  which  is  also  the  case  until 
the  mitral  valve  begins  to  yield.  Then,  however,  both  appear  and  may  be 
very  distressing.  An  especially  frequent  symptom  is  dizziness  with  faint- 
ness,  particularly  on  rising  quickly.  Palpitation  ensues  on  sUght  exertion, 
and  this  effect  is  in  marked  contrast  to  the  comfort  of  the  patient  when  quiet, 
when  the  pulse  may  be  slow  and  breathing  regular.  In  advanced  cases,  on 
the  other  hand,  the  patient  complains  of  a  constant ' '  heating ' '  or  pulsation  all 
over  the  body,  especially  in  the  head,  which  is  exceedingly  unpleasant.  The 
patient  is  very  apt  to  be  troubled  in  his  sleep  and  to  dream,  probably  because 
of  disturbed  circulation  in  the  brain.  Even  permanent  mental  symptoms 
may  resxilt  from  this  cause,  including  insanity  and  suicidal  tendency.  Lesser 
degrees  are  irritability  and  peevishness,  though  these  are  not  confined  to  this 
form  of  heart  disease.  Precordial  pain,  present  also  in  stenosis,  is  frequent 
in  this  form  of  valvular  disease.     It  may  be  a  dull  ache  with  a  sense  of  con- 


582  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

striction  of  the  chest,  or  sharp  and  radiating  down  the  arms,  particularly  the 
left,  as  in  angina  pectoris,  which  condition  itself  is  also  common.  With  the 
^aelding  of  the  mitral  valve  and  loss  of  compensation  come  the  symptoms  of 
mitral  disease  already  described. 

As  previously  stated,  this  is  the  form  of  valvular  disease  in  which  sudden 
death  is  frequent.  It  has  overtaken  many  a  \'ictim  in  the  course  of  his 
daily  vocation  and  without  warning,  though  it  is  most  apt  to  be  induced  by 
some  slight  overexertion  or  mental  excitement.  The  cause  of  such  sudden 
death  is  probably  interruption  of  the  circvilation  in  the  coronan,^  arteries. 
This  may  be  brought  about  in  one  of  two  ways.  These  arteries  in  common 
with  others,  are  especially  disposed  to  endarteritis  with  resulting  sclerosis 
and  atheroma,  a  condition  which  constantly  invites  thrombosis  and  obstruc- 
tion to  the  circulation;  or  it  may  be  due  to  defective  circulation  in  these 
vessels,  caused  by  the  aortic  regurgitation,  for  even  if  the  blood  enters 
the  coronary  arteries  during  systole,  it  must  still  receive  in  health  some 
further  supply  in  the  recoil  of  the  blood  on  the  closed  semilunar  valves, 
which  cannot  take  place  when  the  valves  are  incompetent.  On  this  variety 
of  valvular  disease,  too,  supervenes  not  infrequently  acute  infectious  endo- 
carditis of  the  grave  type,  with  the  train  of  symptoms  and  the  sequels 
described.     Embolism  in  various  organs  is  also  a  complication. 

Physical  Signs. — Inspection  often  discerns  the  prominent  left  precor- 
dium,  with  the  apex-beat  lowered  and  to  the  left,  and  the  visible  pulsation 
far  beyond  the  normal  situation  of  the  apex,  all  confirmed  by  palpation.  The 
apex  beat  frequently  being  in  the  sixth  interspace  outside  the  midclavicular 
line.  Palpation  also  recognizes  at  times  a  diastolic  thrill  over  the  base,  in  the 
carotids  and  subclavians,  and  sometimes  in  the  aorta  at  the  suprasternal  notch . 
This  is,  however,  much  rarer  in  aortic  regurgitation  than  the  systolic  thrill  in 
stenosis.  The  Corrigan  pulse  may  also  be  felt,  either  with  the  finger  on  the 
pulse  or  by  grasping  the  wrist  with  the  entire  hand,  the  palmar  surface  of  the 
wrist  touching  the  pam  of  the  hand,  but  is  much  more  strikingly  mani- 
fested in  the  sphygmogram.  A  capillary  pulse  is  also  sometimes  demonstra- 
ble in  the  skin  and  mucous  membrane.  This  may  be  observed  by  drawing 
a  pencil  lightly  across  the  skin  of  the  cheek  or  forehead;  and  on  the  mucous 
membrane  of  the  everted  lower  lip  by  pressing  a  glass  microscope-slide  against 
it.  It  may  often  be  well  studied  around  the  base  of  the  finger-nail.  Pul- 
sation in  the  retinal  arteries  may  be  recognized  by  the  ophthalmoscope. 
Pulsation  may  even  be  seen  in  the  u\aila  as  originally  pointed  out  by  F. 
Miiller  in    1889. 

Percussion  discloses  increased  dullness  to  the  left  and  downward,  and 
also,  sometimes  in  advanced  cases,  upward  to  the  left  of  the  sternum,  owing 
to  hypertrophy  of  the  left  auricle,  as  well  as  to  the  enlargement  of  the  ven- 
tricle upward. 

Auscultation  recognizes  a  diastolic  murmur,  long,  loud,  and  blowing  in 
quality,  usually  harsher  than  the  aortic  obstructive  murmur,  though  it  is 
also  often  soft  and  faintly  heard.  It  may  or  may  not  replace  the  second 
sound  of  the  heart.  It  is  commonly  well  heard  in  the  aortic  area,  but  its 
seat  of  maximum  intensity  maj'-  be  either  in  this  area,  in  the  third  interspace 
to  the  left  of  the  sternum,  or  at  the  midstemum  between  these  two  points. 
The  munnur  is  naturallv  transmitted  downward  toward  the  ensiform  car- 


A  OR  TIC  INS  UFFICIENC  V  583 

tilage  along  the  left  edge  of  the  sternum.  It  is  sometimes  also  well  conducted 
toward  the  apex  which  is  in  the  direction  of  the  regurgitating  column,  it  is 
conducted  in  the  direction  of  the  great  vessels  of  the  neck,  at  least.  In 
aortic  incompetency  also  occurs  the  Flint  murmur,  described  under  mitral 
stenosis.  This  murmur  is  additional  to  the  distinctive  diastolic  murmur 
being  produced  at  the  mitral  orifice  (see  p.  580).  The  aortic  regurgitant 
murmur  is  probably  the  most  widely  conducted  of  all  cardiac  murmurs.  Over 
the  femoral  vessels  may  be  heard  a  short,  sharp  systolic  sound,  the  pistol- 
shot  sound. 

Differential  Diagnosis. — The  aortic  diastolic  murmur  is  distinguished  from 
the  pulmonic  diastolic  murmur  by  its  wide  conduction,  the  hypertrophy 
of  the  left  ventricle,  the  Corrigan  pulse,  and  the  capillary  pulse.  The 
tricuspid  presystolic  murmur  is  a  diastolic  mtirmur,  heard  in  the  same 
situations  but  it  is  a  rare  murmur  and  is  unaccompanied  by  hypertrophy  of 
the  left  ventricle.  Diastolic  murmurs  without  lesions  of  the  aortic  or  pul- 
monary valves  due  to  relative  insufficiency,  to  hemic  conditions  or  cardio- 
respiratory murmurs^  must  b°  distinguished  as  the  murmur  of  aneurism. 

Auscttltation  of  the  vessels  furnishes  interesting  information  in  aortic 
insufficiency.  It  is  well  known  that  if  the  stethoscope  be  placed  with  slight 
pressure  over  the  carotid  artery  of  a  healthy  person,  two  sounds  are  usually 
audible,  corresponding  to  the  expansion  and  contraction  of  the  artery.  Of 
these  the  latter  is  simply  the  second  aortic  sound  heard  in  the  carotid, 
is  probable  also  that  the  first  arterial  sound  corresponding  with  the  arterial 
expansion  is  produced  by  vibrations  of  the  arterial  wall  induced  by  the 
blood  driven  into  it  from  the  ventricle.  The  second  arterial  sound  is  greatly 
diminished  in  intensity  or  even  absent  in  aortic  incompetency,  since  the 
valve  remains  open.  The  aortic  diastolic  murmur  is  sometimes  faintly 
heard  in  the  carotid.  In  aortic  regurgitation  there  is  Traube's  double  sound, 
in  the  distant  arteries,  especially  the  femoral  and  popliteal.  The  sounds 
are  such  that  the  two  follow  each  other  closely,  so  that  the  first  seems  pre- 
paratory to  the  second,  or  they  are  separated  by  a  longer  interval,  like  the  two 
sounds  of  the  heart.  The  first  is  a  sharp  systolic  (pistol-shot)  sound  and  is 
ascribed  to  a  sudden  filling  of  the  unusually  empty  artery,  and  is  probably 
an  exaggeration  of  the  sound  heard  in  health,  as  above  described.  Traube 
explained  the  first  of  his  sounds  in  this  way,  while  he  ascribed  the  second  to 
a  sudden  relaxation  of  this  tension.  Friedreich  pointed  out  that  a  similar 
double  sound  could  be  heard  in  the  femoral  vein  in  tricuspid  insiifficiency, 
which  he  ascribed  to  tension  of  the  valves  of  the  vein.  It  is  claimed  that 
the  double  sound  is  heard  in  other  diseases  of  the  heart,  especially  mitral 
stenosis,  and  even  in  aneurysm,  but  it  is  acknowledged  to  be  most  frequent 
in  aortic  incompetency. 

Finally,  there  is  Duroziez's  sign,  a  murmur  produced  light  by  pressure  with 
the  stethoscope  upon  the  femoral  artery.  Dtiroziez's  sign  will  be  more 
easily  understood  when  it  is  remembered  that  a  murmur  may  be  produced 
by  pressure  with  the  stethoscope  on  any  artery  of  the  caliber  of  the  carotid 
— a  murmur  during  the  expansion  or  diastole  of  the  artery.  During  the 
coUapse  or  systole  of  the  artery,  on  the  other  hand,  no  murmur  can  be  thus 

1  See  a  ijaper  by  Richard  C.  Cabot  and  Edwin  A.  Locke  on  "The  Occurrence  of  Diastolic  Murmurs 
without  Lesions  of  the  Aortic  or  Pulmonary  Valves."  "Johns  Hopkins  Hospital  Bulletin,"  vol.  xiv.,  May, 
1903- 


584  DISEASES  OF  HEART  A.\D  BLOOD-VESSELS 

produced  in  health.  In  aortic  rej^urgitation,  however,  it  is  different,  a 
double  murmtu-  may  be  produced  and  it  is  the  second  murmur  which  is 
essential  to  Duroziez's  sign.  It  is  said  that  this  sign  dies  out  as  compensa- 
tion fails.  T.  CHfford  Allbutt  does  not  consider  Duroziez's  sign  peculiar 
to  aortic  regurgitation,  though  Vierordt  says  it  is.  A  right  degree  of  pres- 
sure, to  be  determined  by  practice,  is  necessary,  and  the  artery  on  which  it 
is  obtained  is  usually  the  femoral. 

The  gravity  of  aortic  regurgitation  is  measured  by  the  degree  of  hyper- 
trophy of  the  left  ventricle,  by  the  irregularity  of  its  action,  a  symptom 
which  appears  only  in  advanced  stages  of  regurgitation,  the  extent  of 
collapse  of  the  artery  in  diastole,  the  degree  in  which  the  diastolic  murmur 
replaces  the  second  sound  as  heard  at  the  aortic  orifice.  Irregularity  of 
cardiac  action  is  a  much  more  serious  symptom  in  aortic  regurgitation  than 
in  mitral  disease.  Diminution  in  the  loudness  of  the  diastolic  murmur  is  a 
serious  sign. 

Aortic  Stenosis  and  RorcHENiNG. 

Occurrence  and  Mechanism. — By  aortic  stenosis  is  meant  a  narrowing 
of  the  aortic  orifice.  Pure  and  uncomplicated  aortic  stenosis  is  probably  the 
rarest  of  the  valvular  lesions.  Writers  have  been  led  into  error  because  the 
presence  of  an  aortic  systolic  murmur  has  been  interpreted  as  meaning 
stenosis,  where  it  has  been  produced  by  simple  roughening  of  the  valves  or 
of  the  vessel  beyond  them.  Richard  C.  Cabot  says  that  out  of  2  50  autopsies 
made  at  the  Massachusetts  General  Hospital,  there  was  not  one  of  uncompli- 
cated aortic  stenosis.  Indeed  it  is  difficult  to  conceive  an  aortic  stenosis  un- 
accompanied by  insufficiency,  although  it  is  easy  to  conceive  of  insufficiency 
without  stenosis.  Stenosis  is  said  to  be  relative  when  there  is  a  normal 
orifice  while  the  aorta  is  dilated  beyond  it.  It  occiars  in  older  persons, 
and  the  older  the  person,  the  more  likely  are  there  to  be  calcareous  deposits 
cau.sing  it.  It  may  be  congenital.  When  uncombined  with  insufficiency,  it 
is  the  least  dangerous  of  the  various  forms  of  valvular  disease.  The  nar- 
rowed orifice  prevents  the  free  discharge  of  blood  from  the  left  ventricle  into 
the  aorta.  The  ventricle  attempts  to  overcome  this,  and  its  walls  hyper- 
trophy in  proportion  to  the  degree  of  resistance,  and  often  for  a  long  time 
compensate  for  the  obstruction — until  dilatation  occurs,  when  the  danger 
really  begins.  The  hypertrophy  thus  induced,  usually  of  the  simple  form, 
is  only  second  in  degree  to  that  produced  by  incompetency. 

Symptoms. — The  symptoms  of  aortic  stenosis  may  be  long  deferred,  so 
long  as  compensation  is  maintained,  and  when  they  do  occur,  they  are 
usually  those  of  a  deficient  supply  of  blood  to  the  brain  and  heart  itself — 
viz.,  dizziness  and  fainting.  Succeeding  exertion  there  is  apt  to  be  a  sense 
of  constriction  or  oppression  and  even  pain  in  the  precordium,  which  may 
develop  into  the  severe  pain  of  a  true  angina  pectoris. 

Physical  Signs. — Inspection  and  palpation  recognize  usually  a  forcible 
impulse  outside  of  its  normal  site,  and  at  varying  distances,  in  accordance 
with  the  degree  of  hypertrophy.  Some  describe  the  apex-beat  as  without 
force  and  indistinct.  Broadbent  says  it  is  "a  well-defined  and  deliberate 
push  of  no  great  violence."  Palpation  often  recognizes  a  thrill  of  great  in- 
tensity with  each  beat  of  the  heart,  moro  marked  when  dilated  hypertrophy 


AORTIC  STENOSIS  585 

is  established.  A  bulging  of  the  precordium  may  also  be  present,  though 
less  often  than  in  incompetency. 

The  pulse  is  the  pulsus  parvus  et  tardus,  slow  in  reaching  its  maximum 
volume,  which  is  small.  It  is  frequent,  but  regular,  contrasting  in  the  latter 
respect  with  the  pulse  of  mitral  disease.  It  is  sometimes  infrequent,  pulsus 
rarus.     Fig.  58  is  a  sphygmogram  of  the  pulse  in  aortic  stenosis. 

Percussion  elicits  dullness  downward  and  laterally  toward  the  left, 
since,  as  a  rule,  the  enlargement  is  confined  to  the  left  ventricle.  There 
may,  however,  be  slight  enlargement  upward  to  the  left  of  the  sternum  if 
hypertrophy  of  the  left  auricle  is  added. 


Fig.  116. — Pulse-tracing  of  Aortic  Stenosis 


Auscultation  discloses  a  systolic  basic  mtirmur,  loudest  at  the  aortic 
area — second  interspace  at  the  right  of  the  sternum — conducted  distinctly 
into  the  carotids,  and  even  sometimes  along  the  course  of  the  aorta,  behind 
and  to  the  left  of  the  vertebral  column,  into  the  popliteals  and  dorsal  arteries 
of  the  feet.  It  is  not,  however,  confined  to  the  aortic  area,  but  may  be 
heard  over  the  entire  precorditmn.  It  is  usually  rough,  at  least  until  com- 
pensation fails,  but  may  be  soft  and  musical.  It  may  be  heard  even  at  a 
distance  from  the  chest.  It  is  made  louder  by  exercise.  The  aortic  factor 
of  the  second  sound  is  very  feeble,  or  not  at  all  heard,  if  the  constriction  be 
quite  marked,  because  of  the  feeble  recoil,  the  necessary  result  of  the  small 
amount  of  blood  in  the  aorta. 

Roughness  of  the  aorta,  and  of  the  aortic  ring,  dilatation  or  narrowing  of 
the  vessel,  however  caused,  may  also  produce  a  systolic  murmur;  so  may 
roughness  within  the  ventricle  in  the  course  of  the  outgoing  column  of  blood. 
This  is  by  far  the  commonest  cause  of  an  aortic  systolic  murmur.  But 
these  causes  have  a  less  positive  effect  upon  the  substance  of  the  heart — 
that  is,  do  not  produce  as  marked  hypertrophy  of  the  left  ventricle.  Nor 
do  these  causes  interfere  with  the  production  of  a  normal  second  sound, 
except,  perhaps,  dilatation,  which  in  that  event  is  accompanied  by  an 
aortic  regurgitant  murmur.  From  this  it  follows  that  the  important  point 
to  remember  in  diagnosis  is  that  an  aortic  systolic  murmur  rarely  indicates 
aortic  stenosis.  So,  also,  anemic  or  hemic  murmurs,  which  are  always 
systolic  and  for  the  most  part  basic,  may  simulate  aortic  systolic  murmurs, 
but  these  occur  in  young,  delicate  persons  of  both  sexes,  are  often  inter- 
mittent and  without  other  effect  on  the  muscular  heart,  while  they  are  also 
unaccompanied  by  thrill.  There  may  be  roughness,  too,  in  the  pulmo- 
nary artery,  which  can  be  localized  to  the  left  of  the  sternum. 

As  already  mentioned,  stenosis  of  the  aortic  orifice  is  very  apt  to  be  asso- 
ciated with  insufficiency,  the  same  rigidity-  and  adhesion  which  prevent 
complete  patulousness  of  the  orifice  preventing  also  complete  closure. 

Differential  Diagnosis. — Aortic  stenosis  is  always  accompanied  by  hy- 
pertrophy of  the  heart,  a  rough  systolic  murmur  at  the  base  a  small  pulse. 
Without  the  latter  signs  a  systolic  murmur  at  the  base  of  the  heart  means 
simply  one  of  the  forms  of  roughening. 


586  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

Aortic  Obstruction  and  Insufficiency. 

Occurrence. — This  double  lesion  is  a  comparatively  frequent  one;  in- 
deed, it  is  commonly  regarded  as  the  next  in  frequency  after  mitral  insuffi- 
ciency, and  therefore  more  frequent  than  either  aortic  insufficiency  or  aortic 
stenosis  alone.  It  occasions  a  double  basic  murmur,  systolic  and  diastolic, 
and  is  also  a  grave  condition,  giving  rise  to  the  same  dangers  as  aortic 
regurgitation,  and  the  same  enormous  hypertrophy  of  the  left  ventricle. 

Diagnosis. — The  diagnosis  of  this  condition  requires  special  mention, 
because  it  not  infrequently  happens  that  it  is  mistaken  for  anettrysm  of  the 
arch  of  the  aorta,  which  is  associated  with  a  similar  double  murmur  of  which 
the  systolic  element  is  due  to  the  roughness  of  the  aorta  and  aneurysmal 
walls,  and  of  which  the  diastolic  is  a  sign  of  relative  insufficiency  due  to 
dilatation  of  the  aorta.  The  distinctive  differences  between  the  two  condi- 
tions will  be  given  in  treating  aneurysm  of  the  arch  of  the  aorta. 

Prognosis. — What  was  said  of  aortic  obstruction  and  insufficiency  is 
true  in  general  of  these  lesions  when  associated,  but  a  study  of  blood  pressure 
aids  us  in  prognosis  and  treatment.  Great  differences  in  the  extremes  of 
systolic  and  diastolic  pressure  exists  at  times. 

Tricuspid  Insufficiency  or  Inco.mpetency. 

Occurrence  and  Mechanism. — Tricuspid  regurgitation  as  a  primary 
condition  is  extremely  rare,  and,  when  present,  is  probably  the  resvdt  of  an 
endocarditis  which  during  fetal  life  is  more  prone  to  attack  the  right  than 
the  left  side.  Endocarditis  involving  the  tricuspid  valve  may,  however, 
also  occur  in  children — according  to  Byrom  Bramwell,'  more  commonly 
than  has  been  supposed.  Infectious  or  ulcerative  endocarditis  also  affects 
the  tricuspid  valve — according  to  Osier,  in  19  out  of  238  cases.  More  fre- 
quently tricuspid  regurgitation  is  the  result  of  a  relative  insufficiency,  one  of 
the  terminal  events  of  mitral  disease,  the  tricuspid  orifice  yielding  with  the 
dilatation  of  the  right  ventricle,  which  takes  place  sooner  or  later,  conse- 
quent upon  the  resistance  to  the  movement  of  the  blood  through  the  en- 
gorged lungs.  It  is  also  one  of  the  possible  sequelae  of  emphysema  of  the 
lungs  and  long-standing  fibroid  phthisis  or  chronic  bronchitis,  succeeding,  too, 
a  primary  hj'pertrophy  of  the  right  ventricle,  due  to  these  causes. 

Thus,  out  of  405  autopsies  at  Guy's  Hospital  in  which  evidence  of  tri- 
cuspid regurgitation  was  found,  271,  or  two-thirds,  succeeded  on  mitral 
disease,  68  were  due  to  myocardial  degeneration,  55  to  pulmonary  disease, 
viz.,  bronchitis,  emphysema,  and  cirrhosis  of  the  lung.  The  effects  of  ve- 
nous obstruction  growing  out  of  tricuspid  insufficiency  have  been  detailed. 

Tricuspid  insufficiency  succeeding  upon  mitral  insufficiency  is  not  al- 
ways accompanied  by  an  audible  murmur.  It  is  evident  that  everj^  case  of 
mitral  regurgitation  associated  with  dropsy  must  be  attended  with  tricuspid 
regurgitation. 

Symptoms. — These  are  those  described  when  treating  of  mitral  disease 
after  the  stage  of  tricuspid  regurgitation  has  been  reached,  dropsy  more  or 


'  April,  1886.  p.  419. 


TRICUSPID  STENOSIS  587 

less  general,  engorgement  of  the  stomach,  liver,  and  kidneys,  an  enlarged, 
tender,  pulsating  liver,  and  a  jugular  pulse.  The  last  two  symptoms  are 
regarded  as  pathognomonic. 

Jugular  ptdse  is  often  more  forcible  in  the  right  than  in  the  left  jugular. 
There  is  also  cyanosis,  dyspnea,  and  pulmonary  edema.  The  jugular  pulse 
is  systolic  in  time,  and  does  not  appear  until  the  valves  situated  at  the  open- 
ing of  the  internal  jugulars  into  the  innominate  veins  yield.  These  give  way 
first  on  the  right  side,  because  the  course  of  the  right  innominate  is  straighter 
and  communication  is  more  direct.  So  long  as  the  valve  above  the  bulbus 
jugularis  is  closed,  the  pulse  is  confined  to  the  bulb,  but  with  the  yielding  of 
this  valve  the  pulse  becomes  general  throughout  the  vein.  It  is  sometimes 
difficult  to  distinguish  a  true  jugular  pulse  from  the  "physiological"  or 
"false"  jugular  pulse,  which  may  sometimes  be  seen  in  health  and  whenever 
the  venous  system  is  overfull.  Pressure  on  the  vein  above  the  valves  will 
cause  the  false  pulse  to  disappear  while  the  true  pulse,  coming  from  the  right 
ventricle,  will  remain.  The  physiological  or  false  jugular  pulse  alternates 
with  the  ventricular  systole  is  presystolic — a  negative  pulse — while  the  true 
jugular  coincides  with  the  systole  of  the  ventricles. 

Physical  Signs. — In  primary  tricuspid  disease  with  regurgitation,  in- 
spection and  palpation  reveal  an  apex-beat  diffused  toward  the  ensiform 
cartilage  and  the  epigastrium.  Percussion  detects  enlargement  toward  the 
right  edge  of  the  sternum,  due  to  hypertrophy  of  the  right  ventricle,  which 
occurs  for  the  same  reason  as  hypertrophy  of  the  left  ventricle  in  mitral 
insufficiency.  It  is  not,  however,  that  the  right  ventricle  protrudes  to  the 
right  as  much  as  that  it  pushes  the  right  auricle  over  to  the  right. 

To  auscultation  the  systolic  murmur  thus  engendered  is  almost  inva- 
riably feeble,  and  is  heard  almost  solelj^  in  the  tricuspid  area,  just  above  and 
to  the  left  of  the  ensiform  cartilage.  Occasionally  only  is  the  second  pul- 
monic sound  accentuated.  There  should  be  no  confounding  of  this  murmur 
with  that  of  aortic  regurgitation  conducted  toward  the  same  situation,  but 
different  in  time,  nor  with  that  of  mitral  regurgitation  heard  at  no  great 
distance,  for  the  reasons  already  given.  To  these  must  be  added  a  difterence 
in  quality  and  pitch  between  the  tricuspid  and  the  mitral  murmur,  not  al- 
ways, however,  manifest. 

Tricuspid  Stenosis. 

Occurrence. — Tricuspid  stenosis  is  a  rarer  condition,  but  it  may  be  an 
acquired  one  in  association  with  left-sided  heart  disease  as  the  result  of 
rheumatic  endocarditis,  and  of  unknown  causes.  Ninety  per  cent,  of  cases 
are  associated  with  mitral  stenosis.  It  is  much  more  frequent  in  women, 
fully  80  per  cent,  of  all  cases  being  in  them.  As  in  endocarditis  of  the  left 
side,  there  are  thickening,  adhesion,  narrowing. 

A  presystolic  tricuspid  murmur  pointing  to  stenosis,  in  a  case  observed 
by  Gardner,  was  found  due  to  a  growth  from  the  endocardium  of  the  right 
auricle,  so  placed  as  to  fall  over  the  tricuspid  orifice  in  the  manner  of  a  ball 
valve.  Fred.  C.  Shattuck  has  met  one  instance  of  tricuspid  stenosis  with 
mitral  stenosis  and  regurgitation,  along  with  adherent  pericardium,  hepatic 
cirrhosis,  and  sHghtly  granular  kidney,  as  determined  by  autopsy.     In  this 


588  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

case  there  was  a  presystolic  tricuspid  murmur  observed  for  three  years  before 
death. 

Physical  Signs. — Simple  uncomplicated  tricuspid  stenosis  is  extremely 
rare,  and  cannot  safely  be  diagnosed  during  life;  it  would  be  recognized 
by  the  presence  of  a  presystolic  murmur  and  thrill,  best  heard  in  the  tri- 
cuspid area,  unaccompanied  by  hypertrophy  of  the  right  ventricle.  When 
associated  with  left-sided  heart  disease,  the  diagnosis  is  seldom  made, 
because  the  murmur  is  masked  by  the  coincident  mitral  presystolic  murmur. 
In  a  very  few  cases  only  is  it  confined  to  this  valve.  Frequently  there  is 
no  murmur.  Percussion  shows  dullness  to  the  right  of  the  sternum,  if  there 
is  dilatation  of  the  auricle,  which  does  not  always  occur. 

Congenital  stenosis  of  the  tricuspid  orifice  occurs,  but  is  usually  asso- 
ciated with  defects  of  other  valves,  which  early  cause  death. 

Other  symptoms  are  cyanosis  of  the  face  and  lips  and,  in  the  later  stages, 
extreme  and  obstinate  dropsy. 


Pulmonary  Insufficiency  or  Incompetency. 

Occurrence. — Simple  pulmonary  regurgitation  is  rarely  seen.  It  may, 
however,  exist  as  a  congenital  defect  (fusion  of  two  segments),  and  the 
pulmonary  valve  has  been  found  involved  in  ulcerative  valvulitis. 

Physical  Signs. — It  is  easy  from  what  has  gone  before  to  deduce  the 
physical  signs  which  are  to  be  expected — a  diastolic  murmur  heard  in  the 
pulmonic  area,  hypertrophy  of  the  right  ventricle,  later  jugular  pulse,  venous 
congestion,  and  cyanosis.  The  diastolic  murmur  may  be  confounded  with 
that  of  aortic  insufficiency,  but  the  latter  is  accompanied  with  hypertrophy 
of  the  left  ventricle,  with  Corrigan  pulse  and  capillary  pulse.  A  few  cases 
are  related  in  which  a  diastolic  murmur  has  been  found  associated  with 
defects  in  the  pulmonary  valves — in  one,  warty,  which  might  have  been  the 
result  of  infectious  endocarditis.  All  others  are  congenital.  Among  them 
is  aneurysmal  dilatation.  Such  was  the  case  reported  to  the  Pathological 
Society  of  Philadelphia  by  Edward  T.  Bruen  (see  "Transactions"  for  1883). 


PuLMON.\RY  Stenosis. 

Occurrence. — The  great  majority  of  systolic  murmur  heard  at  the  pul- 
monary orifice  are  functional.  Pulmonary  stenosis,  though  very  rare,  may, 
however,  exist,  in  which  case  it  is  far  more  likely  to  be  congenital  from  ar- 
rested development,  although  intrauterine  endocarditis  may  also  cause  it.  So, 
also,  may  infectious  endocarditis,  and  in  rare  instances,  atheroma.  The 
valve  leaflets  are  apt  to  be  fused.  When  the  lesion  is  congenital,  it  is  com- 
monly associated  with  patency  of  the  foramen  of  Botal  or  foramen  ovale, 
together  with  imperfect  ventricular  septum  and  tricuspid  stenosis. 

Physical  Signs. — Pulmonary  stenosis  should  furnish  a  systolic  murmur 
in  the  pulmonary  area,  to  the  left  of  the  sternum..  The  murmur  may  even 
be  heard  behind,  between  the  shoulders,  and  it  maj'  be  rough.  It  is  accom- 
jjanied  by  hypertrophy  of  the  right  ventricle.     There  may  be  a  basic  thrill, 


CONGENITAL  HEART  DISEASE  589 

as  in  aortic  obstruction,  but  the  pulse  is  uninfluenced.  Compensation  may 
be  set  up  by  means  of  a  patulous  foramen  ovale,  an  open  ductus  arteriosus, 
or  interventricular  communication.  The  invariable  presence  of  cyanosis 
due  to  venous  obstruction  and  of  attacks  of  dyspnea  complete  the  picture 
and  aid  greatly  in  the  diagnosis.  Anemic  murmurs  at  the  same  time  and 
place  are  unaccompanied  by  cyanosis. 

Walshe  has  described  a  case  of  death  from  thrombosis  of  the  pulmonary 
artery  in  which  he  heard  a  pulmonary  systolic  murmur  before  the  end  came. 
Before  a  diagnosis  of  primary  tricuspid  or  pulmonary  valve  disease  is  made 
the  case  must  be  carefully  studied  from  all  standpoints.  The  diagnosis  is 
difficult. 


Congenital  Defects. 

Congenital  defects  in  the  cardiac  valves  and  orifices  deserve  a  passing 
notice.  They  may  be  the  result  of  endocarditis  during  fetal  life  or  of  arrest 
of  development.  Their  most  frequent  seat  is  the  right  heart,  and  the  most 
frequent  form  is  stenosis  of  the  pulmonary  orifice,  the  effects  and  signs  of 
which  have  already  been  considered.  Another  is  a  permanently  patulous 
foramen  ovale;  or  there  may  be  a  defect  of  the  septum  of  the  ventricles,  or  a 
communication  between  the  aorta  and  pulmonary  artery — a  persistent  duc- 
tus arteriosus — or  between  the  aorta  and  the  vena  cava  or  aorta  and  right  auricle. 
All  of  these  intercommunications  produce  murmurs  difficult  to  separate, 
and  it  is,  after  all,  by  attention  to  the  general  condition  that  the  defect  is 
recognized.  The  patient  is  a  child  of  arrested  development,  more  or  less 
permanently  cyanosed,  with  continued  embarrassed  breathing — all  of 
these  are  conditions  which  point  to  the  congenital  defect.  If  there  be 
added  to  these  a  persistent  loud  murmur  at  the  base  of  the  heart  without 
other  signs  or  symptoms  of  valvular  disease,  this  may  be  due  to  congenital 
defect. 

In  addition  to  these,  there  are  a  large  number  of  defects  of  development 
which  are  rather  pathological  curiosities  than  of  clinical  interest.  Among 
these  may  be  mentioned  acardia,  or  absence  of  heart,  met  in  the  monstrosity 
thus  named ;  double  heart,  sometimes  present  in  high  degrees  of  fetal  defect ; 
dextrocardia,  in  which  the  heart  is  on  the  right  side,  alone  or  with  other 
viscera.  In  ectopia  cordis,  or  dislocation,  which  is  associated  with  fission  of 
the  chest  wall  and  of  the  abdomen,  the  heart  may  be  in  the  cervical,  pectoral, 
or  abdominal  regions.  Then  there  are  anomalies  of  the  cardiac  septa,  of 
which  the  patulous  foramen  ovale  is  the  most  frequent,  various  in  degree. 
Next  is  a  small  defect  in  the  upper  part  of  the  septum,  between  the  ventricles, 
in  what  is  known  as  the  "undefended"  space,  or  just  anterior  to  it.  A 
6zcuspid  condition  of  the  semilunar  valves,  from  fusion  of  cusps,  is  often 
met — most  frequently  of  the  aorta.  The  combined  valve  is  more  liable  to 
sclerotic  change.     Finally,  there  is  fenestration  of  the  semilunar  cusps. 

Relative  Frequency  of  Valvular  Defects. — The  order  of  frequency  of  the 
various  valvular  defects  is  not  entirely  agreed  upon.  As  to  one,  however, 
there  seems  to  be  universal  concurrence,  and  that  is  that  mitral  regurgita- 
tion is  the  most  frequent.     After  this,  however,  statistics  differ. 


590  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

This  order,  in  the  light  of  modem  studies,  must  be  corrected,  except 
as  to  mitral  incompetency.  Frederick  J.  Smith,  analyzing  the  registers  and 
postmortem  records  of  the  London  hospitals  for  eleven  years — 1877-87 — 
and  taking  the  fatal  cases  only,  arrived  at  the  following  order : 

1.  Mitral  incompetency. 

2.  Mitral  stenosis.  \    ^^  ■    ■,, 

.      ^.    .  ^  (    Ui  practically  equal  frequency. 

3.  Aortic  incompetency.     J  " 

4.  Aortic  stenosis. 

5.  Tricuspid  stenosis. 
To  these  we  may  add: 

6.  Tricuspid  incompetency. 

7.  Pulmonary  stenosis. 

8.  Pulmonary  incompetency. 

It  is  evident  that  the  older  observers  mistook  the  aortic  systolic  murmur 
to  mean  aortic  stenosis,  when  roughening  only  of  some  kind  was  present. 

Prognosis  of  Chronic  Valvular  Disease. — Possible  positive  statements 
as  to  the  prognosis  in  chronic  valvular  disease  are  few,  so  uncertain  is  it  and 
so  many  circumstances  influence  it.  Undoubtedly,  valvular  disease  often 
exists  where  the  subject  is  totally  free  from  symptoms,  and  therefore  quite 
unconscious  of  it.  Yet  such  subject  is  not  free  from  danger.  On  the  other 
hand,  15,  20,  30,  and  even  40  years  pass  over  such  cases  without  incon- 
venience, compensation  being  easily  maintained.  Such  cases  are  usually 
of  mitral  incompetency  or  stenosis,  or  both.  Much  depends  upon  the  life 
led  by  the  patient — whether  one  of  ease  and  quiet,  associated  with  proper 
food  and  clothing  and  without  dissipation.  Even  when  such  disease  occa- 
sions symptoms,  the  same  measures  may  hold  them  in  abej'ance  for  a  long 
time,  and  occasional  judicious  tieatment  may  raise  the  patient  from  a  serious 
condition  to  one  of  comfort.  It  is  astonishing  with  what  little  disturbance 
women  with  these  affections  sometimes  bear  children.  Of  the  lesions 
at  the  mitral  orifice,  incompetency  is  usually  most  easily  compensated,  then 
combined  stenosis  and  incompetency,  and  finallj^  stenosis  only;  but  even  the 
last  exists  at  times  without  subjective  symptoms  in  persons  who  have  worked 
hard.  After  all,  the  prospect  of  life  must  be  judged  from  the  symptoms  in 
each  case.  The  compensation  which  is  obtained  by  extreme  hypertrophy 
and  apex  displacement  is  tottering.  An  additional  danger  in  mitral  dis- 
ease, especially  mitral  stenosis,  is  that  of  embolism.  Recurring  attacks  of 
rheumatism  not  only  increase  the  latter  danger,  but  augment  the  valvular 
defect.  The  supervention  of  dropsy  and  dyspnea  indicate  failing  compensa- 
tion, and  though  they  may  be  overcome,  it  is  with  increasing  difhculty  at 
each  recurrence. 

Aortic  incompetency  is  a  much  graver  condition.  Yet  it,  too,  may  be 
compensated  for  years.  Much  here  depends  upon  the  state  of  the  arteries, 
the  danger  being  increased  when  associated  with  sclerosis  or  atheroma,  for 
these  conditions  are  likely  to  effect  the  root  of  the  aorta  and  the  valves, 
and  especially  the  coronary  arteries.  Any  obstruction  in  these,  as  already 
stated,  may  be  the  cause  of  sudden  death.  Diseased  condition  of  the  coro- 
nary arteries,  which  may  at  any  time  be  followed  by  complete  obstruction 
and  similar  death.     Overdistention,  such   as  takes  place  during   exertion 


TREATMENT  OF  CHRONIC  VALVULAR  DEFECTS  591 

may  be  too  much  for  a  fatty  heart  already  dilated,  and  becomes  also  a  cause, 
of  sudden  death. 

The  most  unfavorable  of  all  forms  of  cardiac  valvular  disease  is  tricuspid 
regurgitation,  which  occasions  obstinate  dropsy  and  dyspnea. 

Chronic  valvuJar  disease  is  regarded  as  much  more  serious  in  young 
children  under  ten  years  of  age;  this,  in  spite  of  the  fact  that  many  condi- 
tions favorable  to  compensation  are  present,  such  as  integrity  of  heart 
muscle  and  vascular  supply.  Notwithstanding  this,  the  valve  lesion  is 
apt  to  increase.  Congenital  defects  in  the  heart  are  apt  to  destroy  the  lives 
of  children  in  the  first  few  years  of  their  existence. 

Finally,  almost  any  serious  illness,  especially  when  involving  the  lung, 
increases  the  danger  to  the  life  of  the  subject  of  cardiac  disease,  while  mitral 
disease,  and  especially  mitral  stenosis,  invites  pulmonary  congestion  and 
inflammations. 

Treatment  of  Chronic  Valvular  Diseases  of  the  Heart. — i.  Prophylaxis. 
There  can  be  no  doubt  that  the  number  of  cases  of  chronic  valvular  disease 
may  be  decreased  by  a  careftd  treatment  of  the  diseases  which  excite  them 
or  favor  their  occurrence,  especially  acute  rheumatism.  Rest  and  quiet 
should  be  prolonged  long  after  the  symptoms  of  pain  and  fever  have  subsided, 
and  a  second  attack  of  rheumatism  should  especially  be  guarded  against,  as 
an  unhealed  endocarditis  is  sure  to  be  followed  by  another  attack.  Tem- 
perance and  the  avoidance  of  excesses  of  all  kinds  which  tend  to  load  the  blood 
with  toxic  substances  constitute  a  prophylaxis  of  no  small  importance. 

2 .  Remedial  Measures. — In  the  first  place,  it  is  well  known  that  there  exist 
chronic  valvular  defects  at  either  of  the  orifices  which  give  rise  to  no  sjmip- 
toms  whatever  and  are  often  accidentally  discovered.  Such  patients  need 
no  drugs,  and  digitalis  preparations  are  harmful.  As  a  rule  persons  with  a 
valvular  lesion  with  complete  compensation  of  the  heart,  should  be  told  of 
their  condition  in  order  to  avoid  excesses  of  all  kinds.  On  the  other  hand  the 
physician  must  know  his  patient.  Many  nervous  individuals  are  made 
miserable  for  life  by  the  knowledge  of  a  valvular  lesion.  To  them  heart  dis- 
ease spells  sudden  death.  Such  persons  should  avoid  overexercise  and  ex- 
citement. Running  or  even  walking  rapidly,  hurriedly  ascending  stairs, 
extremes  of  passion  of  all  kinds,  and  especially  of  anger,  should  be  avoided,  as 
should  also  exposure  and  irregular  living.  In  a  higher  grade  of  involvement 
of  either  orifice,  the  same  treatment  is  demanded  in  a  more  imperative  man- 
ner, since  its  omission  results  in  a  loss  of  compensation,  manifested  by  dysp- 
nea, palpitation,  and  precordial  distress. 

Treatment. — This  is  the  same  whichever  orifice,  or  indeed  in  a  large 
part  where  there  is  no  valvular  lesion.  The  cases  may  well  be  divided  into 
two  classes — those  with  slight  symptoms  of  failing  compensation;  those 
with  more  severe  symptoms,  those  where  the  muscular  power  of  the  heart  is 
entirely  inadequate. 

General  Principals. — The  first  essential  is  conservation  of  the  energy  of 
the  heart,  as  Mackenzie  puts  it,  safeguarding  the  reserve  power  of  the  heart. 
To  this  end  mental  and  physical  rest  combined  with  proper  protection  of 
the  muscular  power  of  the  heart  are  essential.  Regulation  of  the  habits 
of  the  individual  of  his  food,  his  drink,  his  work,  and  his  recreations  are 
important. 


592  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

Cases  with  Slight  Symptoms. — When  a  patient  notices  dyspnea  on  ex- 
ertion, some  palpitation  of  the  heart,  vertigo,  precordial  distress,  cough,  with 
possibly  a  slight  edema  of  the  extremities,  he  must  at  once  be  told  of  the 
heart  lesion  if  he  is  not  already  aware  of  it.  He  should  then  be  put  abso- 
lutely at  rest  until  all  symptoms  disappear;  usually  no  drugs  are  necessary. 
His  diet  should  be  milk,  cereals,  toast,  green  vegetables,  eggs,  a  very  small 
amount  of  meat.  The  bowels  should  be  moved  freely  every  day  with  salines 
or  calomel.  If,  after  a  few  days  the  symptoms  persist,  he  should  be  given 
digitalis,  either  the  tincture  or  the  powdered  drug.  After  a  few  days  he 
should  be  allowed  to  sit  up  and  walk  dail}^  a  short  measured  distance, 
increasing  the  distance  gradually.  At  this  time  the  use  of  carbonated  baths 
and  regtdated  resistance  movements,  Nauheim  or  Schott  treatment  is  of  the 
greatest  value.  The  patient  then  should  be  instructed  to  avoid  all  occupa- 
tions, or  exercise,  or  food,  which  causes  the  least  return  of  symptoms. 
Digitalis  should  not  be  given  in  a  routine  way,  but  under  strict  control  of 
the  physician. 

It  appears  this  simple  method  is  a  necessity  and  better  than  attempting  to 
discover  the  various  causes  for  the  rupture  of  compensation  first.  Get  the 
heart  compensated  as  the  first  essential,  while  this  is  going  on  study  the 
patient's  condition,  his  method  of  living,  and  regulate  it  in  the  future.  It 
is  a  pernicious  habit  to  simply  give  such  individuals  digitalis  and  allow  them 
to  go  about  their  ordinary  life.  They  will  be  s\'mptomatically  better,  but 
will  soon  drift  into  a  more  serious  failure  of  the  heart  muscle. 

Cases  with  Severe  Symptoms. — The  more  serious  class  of  cases,  is  that 
in  which  the  compensation  is  more  completely  broken,  either  because  the 
patient  has  gone  about  his  work  so  long  that  he  has  developed  symptoms 
of  severe  dyspnea;  much  palpitation  of  the  heart;  edema  of  the  legs;  and 
venous  congestion  in  the  liver,  kidney  and  other  organs;  or  because  this  is 
one  of  a  succession  of  attacks  of  failing  compensation.  The  symptoms  may 
be  mild  or  so  severe  that  they  threaten  life.  In  such  cases  absolute  rest  in 
bed  is  a  necessity.  After  the  first  twenty-four  hours  and  sometimes  before, 
digitalis  is  demanded  to  steady  the  heart's  action.  The  patient  must  be 
placed  on  a  milk  diet  preferably.  The  bowels  must  be  kept  open.  Sleep 
is  imperatively  demanded.  For  this  ptirpose,  bromide  of  potassium  in 
fifteen  grain  doses,  chloral  hydrate  in  five  to  ten  grain  doses  may  be  used; 
but  morphine  sulphate  used  hypodermically  is  of  the  greatest  value,  and  ma}' 
cause  a  case  which  threatens  to  terminate  in  death  to  take  on  a  change  for 
the  better,  which  will  finally  end  in  comparative  health. 

After  these  patients  begin  to  improve,  even  before  they  are  out  of  bed, 
resistance  movements,  the  so-called  Schott  treatment  may  be  employed. 
Most  of  these  cases  need  one  of  the  digitalis  group  of  drugs  after  they  are 
about  work  again.  As  this  class  of  cases  presents  so  many  distinct  symp- 
toms, it  seems  worth  while  to  give  the  treatment  best  suited  for  the  symp- 
toms themselves. 

Venesection  has  a  distinct  place  in  cardiac  therapeutics,  when  the  right 
heart  is  dilated  the  heart  throbbing  against  much  peripheral  pressure,  the 
second  sound  much  accentuated,  the  patient  cyanosed  as  with  acute  cardiac 
dilatation.  Ten  to  twelve  ounces  of  blood  taken  from  the  arm  is  often  life 
saving. 


TREATMENT  OF  CHRONIC  VALVULAR  DEFECTS  593 

Physical  Methods 

Nauheim  and  Schott  Treatment. — It  is  in  this  condition  that  the  Schott 
or  Nauheim  treatment  is  especially  useful.  It  consists  in  the  use  of  the 
carbonated  saline  baths  at  Bad  Nauheim,  associated  with  special  exercises 
called  "resistance"  movements,  originated  by  the  brothers  Schott.  Fortu- 
nately, artificial  baths  may  be  substituted  for  the  natural  baths,  or  the 
treatment  would  have  limited  application.  Ignoring  for  the  present  the 
rationale  of  the  action  of  these  baths,  their  therapeutic  efficacy  is  un- 
doubted. The  waters  of  Nauheim  have  a  temperature  ranging  from  82°  F. 
(27°  C.)  to  95°  F.  (35°  C).  Their  important  constituents  are  chlorid  of 
sodium  and  chlorid  of  calcium. 

The  baths  may  be  imitated  at  home  by  dissolving  chlorid  of  sodium  and 
chlorid  of  calcium  in  water,  to  which  carbonic  acid  is  added  by  decom- 
posing bicarbonate  of  sodium  by  hydrochloric  acid.  K.  N.  B.  Camac  has 
calculated  the  required  quantities  of  salt  to  each  40  gallons  of  water  for 
six  different  strengths  of  the  baths.  The  following  are  the  proportions  of 
sodium  chlorid  and  calcium  chlorid  calculated  by  Camac.  The  proportions 
of  carbonic-acid-forming  constituents,  HCl  25  per  cent.,  6  ounces;  HCl 
25  per  cent.  7  ounces;  HCl  25  per  cent.  8  ounces,  making  three  strengths  of 
the  latter,  after  the  method  recommended  by  Bezley  Thome,  of  London: 

Bath  No.  I:  Sodium  chlorid,  4  pounds;  calcium  chlorid,  6  ounces. 
Bath  No.  2:  Sodium  chlorid,  5  pounds;  calcium  chlorid,  8  ounces. 
Bath  No.  3:  Sodium  chlorid,  6  pounds;  calcium  chlorid,  10  ounces. 
Bath  No.  4:  Sodium  chlorid,  7  pounds;  calcium  chlorid,  10  ounces ;  sodium  bicar- 
bonate 1/2  pound;  HCl  (25  per  cent.),  12  ounces. 

Bath  No.  5:  Sodium  chlorid,  9  pounds;  calcium  chlorid,  11  ounces;  sodium  bicar- 
bonate, I  pound;  HCl,  i  1/2  pounds. 

Bath  No.  6:  Sodium  chlorid,  10  pounds;  calcium  chlorid,   12  ounces;  sodium  bi- 
carbonate, 2  pounds;  HCl,  3  pounds. 

The  alkali  should  always  be  slightly  in  excess,  unless  a  porcelain  or 
paper  tub  is  used. 

In  preparing  the  baths,  the  salts,  including  the  right  proportion  of  bi- 
carbonate of  sodium,  are  dissolved  in  the  water  which  should  have  a  tempera- 
ture of  95°  F.  (35°  C.)  gradually  reduced  at  successive  baths  to  82°  F. 
(27°  C).  A  course  consists  of  from  15  to  20  baths.  The  bottle  containing 
the  hydrochloric  acid  is  inverted  and  lowered  until  its  mouth  is  below  the 
surface,  when  the  stopper  is  withdrawn  and  the  bottle  moved  about  so  as 
to  diffuse  the  acid  as  uniformly  as  possible  through  the  water.  In  this  way 
the  bath  is  made  ready  in  a  few  minutes.  The  carbonic  acid  is  the  most 
unsatisfactory  feature  of  the  artificial  bath,  since  it  is  rapidly  dissipated, 
and  produces  only  feebly  the  effect  of  the  acid  in  the  natural  baths.  Hence 
the  patient  should  be  promptly  put  into  the  bath  after  the  HCl  is  added, 
lest  the  CO2  is  lost  before  he  can  get  the  effect  of  it.  A  good  plan  is  to 
give  the  baths  on  alternate  days,  using  the  weaker  until  its  effects  are 
exhausted,  then  passing  on  to  Nos.  3  and  4  in  the  same  manner.  Nos.  5 
and  6  are  not  often  called  for. 

As  already  stated,  the  baths  are  most  efficient  in  cardiac  disease,  but 
they  are  also  useful  in  renal  affections.  Their  immediate  effect  is  a  dimin- 
ished pulse-rate,  intensified  heart-sounds,  diminished  breathing-rate,  while 
the  dilated  heart  is  reduced  in  size — under  favorable  circumstances  to 


594  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

almost  its  natural  limits.  The  effect  is  also  to  increase  the  action  of  the 
kidneys  and  that  of  the  skin.  These  effects  are  apparent  in  a  free  flow  of 
urine,  which  may  continue  for  days  and  weeks.  Metabolic  changes  are 
accelerated  and  improved;  the  deep-seated  organs,  especially  the  liver  and 
pelvic  viscera,  are  relieved  of  congestion;  while  the  heart,  relieved  of  its 
burden,  and  contracting  strongly,  derives  from  its  improved  coronary 
circulation  material  for  the  repair  of  weakened  and  damaged  tissue. 

Theodore  Schott'  has  shown  that  an  increase  of  hemoglobin  in  the 
blood  succeeds  upon  the  systematic  use  of  Nauheim  baths. 

The  exercises  are  not  usually  commenced  until  some  very  positive 
effect  of  the  baths  is  secured,  when  they  are  associated  with  the  baths  or 
substituted  after  the  latter  are  discontinued.  The  eff'ects  of  these  gymnas- 
tics are  described  as  identical  with  those  of  the  baths.  The  extremities 
become  warm,  the  breathing  is  deepened,  the  sense  of  oppression  is  relieved, 
the  pulse  become  slower,  the  dilated  heart  area  reduced.  Even  the  liver, 
which  is  so  often  enlarged- in  heart  disease  as  a  result  of  passive  congestion, 
is  said  to  be  reduced  in  size. 

The  following  condensed  statement  of  the  Schott  movements  is  from 
Sir  T.  Lauder  Brunton's  "Lectures  on  the  Action  of  Medicines,"  London, 
Macmillan  and  Co.,  1898. 

"L  The  arms  are  to  be  raised  slowly  outward  from  the  side  until  they 
are  on  a  level  with  the  shoulder.  After  a  pause  they  shoidd  be  slowly 
lowered. 

"II.  The  body  should  be  inclined  sideways  as  much  as  possible  toward 
the  right,  and  then  to  the  left. 

"III.  One  leg  should  be  extended  as  far  as  possible  sideways  from  the 
body,  the  patient  steadying  himself  by  holding  on  to  a  chair.  The  leg  is 
then  dropped  back.     The  same  movements  are  repeated  by  the  other  leg. 

"  IV.  The  arms  are  raised  in  front  of  the  body  to  a  level  vnth  the  shoul- 
der, and  then  put  down. 

"V.  The  hands  are  rested  on  the  hips,  and  the  body  is  bent  forward  as 
far  as  possible,  and  then  raised  to  the  upright  position. 

"VI.  One  leg  is  raised  with  the  knees  straight,  forward  as  far  as  possible, 
then  brought  back.     The  movement  is  repeated  with  the  other  leg. 

"VII.  With  the  hands  on  the  hips,  the  body  is  tvsdsted  round  as  far  as 
possible  to  the  right,  and  then  again  to  the  left. 

"VIII.  With  the  hands  resting  on  a  chair,  and  the  back  stiff  and 
straight,  each  leg  is  raised  as  far  as  possible  backward,  first  one  and  then 
the  other. 

"IX.  The  arms  are  extended  and  the  fists  supinated.  The  arms  are 
then  extended  outward,  next  inward  at  the  height  of  the  body. 

"X.  Each  knee  is  first  raised  as  far  as  possible  to  the  body,  and  then 
the  leg  is  extended. 

"XI.  This  movement  is  the  same  as  IX,  but  with  the  fists  pronated. 

"XII.  Each  leg  is  bent  backward  from  the  knee  and  then  straightened. 

"XIII.  Each  arm  is  bent  and  straightened  from  the  elbow. 

"XIV.  The  arms  are  brought  from  the  sides  forward  and  upward, 

*  "On  some  Hemoglobin  Investigation."     Reprint  from  the  "British  Medical  Journal,"  1904. 


TREATMENT  OF  CHRONIC  VALVULAR  DEFECTS  595 

then  downward  and  back  as  far  as  they  will  go,  the  elbows  and  the  hands 
being  straight. 

"XV.  The  arms  are  put  at  a  level  with  the  shoulder,  and  then  bent 
from  the  elbow  inward  and  again  extended. 

"XVI.  With  the  arms  in  front  at  the  level  of  the  shoulder  and  the 
hands  stretched,  the  arms  are  opened  out  sideways  and  then  brought 
together. 

"XVII.  The  arms  are  bent  from  the  elbow  outward  and  extended. 

"The  movements  shotdd  be  slow  and  regular,  each  one  being  gently 
resisted  by  the  nurse  or  attendant  or  by  the  patient  himself,  putting  into 
action  the  muscles  opposing  the  movement. 

"There  should  be  a  pause  of  half  a  minute  between  each  movement  of 
the  same  class  and  a  pause  of  one  or  two  minutes  between  movements 
of  an  entirely  different  kind,  as  I  and  II." 

Use  of  Remedies  in  Cardiac  Decompens.'Vtion. 

Digitalis. — The  preparations  of  this  drug  are  the  most  useful  and  some- 
times the  least  to  be  depended  upon  of  any  set  of  drugs  in  the  Pharmacopeia. 
Digitalis  when  used  with  thoughtfulness,  in  active  preparations  is  life 
saving.  When  used  without  proper  considerations  and  in  inactive  prepara- 
tions, not  only  may  it  fail  to  save  life,  but  by  the  thoughtless  use,  or  the  use 
of  a  weak  preparation,  it  may  allow  a  fatal  termination  to  a  case  which 
otherwise  might  have  recovered. 

In  this  age  with  commercial  drug  houses  of  known  good  reputations, 
fitted  with  laboratories  and  apparatus  to  efficiently  test  the  value  and 
strength  of  the  preparations  they  make,  whose  word  may  be  depended  upon, 
there  is  not  the  slightest  excuse  for  the  general  practitioner  to  use  old  or 
inefficient  preparations.  Tablets  of  the  tincture  and  the  hypodermic 
tablets  of  digitalin,  are  not  to  be  depended  upon. 

Tincture  of  digitalis  should  be  not  more  than  one  j^ear  old  and  should 
be  tested  physiologically.  If  this  is  used  as  a  fat-free  tincture  it  may  be 
used  hypodermically  when  occasion  requires,  without  the  slightest  fear  of 
abscess  formations  and  without  an  extreme  amount  of  pain,  and  certainly 
with  good  effect. 

The  infusion  of  digitalis  must  always  be  made  fresh  from  leaves  which 
are  assayed  and  physiologically  tested.  When  so  used  it  unquestionably 
is  the  best  form  of  digitalis  to  use  when  one  desires  a  diuretic  action  plus 
the  action  on  the  heart  muscle.  The  so-called  infusions  sometimes  made  up 
from  an  extract  of  uncertain  strength  are  thoroughly  unreliable. 

The  various  forms  of  digitalis  derivatives,  which  are  upon  the  market, 
must  be  used  with  some  degree  of  caution.  Each  manufacturer  claims  that 
his  preparation  of  digitalone,  digitoxin,  or  digitalin,  or  whatever  it  may  be, 
acts  better  than  any  other  form  of  digitalis.  This  when  weighed  in  the 
balance  of  clinical  experience,  is  found  to  be  distinctly  not  true.  There 
are  very  few  of  the  various  preparation  which  have  not  been  tested  by  us. 
The  ordinary  preparation  of  digitalin  is  absolutely  without  any  value,  not- 
withstanding the  fact  that  the  manufacturer  makes  such  great  claims  for 
its  action.     Digitoxin,  or  its  solution  digalen,  is  the  preparation  for  which 


596  DISEASES  OF  HEART  AND  B LOO D-V ESSIES 

the  manufacturers  claim  all  the  merits  of  the  digitalis  preparation'.  It  is 
of  some  value,  but  it  is  not  the  fact  that  it  can  be  used  hypodermically  with- 
out untoward  effects. 

Digiptuatum,  like  the  other  preparations,  may  be  tried. 

When  the  actual  effect  of  digitalis  is  desired,  either  the  tincture,  the  fluid 
extract,  the  powdered  drug,  or  the  infusion  should  be  used. 

The  more  important  action  of  digitalis  is  that  upon  the  heart  muscle. 
The  systole  is  strengthened  and  prolonged,  and  the  diastole  is  shortened. 
It  is  because  of  this  action  upon  the  heart  muscle,  that  digitalis  is  such  an 
extremely  valuable  drug.  It  has,  however,  also  an  action  upon  the  central 
nervous  system,  an  inhibitory  upon  the  medullary  centers,  and  this  action 
tends  to  lengthen  the  diastole,  instead  of  shorten  it,  but  this  does  not 
happen  unless  large  doses  are  taken  and  signs  of  poisoning  occur. 

According  to  Cushny  "  the  blood  pressure  does  not  seem  to  be  aug- 
mented in  man  to  any  extent  preceptibly  by  the  methods  in  use  for  measur- 
ing it  clinically,  and  in  some  instances  it  has  been  decidedly  reduced." 

One  of  the  unfortunate  effects  of  digitalis  is  local  action  upon  the  stom- 
ach. It  is  a  well-known  clinical  fact,  that  when  this  drug  is  taken  for  a 
prolonged  time  or  in  large  doses,  vomiting  occurs.  This  is  probably  the 
direct  result  of  its  local  action,  and  not  due  to  its  general  poisoning  effect, 
although  if  the  dose  "has  been  large  enough  and  the  drug  has  been  taken 
during  a  long  period  of  time,  rmquestionably  some  of  the  vomiting  and 
other  untoward  symptoms  will  come  about  because  of  the  central  ner\'ous 
condition. 

Therapeutic  Indications.- — The  great  indication  for  the  use  of  digitalis 
is  cardiac  insufficiency  as  indicated  by  the  symptom  complex  of  decompensa- 
tion, dyspnea,  cardiac  palpitation  and  edema.  Yet  all  attacks  of  cardiac 
insufficiency  thus  characterized  are  not  helped  b\^  the  administration  of 
digitalis;  indeed,  some  such  cases  distinctly  contraindicate  the  use  of  the 
drug.  The  insufficiency  which  comes  from  long-continued  fever,  from 
septic  infection,  etc.,  is  but  little  helped  by  its  use,  though  certain  cases 
appear  to  be  better  for  its  use. 

Cardiac  disease,  vahnilar  disease,  when  the  heart  is  fully  compensated 
and  there  is  only  the  cardiac  muimur  to  indicate  any  trouble,  dees  not  de- 
mand the  use  of  digitalis,  indeed,  this  drug  is  distinctly  contraindicated 
under  such  conditions.  If  there  is  one  error  which  we  physicians  are  prone 
to  commit,  it  is  to  administer  digitalis  on  the  mere  presence  of  a  heart 
murmur.  Indeed  the  total  examination  of  a  heart  to  some  seems  to  be 
summed  up  in  the  act  of  auscultation,  to  discover  whether  or  not  a  murmur 
exists.     Nothing  can  be  further  from  the  true  cardiac  examination. 

Patients  with  cardiac  dilatation,  whether  the  failure  of  the  left  heart  is 
due  to  valvular  disease  or  to  a  primary  myocarditis,  should  not  be  given 
digitalis  when  first  seen.  Instead  the  patient  must  be  absolutely  still  in 
bed  for  at  least  twenty-four  hours,  so  that  important  therapeutic  measm^es 
may  be  tested,  and  to  avoid  the  danger  of  overstimulating  a  heart  muscle 
which  is  already  working  to  the  limit  of  its  capacity.  Then  the  digitalis 
can  be  given  tentatively,  in  small  doses  at  first,  gradually  increasing  the 
dose  and  feeling  one's  way  with  it  until  the  proper  degree  of  stimulation 
may  be  obtained.     Some  patients  with  primary  myocarditis  are  distinctly 


TREATMENT  OF  CHRONIC  VALVULAR  DEFECTS  597 

harmed  by  the  use  of  digitahs.  There  is  no  "hard  and  fast  rule"  by  which 
one  can  determine  the  proper  cases  of  this  condition  in  which  to  use  digitaUs. 
As  a  broad  rule,  however,  those  patients  with  extreme  irregularity,  anginal 
pains,  and  very  low  pressure,  contraindicate  the  use  of  the  drug.  The 
only  safe  procedure,  however,  is  to  follow  the  above  rule,  put  the  patient 
to  bed  and  feel  one's  way  with  the  drug. 

A  most  improper  use  of  digitalis  is  its  use  in  cases  of  broken  compensa- 
tion of  slight  degree  while  the  patient  is  on  foot  and  about  his  business.  It 
is  improper,  notwithstanding  its  good  symptomatic  results,  because  oc- 
casionally the  drug  stimulates  the  heart  muscle  and  makes  it  work  against 
the  various  local  congestions,  against  the  overexertion  which  is  the  cause 
of  the  sj^mptoms,  instead  of  removing  the  cause  by  rest,  and  then  using  the 
drug  to  tone  up  the  muscle. 

After  a  patient  with  cardiac  symptoms  who  has  gone  through  a  siege  of 
decompensation  has  recovered,  so  that  it  is  proper  to  begin  exercise,  then 
digitalis  may  be  continued  for  some  weeks  in  order  to  continue  the  good 
effects  upon  the  heart  muscle.  Here,  however,  one  must  be  most  careful 
to  stop  the  drug  when  the  heart  can  safely  do  without  its  aid;  failure  to 
observe  this  caution  will  most  surely  land  one  exactly  in  the  position  he 
would  be,  if  the  drug  were  used  in  the  beginning  of  a  case  before  symptoms 
of  failure. 

Tachycardia  from  nervous  conditions,  from  an  essential  myocarditis,  or 
frcm  any  cause  save  that  of  a  failure  due  primarily  to  valvular  insufficiency, 
is  not  favorably  affected  by  digitalis.  Patients  vnth.  cardiac  failure,  with 
much  edema,  with  scant  urine,  frequently  respond  better  to  full  doses  of  the 
infusion  than  to  any  other  form  of  digitalis. 

The  cumulative  action,  so  much  talked  of  especially  in  former  years, 
is  certainly  rare.  Usually  too  much  digitalis  is  indicated  by  nausea,  vomit- 
ing, vertigo,  the  heart  becoming  rapid  and  feeble. 

To  conclude,  digitalis  must  be  used  in  a  physiologically  tested  and 
freshly  prepared  specimen.  It  must  not  be  used  in  heart  disease  without 
symptoms.  It  is  of  little  value  and  sometimes  harmful  in  inorganic  con- 
ditions and  in  chronic  myocarditis. 

It  is  life  saving  or  useless,  according  to  the  efficiency  of  the  preparation 
and  the  method  of  its  use. 

Strophanthus. — This  may  be  used  in  the  same  manner  and  under  the 
same  circumstances  as  digitalis.  Strophanthin  given  intravenously  in 
i/ioo  grain  doses,  is  often  of  extreme  value,  especially  in  acute  dilata- 
tion. 

Caffein. — Caffein  may  be  given  in  the  form  of  the  alkaloid.  In  the  form 
of  benzoate  of  caffein,  it  may  be  used  hypodermically. 

Camphor. — Camphor  is  an  excellent  stimulant  of  the  heart,  and  may  be 
used  in  the  form  of  camphorated  oil  by  the  hypodermic  method.  When  so 
used  it  is  better  to  use  the  sterile  ampoules  put  up  by  various  firms,  unless 
it  can  be  made  fresh  by  some  pharmacist  experienced  in  making  sterile 
solutions. 

Nitro-glycerine. — This  is  not  a  heart  stimulant  and  has  little  place  in 
the  treatment  of  cardiac  disease.  It  should  be  used  when  peripheral  pressure 
is  high  and  only  in  conjunction  with  digitalis. 


598  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

Theobromin. — Theobromin,  as  stated  above,  is  of  great  value  in  certain 
cases  of  cardiac  decomposition  accompanied  by  oedema. 

Treatment  of  Dyspnea. — As  the  dyspnea  is  primarily  the  result  of 
deficient  blood  aeration  in  the  congested  lungs,  the  same  remedies  which 
force  the  blood  through  these  organs,  and  thus  relieve  the  congestion,  tend 
also  to  relieve  the  dyspnea,  and  often  do  so.  When  the  dyspnea  persists, 
it  is  frequently  caused  by  effusions  into  the  pleural  cavity,  which  are  most 
promptly  and  successfully  removed  by  tapping.  Repeated  tapping  may 
be  necessary.  Dyspnea  not  thus  relieved  demands  an  opiate,  and  of  opiates 
under  these  circumstances,  morphin  is  the  best.  One-fourth  of  a  grain 
(0.0165  gn^-)  S't  bedtime,  by  the  mouth  or  hypodermically,  gives  comfort. 
It  should  not,  however,  be  given  constantly,  but  at  well  selected  intervals. 
Hoffmann's  anodyne,  given  in  fluidram  doses  (3.5  c.c),  will  sometimes 
relieve  the  milder  degrees,  and  should  perhaps  be  tried  first,  as  it  is  always 
desirable  to  put  off  the  use  of  morphin  as  long  as  possible.  Paraldehyd  may 
be  substituted  for  Hoffmann's  anodyne  in  the  same  doses.  Chloralamid  is 
even  a  better  remedy  in  30  grain  (2  gm.)  doses.  Sulphcnal  may  be  tried 
in  full  doses  of  15  to  30  grains  (i  to  2  gm.).  Trional  in  the  same  doses  is 
a  similar  drug.  So  is  veronal  in  somewhat  smaller  doses,  7  to  10  grains 
(0.462  to  0.66  gm.).  None  of  these  is  an  anodyne.  They  are  simple  hyp- 
notics, and  cannot  be  expected  to  take  the  place  of  morphin,  though  they 
may  be  tried  at  first.  All  the  coal-tar  products  are  more  soluble  in  hot 
liquids,  of  which  milk  is  a  typical  form.  Inhalations  of  oxygen  should  not 
be  forgotton  as  sometimes  giving  signal  relief  in  dyspnea. 

Treatment  of  Dropsy. — In  like  manner  the  measures  that  relieve  the 
congestion  and  dyspnea  tend  also  to  relieve  the  dropsy,  but  special  means 
are  also  necessary.  Here  it  is  that  full  doses  of  digitalis  are  especially 
indicated,  and  at  closer  intervals.  It  is  to  be  remembered,  too,  that  the 
infusion  is  a  better  diuretic  than  the  tincture. 

But  these  measures  are  often  insufficient.  They  may  be  materially 
aided  by  restricting  the  ingestion  of  liquids.  With  the  tissues  water-logged 
and  secretion  insufficient,  it  is  plain  that  copious  liquid  ingestion  only  in- 
creases the  diflSculty.  This  refers  to  cases  in  which  there  is  general  dropsy 
which  resists  the  ordinary  treatment.  It  is  sometimes  better  to  omit  solid 
food  altogether  and  reduce  the  liquid  to  a  minimum  that  will  sustain  life — 
not  more  than  three  ounces  every  two  hours,  and  that  only  during  the 
waking  hotu-s.  To  this  may  be  added  the  use  of  purgatives.  While 
diuretics  sometimes  fail  us,  we  can  always  secure  an  effect  from  purgatives. 
A  daily  morning  dose  of  Epsom  salt  or  Rochelle  salt  or  compound  jalap 
powder  is  given.  Elaterium  or  its  active  principle  elaterin  is  valuable. 
The  latter  is  less  apt  to  produce  nausea.  Its  dose  is  1/40  to  i/io  grain 
(0.00165  to  0.0066  gm.),  while  that  of  elaterium  is  i/io  to  1/2  gr.  (0.0066 
to  0.033  gm-)-  Then,  when  action  of  the  bowels  begins,  full  doses  of  digi- 
talis, caffein,  or  spartein,  associated  wdth  nitroglycerin,  are  almost  sure  to 
be  followed  b}-  copious  diiu^esis;  and  when  diiu-esis  starts  up  in  these  cases, 
it  is  astonishing  what  quantities  of  luine  are  passed.  The  association  of 
nitroglycerin  wnth  digitalis  at  this  stage  may  be  helpful.  The  object  of 
nitroglycerin  is  to  dilate  the  arterioles  and  allow  the  blood  to  move  freely 
through  them;  i    100  to  1/50  grain  (0.00065  to  0.0013  gm-)  may  be  given  as 


TREATMENT  OF  CHRONIC  VALVULAR  DEFECTS  599 

often  as  the  digitalis  and  simultaneously.  One  need  not  be  afraid  of  this 
drug.  To  be  of  value  it  must  be  given  in  large  doses  frequently  repeated. 
Elimination  by  the  bowels  and  kidneys  being  simultaneously  stimulated, 
the  disappearance  of  the  interstitial  fluid  is  greatly  favored  and  often 
rapidly  brought  about.  If  these  measures  be  associated  with  paracentesis 
of  the  chest,  which  may  be  required,  the  diuresis  set  up  is  often  enormous, 
while  the  swelling  rapidly  declines.  As  diuresis  is  established  or  hunger 
sets  in  the  quantity  of  milk  allowed  may  be  increased,  and  when  the  dropsy 
has  entirely  disappeared,  a  cautious  return  to  solid  food  may  be  permitted. 

A  time-honored  remedy  in  the  treatment  of  cardiac  dropsy  which  should 
not  be  overlooked  is  the  combination  of  calomel,  squills,  and  digitalis, 
the  so-called  Niemeyer  pill,  in  doses  of  1/2  grain  (0.03  gm.)  of  the  first  and 
I  grain  (0.065  gm-)  of  the  second  and  third  every  three  or  four  hours; 
this  is  sometimes  most  happy  in  its  results.  Still  another  remedy  often 
very  efficient  in  this  form  of  dropsy  is  theobromin.  It  is  obtained  from 
cacao,  and  is  chemically  closely  allied  to  caffein.  Like  caffein,  theobromin 
is  a  renal  diuretic  as  well  as  a  heart  tonic.  The  dose  which  is  most  satis- 
factory is  30  grains  (2  gm.)  in  the  24  hours,  conveniently  divided  into  doses 
of  7  1/2  grains  (0.5  gm.)  every  six  hours.  Larger  doses  may  be  given.  A 
better  diuretic  of  the  same  class  is  aceto-theocin  (double  salt  of  acetate  of 
sodium  and  dimethyl-xanthin  sodium).  It  may  be  given  in  doses  of  4 
to  8  grains  (10.25  to  0.5  gm.)  three  to  four  times  daily  in  capsule  or  solution. 

Caffein  is  an  excellent  heart  tonic  and  although  not  so  reliable  as  a 
diuretic  should  not  be  forgotten.  It  is  often  given  with  good  results  alter- 
nating with  the  infusion  of  digitalis.  It  may  be  used  hypodermicaUy  in 
shape  of  caffein  sodio-benzoate  in  3  grain  (0.2  gm). 

In  many  cases  there  comes  a  time  when  the  measures  above  described 
becom.e  inoperative.  Diuretics  will  not  act  and  purgatives  are  insufficient. 
Then  it  is  that  incisions  in  the  anasarcous  legs  or  Southey's  tubes  inserted 
in  the  legs  for  draining  off  the  liquid  effusion  are  sometimes  very  effici-ent. 
I  generally  prefer  the  incision,  an  inch  long  behind  the  inner  malleolus  of 
each  leg.  Enormous  quantities  of  fluid  are  thus  drained  off  after  which 
diuretics  again  become  active,  and  I  have  seen  many  a  case  rescued  from  the 
grave  for  a  time  at  least.  It  is  most  important  that  antiseptic  dressings 
should  be  employed  to  protect  the  incisions  against  infection. 

Treatment  of  Irregularity  of  Heart  Action  and  Palpitation. — For  these 
symptoms,  in  addition  to  the  cardiac  tonics  mentioned,  belladonna  is  also  a 
useful  remedy.  It  may  be  combined  with  digitalis.  A  good  belladonna 
plaster  placed  over  the  palpitating  heart  is  one  of  the  most  efficient  agents  in 
subduing  it.  Nitroglycerin  as  already  mentioned  is  often  very  useful  to 
the  same  end — i/ioo  grain  (0.00065  gm.),  rapidly  increased  to  1/50  grain 
(0.0013  gni-).  every  four  hours  or  oftener.  It  must  be  remembered  that 
nitroglycerin  is  not  a  heart  tonic  but  is  of  value  in  heart  disease  only  when 
one  desires  to  lower  peripheral  pressure  in  order  to  make  the  tonic  action  of 
digitalis  more  effective.  It  may  also  be  combined  with  digitalis,  as  pre- 
viously directed.  Cardiac  pain  is  also  sometimes  relieved  by  the  same 
remedies.  For  this,  however,  hypodermic  injections  of  morphin  are  some- 
times necessary  while  palpitation  may  require  the  same  drug. 

Treatment  of  Sudden  Acttte  Cardia  Dilatation. — Immediate  absolute  rest 


600  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

either  in  bed  or  on  a  chair  is  imperative.  Here  a  hypodermic  of  i/8  of  a 
grain  of  morphine  with  1/150  of  a  grain  of  atropin  wall  frequently  save  life. 
Rest  after  the  attack  must  be  insisted  upon,  together  with  the  use  of  digitalis 
and  other  remedies  spoken  of  above. 

DISEASES  OF  THE  MYOCARDIUM. 

The  heart  is  subject  to  alterations  in  its  muscular  substance  independent 
of  valvular  defect.  Hypertrophy,  dilatation,  fattj'  infiltration,  and  fatty 
metamorphosis  or  true  fatty  degeneration,  and  atrophy  are  the  most  im- 
portant. Acute  myositis,  abscess,  and  aneurj-sm  of  the  walls  of  the  heart 
are  such  rare  conditions  that  they  need  only  be  mentioned  in  passing,  espec- 
ially as  there  is  no  way  to  recognize  them  before  death. 

Hypertrophy  of  the  Heart. 

Etiology. — Hypertrophy  implies  an  overgrowth  of  muscular  tissue,  and 
is  naturally  the  result  of  extra  work,  increased  effort  to  overcome  increased 
resistance,  whatever  its  cause. 

The  resistance  needed  to  excite  increased  action  may  be  from  within  or 
from  without,  or  due  to  nervous  influence.  Resistance  from  within  is  occa- 
sioned by  obstruction  to  the  outflow  of  blood  from  the  heart  at  one  of  its 
orifices,  or  to  increased  intravascular  pressure.  Such  obstruction  is  offered 
in  the  case  of  the  left  ventricle  by  aortic  stenosis,  congenital  narrowing,  aortic 
insufficiency,  and  mitral  insufficiency.  Increased  intravascular  pressure  is 
caused  by  endarteritis  and  resulting  sclerotic  changes  in  the  vessel-walls,  by 
strong  contraction  stimulated  by  the  irritation  of  toxic  substances  in  the 
blood,  such  as  accumulate  in  Bright's  disease,  or  as  the  restilt  of  overeating 
or  excessive  drinking,  especially  of  large  quantities  of  beer;  finally,  by  exces- 
sive physical  exertion. 

External  obstruction  to  the  contraction  of  the  left  ventricle  is  found  in 
pericardial  adhesions  and  myocarditis.  Such  hypertrophy  is  always  eccen- 
tric. Hypertrophy  of  the  left  ventricle  from  nerv'ous  influence  is  seen  in 
exophthalmic  goiter  and  aUied  conditions,  and  in  long-continued  palpitation. 
Constant  mental  excitement  is  a  possible  cause. 

In  the  case  of  the  right  ventricle,  internal  resistance  is  produced  by  pul- 
monary congestion  due  to  mitral  regurgitation  or  to  mitral  stenosis,  to 
narrowing  of  the  pulmonary  vessels,  such  as  occurs  in  pulmonary  emphy- 
sema. Valvular  lesions  of  the  right  side  of  the  heart  produce  hypertrophy 
of  the  right  ventricle,  just  as  those  of  the  left  cause  it. 

Auricular  hypertrophy  is  always  eccentric — that  is,  while  the  walls  are 
thickened,  the  cavities  are  also  dilated.  Hypertrophy  of  the  left  auricle  is 
usually  caused  bj^  stenosis  of  the  mitral  orifice,  and  to  a  less  degree  is  a  result 
also  of  regurgitation  of  the  blood  in  incompetency  of  the  mitral  valve.  Hy- 
pertrophy of  the  right  auricle  might  also  be  expected  as  a  consequence  of 
regurgitation  of  blood  from  the  right  ventricle  to  the  right  auricle,  but  the 
resistance  to  the  further  backward  flow  into  the  veins  is  so  much  less  than  in 
the  left  side  disease,  h}-pertrophy  is  correspondingly  less  frequent.  In  like 
manner,  even  if  stenosis  of  the  tricuspid  orifice  is  present,  the  same  condi- 
tions prevent  any  marked  degree  of  hypertrophy  of  the  right  auricle. 


DILATATION  OF  THE  HEART  601 

In  all  cases  of  hypertrophy  due  to  disease  of  the  valves  it  is  likely  that  a 
certain  amount  of  distention  of  the  heart  cavity  by  blood  precedes  the  mus- 
cular overgrowth. 

Symptoms. — Hypertrophy,  being  a  process  of  compensation,  is  not  at 
first  attended  by  any  symptoms.  It  is  the  result  of  a  conservative  effort  of 
nattu-e,  by  means  of  which  symptoms  are  averted.  But  unlike  the  hyper- 
trophy of  the  muscles  of  the  blacksmith's  arm,  it  tends  ultimately  to 
degeneration,  and  thus  becomes  the  initial  link  in  a  chain  of  evil  which  is 
well  stated  by  J.  G.  Adami;!  "In  the  first  place,  it  leads  to  an  increased 
nutrition  of  the  walls  of  the  arteries;  increased  nutrition  leads  to  increased 
connective-tissue  growth  of  the  walls;  increased  fibrous  tissue  of  the  walls 
leads  to  contraction  and  increased  rigidity  of  those  walls;  the  increased 
rigidity  leads  to  increased  resistance  to  the  passage  of  the  blood  current. 
The  increased  resistance  requires  increased  propulsive  power  on  the  part  of 
the  ventricular  muscle — that  is  to  say,  increased  work ;  the  increased  work  of 
the  heart  leads  to  overgro^vth  and  hypertrophy,  and  \\^th  this,  heightened 
blood  pressure  and  further  increased  nutrition  of  the  walls,  and  now,  at 
last,  the  stage  is  reached,  this  vicious  circle  continuing,  in  which  either  the 
vessel  walls  give  way  or  the  heart."  From  this  standpoint  increased 
blood  pressure  alone  is  sufficient  to  explain  in  come  cases  the  anatomical 
changes — i.  e.,  the  arterial  sclerosis,  atheroma,  and  fibroid  thickening 
so  constantly  seen  in  valves  and  heart-walls  without  calling  on  chronic 
inflammation  or  specific  agency.  Certain  it  is  that  the  two  conditions 
react  on  each  other,  and  it  is  more  than  likely  that  the  former  (increased 
blood  pressure)  may  produce  the  latter  (chronic  inflammation)  de  novo, 
and  many  otherwise  unexplained  facts  are  rendered  clear. 

With  degeneration  we  begin  to  have  symptoms  which  are  at  first  inter- 
mittent, brought  about  onlj^  by  some  temporarv'  cause  which  excites  the 
heart,  such  as  exercise,  mental  emotion,  fatigue,  mental  or  phj'sical,  tobacco, 
or  alcohol.  There  is  a  feeling  of  vague  chscomfort  about  the  heart,  sel- 
dom amounting  to  pain,  sometimes  increased  when  the  patient  lies  on  the 
left  side.  To  this  may  be  added  palpitation,  a  consciousness  of  the  beating 
of  the  arteries  in  the  head,  dizziness,  headache,  ringing  in  the  ears,  flushes 
or  flashes  of  light,  and  a  tendency  to  hemorrhage  of  the  nose.  So  long  as 
the  integrity  of  the  heart  muscle  is  maintained  the  blood  pressiire  in  certain 
cases  is  increased  and  reaches  i6o  to  200  or  more  mm.;  as  the  heart  begins 
to  degenerate  the  blood  pressure  rapidly  falls. 

Physical  Signs. — While  symptoms  other  than  physical  signs  may  be 
wanting,  the  latter  are  present  from  the  beginning,  increasing  with  the 
duration  of  the  hypertrophy.  These  have  been  for  the  most  part  con- 
sidered when  treating  of  valvular  diseases.  Accentuation  of  the  aortic  second- 
sound  in  hypertrophy  of  the  left  ventricle  and  of  the  pulmonic  second  in 
hypertrophy  of  the  right  ventricle  should  be  spoken  of. 

Dilatation  of  the  Heart. 

Definition. — This  has  already  been  defined,  so  far  as  the  state  of  the 
chambers  is   concerned.     Dilated    heart    is   of    two    kinds;    first,   acute 

I  "Notes  upon  Cardiac  Hypertrophy,"  "Montreal  Medical  Journal,"  May,  1895. 


602  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

dilatation;  and,  second,  chronic  dilatation,  or  dilatation  accompanied 
by  fatty  degeneration.  Of  the  latter,  two  varieties  exist:  (i)  That  succeed- 
ing valvular  disease;  (2)  that  succeeding  hypertrophy  due  to  muscular 
effort,  especially  when  associated  with  alcoholic  intemperance  and  other 
forms  of  dissipation.  Acute  dilatation  may  be  unassociated  with  structural 
change,  except  as  to  mechanical  arrangement  of  the  muscular  elements. 
Cloudy  swelling  may  be  present.  The  latter  may  be  associated  with  fatty 
change. 

Etiology. — Chronic  dilatation  is  the  last  stage  in  a  valvular  disease  the 
result  of  failing  nutrition.  The  conditions  under  which  this  manifests  itself 
have  been  described.  Acute  dilatation  without  vahodar  defect  is  the 
result  of  prolonged  muscular  effort,  such  as  occurs  in  rowing,  running,  and 
mountain-climbing.  Moderate  degrees  of  distention  occur  with  any  decided 
muscular  effort.  The  more  marked  degrees  capable  of  mischievous  conse- 
quences are  the  result  of  prolonged  severe  muscular  exertion.  The  effect  of 
moderate,  well-regulated  exercise  on  the  heart,  known  as  training,  by  which 
endurance  is  developed,  is  to  produce  eccentric  hypertrophy,  or  hypertrophy 
with  dilatation,  which  is  not  dilatation  in  the  sense  under  consideration — 
enlargement  of  the  cavity  with  thinning  of  the  walls.  The  right  heart  is 
the  seat  of  such  dilatation.  In  overexertion  the  harmful  effect  of  excessive 
acute  strain  is  averted  for  a  time  by  the  safety-valve  action  of  the  tricuspid 
valve,  permitting  a  regurgitation  of  blood  into  the  right  auricle.  Dilatation 
has  exceeded  its  physiological  limit  when  the  ca\'ity  is  no  longer  able  to 
empty  itself  of  blood.  While  moderate  degrees  of  acute  dilatation  may  be 
recovered  from,  either  rapidlj-  or  slowly,  dilatation  may  be  carried  to  degrees 
at  which  recovery  is  impossible  and  death  results.  Such  results  have 
followed  rowing  and  mountain-climbing. 

The  so-called  -irritable  heart,  to  which  attention  was  first  called  by  J.  M. 
Da  Costa  in  a  graphic  description  based  on  a  study  of  the  cases  of  soldiers 
in  the  American  Civil  War,  is  an  example  of  an  abnormally  dilated  heart, 
a  heart  in  which  compensation  has  failed.  Sudden  dilatation  may  happen 
to  hearts  whose  muscular  substance  is  degenerated,  though  seemingly  hyper- 
trophied,  as  in  chronic  Bright's  disease,  where  overexertion  often  brings 
on  dilatation.  In  a  few  instances  in  malignant  forms  of  the  infectious 
diseases,  such  as  scarlet  fever  and  diphtheria,  the  nutrition  of  the  heart 
may  be  so  rapidly  impaired  by  the  toxic  agency  which  causes  the  disease 
that  dilatation  occurs  wath  very  little  or  no  undue  intravascular  pressure. 
All  these  belong  to  the  second  category,  that  of  chronic  or  slow  dilatation. 

Symptoms. — The  symptoms  of  "heart  strain"  are  sudden  pain  in  the 
region  of  the  heart  or  epigastrium,  Jaintness,  shortness  of  breath,  and  rapid, 
feeble  action  of  the  heart.  If  it  be  not  immediately  fatal,  the  symptoms  may 
pass  off,  but  are  renewed  on  the  slightest  exertion.  In  the  acute  cases 
described  as  due  to  the  toxic  causes  of  infectious  disease,  sudden  death  may 
be  the  only  s^Tiiptom.  In  some  cases  it  may  be  preceded  or  not  by  very 
brief  precordial  distress.  Less  serious  degrees  may  be  associated  with 
faintness  or  palpitation  on  exertion,  extreme  feebleness  of  the  heart's  action, 
and  dyspnea.  It  is  rather  characteristic  for  these  symptoms  to  pass  away 
when  the  patient  is  at  rest,  to  be  renewed  on  the  slightest  exertion. 

Symptoms  growing  out  of  dilatation  of  the  heart,  going  also  to  make 


DILATATION  OF  THE  HEART  603 

up  the  sum  of  those  constituting  chronic  valvular  disease  with  failure  of 
compensation,  are  general  venous  congestion,  dropsy,  feeble,  frequent,  and 
irregular  radial  pulse — rarely,  on  the  other  hand,  a  slow  pulse.  Frequent 
and  irregular  pulse  may  be  due  to  impaired  pneiunogastric  inhibition  the 
result  of  anemia  of  the  brain,  slow  pulse  to  scanty  nutrition  and  a  loss  of 
the  natural  irritability  of  heart  muscle.  To  anemia  especially  affecting 
the  medulla  oblongata  may  be  ascribed  Cheyne-Stokes  breathing,  also  a 
symptom  of  the  terminal  stage  of  the  disease.  To  it  may  be  ascribed,  too, 
symptoms  simulating  apoplexy,  which  characterize  the  slower  dying  in  some 
of  these  cases.  Palpitation,  angina  pectoris,  and  dyspnea — cardiac  asthma, 
with  syncopal  attacks,  coldness,  and  slow  pulse  (30  to  40) — are  all  symp- 
toms more  or  less  associated  with  dilatation  of  the  heart.  It  is  further 
characteristic  of  these  symptoms  of  dilatation  that  they  are  often  not 
transient  or  amenable  to  treatment  by  the  usual  heart  tonics,  of  which 
digitalis  is  the  type. 

In  some  instances,  especially  in  the  dilated  heart  of  pernicious  anemia, 
there  may  be  a  full,  strong,  and  regular  pulse,  but  in  the  majority  of  cases 
the  blood  pressure  is  lowered. 

High-colored,  scanty  urine  of  high  specific  gravity,  sometimes  contain- 
ing hyaline  casts  and  blood-disks,  also  result  from  cardiac  dilatation. 

Physical  Signs. — When  the  termination  is  not  immediate,  physical  signs 
may  be  recognized.  To  inspection,  the  impulse,  if  visible,  may  be  diffused 
over  a  wide  area,  but  is  feeble  and  fluttering,  a  point  of  greatest  intensity 
or  an  apex-beat  being  often  wanting.  At  times  it  is  found  higher  up  and  to 
the  left  of  its  normal  position.  If  the  right  heart  is  chiefly  involved,  the  beat 
as  far  as  caused  by  the  left  apex,  is  completely  wanting,  while  an  impulse 
may  be  felt  below  or  to  the  right  of  the  ensiform  cartilage,  as  well  as  a  wavy 
impulse  in  the  fourth,  fifth,  and  sixth  interspaces  to  the  left  of  the  sternum. 
A  pulsation  may  be  seen  in  the  second  left  interspace,  which,  while  some- 
times presystolic,  is  commonly  systolic.  In  the  latter  event  it  may  be  a 
further  expansion  of  an  already  dilated  auricle  by  blood  regurgitating 
during  systole  of  the  left  ventricle;  or  if  presystolic,  it  may  be  the  pulse 
of  auricular  systole.  Such  at  least  are  possible  explanations.  The  fact 
that  at  autopsies,  even  in  extreme  dilatation,  the  left  auricle  is  found  so 
far  back  from  the  thoracic  wall  as  to  be  scarcely  able  to  beat  against  the 
second  interspace,  does  not  preclude  the  possibility  of  this  during  life.  In 
dilatation  of  the  right  auricle,  on  the  other  hand,  there  is  sometimes  seen  an 
impulse  in  the  third  interspace  on  the  right  side  which  is  clearly  systolic 
and  due  to  regurgitation  from  the  right  ventricle  during  its  systole.  The 
pulsating  symptoms  described  in  this  paragraph  are  commonly  seen  in 
persons  only  with  thin  chest-walls.  A  vauable  diagnostic  sign  is  the  sharp, 
short  first  sound  resembling  the  second  sound  due  to  the  loss  of  the  muscular 
quality. 

To  percussion  there  is  increased  dullness  to  the  right  and  downward 
toward  the  epigastrium  or  to  the  left  beyond  the  normal  line,  though  these 
boundaries  may  be  obscured  by  an  emphysematous  lung.  The  results  of 
auscultation  are  greatly  influenced  by  complications.  If  cardiac  murmurs 
are  present,  they  may  obscure  all  else.  On  the  other  hand,  previous  mur- 
murs may  disappear.     The  impulse  is  feebly  heard  as  well  as  felt;  the 


604  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

first  sound  is  feeble  but  pure —  that  is,  shorter  and  more  like  the  second, 
lacking,  as  it  does,  the  muscidar  element.  It  may  be  scarcely  audible, 
even  in  the  absence  of  murmurs.  It  is  sometimes  reduplicated  because 
of  asynchrony  in  the  action  in  the  two  halves  of  the  heart.  Sometimes 
there  is  a  loud  systolic  murmur  at  the  apex,  due  to  relative  insufficiency 
of  the  mitral  valve,  the  true  nature  of  which  becomes  apparent  only  in  the 
event  of  its  disappearance.  The  second  pulmonic  sound  may  remain 
sharp  if  there  is  dilatation  only  of  the  left  ventricle  and  there  is  compensatory 
hypertrophy  of  the  right;  feeble  if  the  right  ventricle  is  involved.  Finally, 
there  is  intermittent  and  irregular  action;  at  times  the  characteristic  gallop 
rhythm,'-  which  is  almost  pathognomonic  of  dilatation,  is  present.  The 
pulse  is  very  rapid  and  feeble. 

Diagnosis. — An  acknowledged  difficult  matter  at  times  is  the  dis- 
tinction of  pericarditis  with  ejffusion  from  the  dilated  heart.  Whether  in- 
spection furnishes  any  information,  depends  mainly  upon  the  stoutness  or 
leanness  of  the  patient.  In  the  stout  person  nothing  is  recognizable  in 
either  condition.  In  the  thin-chested  the  impulse  is  visible  and  wave-like 
in  dilatation;  it  is  not  visible,  or  barely  so,  in  pericardial  effusion.  The 
same  is  true  of  palpation,  except  that,  if  the  patient  leans  forward,  the 
imptilse  may  be  felt  in  pericarditis. 

Percussion  affords  the  most  valuable  information.  If  it  brings  out 
the  well-known  triangular  shape  of  dullness,  with  the  apex  toward  the  inner 
end  of  the  left  clavicle,  and  the  base  in  the  fifth  or  sixth  interspace,  espe- 
cially in  the  absence  of  a  cardiac  impulse,  there  must  be  pericardial  effusion. 
Percussion  of  the  dilated  heart  elicits  a  quadrangular  shape  or  triangular 
with  the  apex  downward.  To  auscultation,  while  the  heart-sounds  have 
lost  their  characteristic  sharpness,  they  still  contrast  with  the  distant  and 
muffled  sounds  in  pericardial  effusion.  Especially  if  there  is  left  any  of 
the  original  hypertrophy,  the  second  sound  will  retain  some  of  its  sharpness, 
while,  if  there  happens  to  have  been  valvular  disease,  the  murmurs  remain 
to  help  us. 

Bamberger's  sign,  described  on  p.  557,  must  be  sought  for  in  evidence 
of  pericardial  effusion.  There  may  be  encroachment  on  the  lung  in  dila- 
tation, but  it  is  very  much  less  in  dilatation  than  in  pericarditis  with  eftusion. 
This  encroachment  in  the  case  of  dilatation  does  not  give  rise  to  Skodaic 
resonance  in  the  axilla.  While  there  is  shortness  of  breath  in  both,  it  is 
less  pronounced  in  dilatation  and  more  influenced  by  exertion,  being  less 
while  the  patient  is  quiet. 

Prognosis. — This  is  ultimately  fatal  in  chronic  dilatation;  in  fact,  the 
stage  of  dilatation  is  the  stage  in  which  remedies  become  unavailing.  At 
the  same  time,  marvelous  resiilts  sometimes  follow  treatment.  We  have  seen 
general  anasarca  with  effusions  in  the  serous  cavities  disappear  when  least 
expected,  so  that  one  is  never  justified  in  giving  an  unqualifiedly  unfavorable 
prognosis.  In  acute  dilatation  the  prognosis  depends  upon  the  degree  of 
the  stretching  and  degenerating.  If  they  are  extreme,  death  follows  in- 
stantly. If  not  followed  b}^  immediate  death  slow  improvement  and 
ultimate  recovery  are  possible. 


'  For  explanation  of  gallop  rhythm  see  Barth  and  Roger,  "  Traits  Pratique  d'Auscultation."     Thirteenth 
Edition.  Paris,  1898.  p.  352. 


MYOCARDIAL  DISEASE  605 

DEGENERATIONS  OF  THE  CARDIAC  MUSCLE. 

The  heart  muscle  is  subject  to  parenchymatous  degeneration,  to  fatty 
degeneration,  to  fatty  infiltration  to  amyloid  degeneration,  to  the  hyaline 
transformation  of  Zenker,  to  calcareous  degeneration,  and  to  the  changes 

known  as  brown  atrophy. 

Parencyhm.\tous  or  Albuminoid  Degeneration  (Cloudy  Swell- 
ing).— This  is  a  change  in  which  the  sarcous  substance  is  converted  into 
granular  matter  of  albuminoid  composition,  which  produces  also  more  or 
less  indistinctness  in  the  striated  appearance  of  the  fasciculi.  The  albu- 
minoid composition  of  the  product  is  attested  by  its  solubility  in  acetic  acid, 
and  its  insolubility  in  either.  The  general  effect  is  one  of  softening  and 
flaccidity. 

It  is  ascribed  to  some  toxic  agency,  and  occurs  most  frequently  in  the 
infectious  fevers — typhoid  fever,  scarlet  fever,  diphtheria,  and  the  like.  It 
was  at  one  time  considered  a  consequence  of  high  temperature,  but  this  view 
is  no  longer  held.  It  is  believed  also  to  be,  at  times,  at  least,  the  first  stage 
of  fatty  degeneration,  or  to  precede  fatty  degeneration.  It  is  certainly 
at  times  associated  with  it.  Cloudj^  swelling  may  disappear  and  the  muscle 
resume  its  natural  histology. 

Fatty  Degeneration  or  Fatty  Metamorphosis. — In  this  change, 
the  sarcous  substance  of  the  muscular  fasciculi  is  directly  converted  into 
globular  fat,  as  contrasted  with  the  condition  of  fatty  infiltration,  in  wnich 
the  fat  is  deposited  between  the  fasciculi.  The  little  fat  drops — and  they 
are  very  minute,  as  a  nale — are  seen  in  rows  parallel  to  the  fibrills  of  the  fas- 
ciculus, and  all  transverse  striation  has  disappeared.  As  intimated,  the 
cause  of  such  degeneration  is  an  interference  with  the  proper  nutrition  of  the 
heart  muscle. 

It  Taa.y  be  general,  when  it  has  its  most  frequent  expression  in  the  di- 
lated heart  which  succeeds  upon  hypertrophy,  invohdng  the  walls  of  one 
or  more  cavities.  It  is  also  a  result  of  the  impaired  nutrition  of  old  age,  of 
the  grave  infectious  diseases,  and  of  cachectic  states  generally — such,  for 
example,  as  pernicious  anemia.  In  the  infective  diseases  and  cachexias  it 
may  be  associated  mth  parenchymatous  degeneration  or  succeed  upon  it. 
It  is  also  a  result  of  the  action  of  certain  poisons,  as  phosphorous  and  arsenic, 
the  effects  of  which  may  extend  to  other  muscular  organs.  Under  these 
circumstances,  the  heart  is  generally  enlarged  (dilated),  flabby,  and  relaxed, 
of  a  light  yellow  or  yellowish-brown  color,  and  very  friable,  permitting  the 
finger  to  be  easily  poked  through  it.  The  papillary  muscles  and  the  tra- 
becule in  the  left  ventricle  may  be  the  seat  of  circumscribed  fatty  degenera- 
tion, and  be  dotted  and  streaked  with  yellow,  fatty  matter.  Unlike  par- 
enchymatous degeneration,  fatty  degeneration,  when  once  established,  is 
considered  irremediable. 

Fatty  degeneration  of  the  heart  may  also  be  circumscribed  in  small  foci 
variously  distributed.  Thus,  it  may  be  confined  to  the  superficial  or  sub- 
pericardial  layers,  when  it  is  especially  the  result  of  pericarditis.  Or  there 
may  be  nvunerous  pinhead-sized  foci  in  the  subendocardial  layer  in  cases  of 
extreme  dilatation. 


606  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

Finally,  there  may  be  a  single  focus  in  the  substance  of  the  left  ven- 
tricle of  the  septum,  due  to  total  obstruction  of  one  of  the  branches  of  the 
coronary  artery,  usually  the  anterior,  by  a  thrombus  or  embolus.  The 
product  is  an  area  of  fatty  degeneration  known  also  as  anemic  necrosis,  or 
white  infarct.  In  the  early  stage  the  infarction  is  brownish-yellow  or  hemor- 
rhagic. Minutely  examined,  the  muscular  fasciculi  are  without  nuclei,  and 
later  they  break  up  into  a  cheesy  detritus.  The  infarct  is  not  always  thus 
made  of  fatty  d6bris,  but  may  present  a  hyaline  appearance.  It  may  be 
the  seat  of  rupture,  and  thus  cause  hemorrhage  into  pericardium,  and  im- 
mediate death. 

Diagnosis. — The  diagnosis  of  fatty  degeneration,  so  far  as  recognizable, 
is  that  of  dilatation,  slight  degrees  and  circumscribed  fatty  degeneration 
being  unrecognizable,  while  considerable  areas  bf  partial  degeneration  may 
also  exist  without  exhibiting  symptoms.  In  fact,  the  presence  of  some 
dilatation  of  the  cardiac  cavities  seems  to  be  necessary  to  the  production 
of  symptoms — the  feeble  pulse,  palpitation,  and  dyspnea  being  symptoms 
of  the  dilatation,  rather  than  the  fatty  degeneration. 

Prognosis. — This  is  grave.  It  is  impossible  to  restore  the  degenerated 
muscular  substance  to  its  natural  structure.  With  degeneration  estab- 
lished death  is  liable  to  occur  suddenly,  and  remedies  which  avail  with  an 
integral  organ  are  useless  here. 

Treatment. — This  embraces  that  of  cardiac  dilatation.  Acute  attacks 
should  be  met  by  stimulants,  of  which  alcohol,  aromatic  spirit  of  ammonia. 
Strychnin  is  also  indicated,  and  may  be  used  hypodermically. 

Fatty  Infiltration  or  Fatty  Overgrowth. — Strictly  speaking,  this 
condition  is  not  a  degeneration  of  the  heart  muscle,  though  it  leads  ulti- 
mately to  fatty  metamorphosis.  It  is  the  cor  adiposimi  of  the  older  authors, 
and  differs  from  fatty  metamorphosis  in  that  the  fat  is  infiltrated  between  the 
muscular  fasciculi.  In  the  true  cor  adiposmn,  the  fat  extends  deep  into  the 
substance  of  the  muscle,  sometimes  as  far  as  the  endocardium.  It  covers 
also  the  outside  of  the  heart,  at  times  so  completely  that  the  true  muscular 
structure  is  invisible.  This  infiltration  sooner  or  later  interferes  with  the 
proper  nutrition  of  the  muscular  substance,  a  true  fatty  degeneration  re- 
sults, with  its  symptoms,  so  far  as  any  are  manifested,  and  becomes  ulti- 
mately also  a  cause  of  death. 

The  fatty  infiltrated  heart  is  commonly  a  part  of  general  obesity,  and 
occurs,  therefore,  at  a  time  of  life  when  this  is  usual — that  is,  between  the 
ages  of  40  and  70  years — and  is  more  than  twice  as  frequent  in  men  as 
in  women. 

The  condtion  is  inferred  from  the  presence  of  extreme  obesity  asso- 
ciated with  .signs  of  cardiac  weakness. 

The  treatment  is  that  of  obesity. 

Amyloid  infiltration  invades  the  heart  as  it  does  other  organs,  at- 
tacking the  blood-vessels  and  intermuscular  connective  tissue.  Zenker's 
hyaline  transformation  attacks,  on  the  other  hand,  the  muscular  fasciculi, 
causing  them  to  appear  swollen  and  transparent,  and  the  strife  to  be  indis- 
tinct or  absent. 


MYOCARDITIS  607 

Calcareous  infiltration  is  a  rare  condition,  in  which  the  muscular 
fasciculi  are  infiltrated  with  lime  salts. 

MYOCARDITIS. 
Chronic  Myocarditis  or  Fibromvocarditis. 

Synonyms. — Fibroid  Degeneration  of  the  Myocardium;  Fibroid  Heart; 
Fibrous  Myocarditis;  Interstitial  Myocarditis;  Indurated  Degeneration; 
Myodegeneration;  Sclerosis  of  the  Coronary  Arteries. 

Definition. — A  chronic  disease  of  the  cardiac  muscle  in  which  there  is 
more  or  less  substitution  of  the  normal  substance  by  fibroid  or  cicatricial 
tissue,  either  localized  in  patches  or  diffused  throughout  the  organ. 

Etiology  and  Pathology. — The  condition  is  not,  strictly  speaking,  in- 
flammatory, the  patches  representing  transformed  areas  of  anemic  necrosis, 
due  to  obstructive  disease  of  the  coronary  arteries  and  branches.  The  dis- 
ease in  the  coronary  arteries  is  endarteritis,  resulting  in  arterio-sclerosis. 
Through  a  diminished  blood-supply,  it  causes  degeneration  of  the  muscular 
fasciculi,  and  their  substitution  by  fibrous  tissue.  Only  in  the  event  of  such 
diminished  supply  do  the  changes  occur.  Hence  it  is  that  arterio-sclerosis  of 
the  coronary  arteries  is  not  always  followed  by  fibroid  change.  The  causes 
of  arterio-sclerosis  of  the  coronary  arteries  are  those  of  endarteritis  elsewhere. 
The  tendency  to  arterio-sclerosis  is  often  hereditary.  It  is  a  disease  also 
which  seldom  occurs  prior  to  middle  life,  though  sometimes  seen  surprisingly 
early.  It  might  be  said  that  it  is  natural  to  old  age— one  of  its  evolutional 
terminations.  In  pure,  uncomplicated  cases  of  myocarditis  the  valves  are 
normal,  while  the  muscle,  on  examination,  is  found  dotted  with  white,  shin- 
ing areas  present  in  varying  numbers.  Minutely  examined,  these  are  found 
made  up  of  pure  or  partly  fibroid  tissue,  the  muscular  substance  being  cor- 
respondingly destroyed.  They  are  seated  for  the  most  part  in  the  left  ven- 
tricle toward  the  apex  and  in  the  anterior  wall,  though  they  may  be  found 
elsewhere.  They  may  often  be  seen  from  the  endocardial  or  pericardial 
surface  as  cicatricial-like  depressions.  Sometimes  there  is  a  single  large 
patch  known  as  a  fibroid  patch.  The  papillary  muscles  may  exhibit  the 
same  fibroid  change.  Another  cause  of  fibrosis  is  pericarditis  which  pro- 
duces small  and  larger  areas  of  degeneration  in  the  shape  of  the  milk-white 
fibroid  patch  on  the  surface  of  the  heart  and  extending  more  or  less  into  its 
substance.  Mural  endocarditis  may  produce  similar  patches  on  the  inner 
surface  of  the  heart. 

The  fibroid  change  may  also  be  associated  with  valvular  disease,  the 
mechanical  impediment  to  the  movement  of  blood  in  this  condition  being 
the  cause  of  a  chronic  venous  congestion,  which  results  in  a  fibroid  infiltra- 
tion; or  the  valvulitis  may  give  rise  to  embolism  of  the  coronary  arteries  or 
branches,  thus  cutting  off  nutrition.  From  the  cardiac  thrombosis  which 
sometimes  results  there  may  arise  cerebral,  renal,  and  pulmonary  embolism. 
Long-standing  emphysema  of  the  lungs  results  in  similar  congestion ;  so  does 
obstruction  of  the  pulmonary  artery  from  any  cause. 

A  further  result  of  the  fibroid  change  is  dilatation  of  a  part  or  of  the 
whole  of  one  of  the  heart  cavities,  producing  in  the  former  instance  what  is 


608  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

known  as  cardiac  aneurysm.  Fibrosis  may  also  be  associated  with  hyper- 
trophy without  valvular  disease,  though  the  recognition  of  such  combina- 
tion before  death  must  be  a  matter  of  inference,  based  on  the  presence  of 
arterio-sclerosis  elsewhere  and  of  the  causes  of  such  hypertrophy. 

Recently  the  term  myocarditis  has  been  extended  to  include  fatty  as 
well  as  fibroid  change  since  the  same  symptoms  may  result  from  both. 

Symptoms. — Slight  degrees  of  fibroid  change  occasion  no  symptoms, 
while  autopsies  even  disclose  advanced  stages  of  indurative  myocarditis 
which  were  not  suspected.  In  consequence  of  the  frequent  association,  too, 
of  endocarditis  and  pericarditis,  the  s^inptoms  of  these  diseases  are  often 
combined  and  mask  the  distinctive  sj'^mptoms  of  the  fibroid  change.  Un- 
masked, the  symptoms  are,  in  a  word,  those  of  dilatation  of  the  heart,  in- 
cluding dyspnea,  often  so  severe  that  the  patient  cannot  lie  down.  With 
this  may  be  associated  Cheyne-Stokes  breathing,  commonly  occurring  during 
sleep.  There  may  be  palpitation,  with  small,  frequent,  and  irregidar  pidse, 
or  the  pulse  may  be  persistently  slow.  There  is  precordial  oppression,  with 
attacks  of  faintness,  and,  finally,  venous  stasis  with  cyanosis,  general  edema, 
congestion  of  the  liver,  stomach,  and  kidneys,  feeble  digestion,  scanty  urine,  and 
albuminuria.  These  symptoms  may  set  in  gradually  or  suddenly.  On 
such  a  heart,  digitalis  and  other  heart  tonics  are  often  without  effect. 
Angina  pectoris  is  also  a  symptom  of  indurative  myocarditis,  though  it  also 
occurs  in  other  cardiac  diseases,  especially  aortic  stenosis.  It  will  be  de- 
scribed later. 

Physical  Signs. — Physical  examination  recognizes  a  feeble  impulse  which 
may  be  displaced  to  the  left,  often  scarcely  appreciable,  and,  on  percussion, 
enlargement  of  the  cardiac  area.  The  first  sound  lacks  its  muscular  element 
and  is  more  lil<:e  the  second — more  purely  valvular,  aud  therefore  short. 
Both  sounds  maintain  for  a  time  considerable  distinctness,  but  ultimately 
grow  feeble.  Occasionally  there  may  be  a  mitral  murmur,  which  may  be 
relative  and  transitory  or  permanent.  Such  murmur  is  explained  by  the 
experiments  of  Ludwig  and  Hesse,  already  alluded  to,  and  more  recently 
confirmed  by  Krehl.  These  go  to  show  that  a  certain  integrity  of  the 
muscles  about  the  mitral  orifice  or  of  the  papillary  muscles  is  necessary  to 
a  complete  closure  of  the  latter.  Such  integrity  is  impaired  by  myocarditis, 
and  the  resulting  murmur  increases  the  difficulty  of  diagnosis.  The  murmur 
is  systolic,  soft,  low  pitched,  heard  at  the  fourth  rib.  There  is,  however, 
usually  absence  of  accentuation  of  the  pulmonic  second  sound  characteristic 
of  mitral  regurgitation,  though  this  may  also  be  relatively  present  if  the 
right  ventricle  happen  to  be  less  severely  involved  than  the  left.  There 
may  be  systolic  shock  greater  than  would  be  expected  from  the  feebleness 
of  the  cardiac  impulse.  The  second  sound  is  also  sometimes  reduplicated, 
or  there  may  be  gallop  rhythm  sometimes  early.  The  mitral  murmur  in  the 
fibroid  heart  is  more  variable  and  more  subject  to  intermissions  than  that  of 
mitral  regurgitation  due  to  valvular  disease.  The  sudden  addition  of  a 
mitral  systolic  murmur  in  a  fibroid  heart  previously  without  murmur  may 
also  indicate  a  lacerated  valve. 

Diagnosis. — -This  is  often  difficult,  requiring  the  opportunity  of  pro- 
longed study  of  the  case.  For  the  most  part,  we  are  compelled  to  rely  on 
the  absence  of  the  symptoms  and  signs  of  valvular  disease,  and  the  presence 


ACUTE  SUPPURATIVE  MYOCARDITIS  609 

of  the  symptoms  of  dilatation,  the  evidences  of  arterio-sclerosis  elswhere, 
a  persistently  slow  pulse,  angina  pectoris,  the  histor\'  of  syphilis  and  of 
other  causes,  together  with  the  age  of  the  patient.  When  the  fibroid  con- 
dition is  associated  with  murmurs,  the  diagnosis  is  still  more  difficult,  and 
must,  indeed,  be  a  matter  of  probability,  if  even  suggested,  so  much  more 
likely  are  the  signs  to  be  interpreted  as  those  of  valvular  disease,  with 
which,  however,  the  myocarditis  may  be  associated.  The  presence  of 
radial  sclerosis  is  strongly  confirmatory,  but  not  essential. 

Prognosis. — This  is  grave,  or,  to  say  the  least,  uncertain.  Associated 
as  it  is  with  sclerosis  and  narrowing  of  the  coronary  arteries  or  branches, 
complete  obstruction  is  liable  to  occur  at  any  time,  producing  sudden 
death.  On  the  other  hand,  the  patient  may  live  for  many  years  with  the 
heart  the  seat  of  considerable  fibroid  change. 

Treatment. — This  must  mainly  consist  in  treating  the  causes,  and  in 
a  proper  hygienic  management.  Habits  of  overeating  and  excessive  drink- 
ing should  be  overcome.  The  avoidance  of  overexertion,  associated  with 
just  sufficient  exercise  to  develop  the  heart  healthfully,  should  be  observed. 
Outdoor  life  and  a  proper  hygiene  of  the  skin  and  body  by  bathing  and 
massage  are  important. 

Drugs  which  will  remove  the  diseased  condition  of  the  coronary  arteries 
and  fibroid  overgrowth  do  not  exist.  Still,  the  reputation  of  iodid  of 
potassium  as  a  remover  of  fibroid  overgrowth  and  for  the  cure  of  syphilitic 
disease  should  be  availed  of.  The  iodid  is  also  serviceable  in  producing 
vascular  dilatation  and  facilitating  the  movement  of  the  blood.  For  the 
symptoms  of  stasis  and  heart  weakness,  of  dyspnea  and  of  angina  pectoris, 
the  treatment  is  the  same  as  that  for  these  conditions  under  other  circimi- 
stances.     Digitalis  is  rarely  indicated  and  ma}^  do  harm. 

The  "Oertel  cure,"  consisting  in  graduated  hill  climbing,  proteid  food 
and  restricted  intake  of  liquid,  is  recommended. 


Acute  Suppurative  Myocarditis. 

Synonym. — Abscess  of  the  Heart. 

This  is  a  rare  condition.  It  is  always  metastatic  or  pyemic  in  origin, 
in  association  with  puerperal  fever,  malignant  endocarditis,  or  other  septic 
processes.  It  may  occur  in  the  septum,  as  well  as  the  outer  ventricular 
walls. 

As  such  it  is  not  recognizable  before  death,  and  is  commonly  discovered 
at  autopsies.  It  may,  however,  rupture  into  the  heart  cavities,  causing 
other  metastatic  abscesses,  or  into  the  pericardium,  causing  septic  pericar- 
ditis and  early  fatal  termination. 

Aneurysm  of  the  Heart. 

This  is  a  term  given  to  two  conditions : 

I.  A  saccular  projection  from  the  ventricular  surface  of  a  sigmoid  or 
cuspid  leaflet,  where  the  valve  is  weakened  by  ulceration  through  one  of 
the  lamella,  the  intravascular  or  intracardiac  pressure  furnishing  the  dis- 


610  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

tending  force.     It  is  much  more  common  in  the  aortic  segments.     The  sac- 
cule may  ultimately  perforate,  causing  laceration  of  the  valve. 

2.  Projection  outward  of  a  circumscribed  portion  of  the  muscular  wall, 
which  has  been  weakened  by  the  fibroid  patch  or  by  an  injury  to  the  wall. 
Here,  naturally,  the  left  ventricle,  too,  suffers,  and  near  the  apex  in  more 
than  half  the  cases.  The  resulting  pullulation  varies  in  size  from  2/5  inch 
(i  cm.)  or  lesr  to  dimensions  equal  to  those  of  the  heart  itself.  The  aneu- 
rysm may  be  sacculated  or  partitioned  and  even  multiple. ' 

There  are  no  symptoms  by  which  the  condition  may  be  recognized 
with  any  degree  of  probability.  It  may  also  terminate  fatalh'  by  rupture 
into  the  pericardium. 

Rupture  of  the  Heart. 

Rupture  of  the  normally  integral  heart  muscle  does  not  occur.  It  is 
only  when  weakened  by  disease  that  such  an  event  is  possible.  Fatty  meta- 
morphosis furnishes  the  most  frequent  predisposing  condition,  in  77  out  of 
100  cases  collected  by  Quain.  The  softening  due  to  obstruction  of  a  branch 
of  the  coronary  artery,  as  already  described,  and  known  as  massive  soften- 
ing, is  the  most  frequent  cause  of  heart  rupture,  but  the  fibroid  change, 
abscess,  or  tdceration,  are  all  conditions  which  at  times  precede  rupture. 
Morbid  gro^vths  in  the  heart-wall,  such  as  giunmy  tumor,  cysts,  and  car- 
cinoma, are  also  possible  causes.  Segmentation  and  fragmentation  of  the 
muscle  has  been  observed  but  this  condition  is  by  some  considered  as  of 
doubtful  occurrence. 

These  preliminary  conditions  presupposed,  any  unusual  strain,  physi- 
cal or  mental,  is  sufficient  to  produce  rupture,  though  this  is  not  always 
necessary,  especially  in  the  case  of  the  white  infarct,  where  the  degeneration 
is  so  great  as  to  admit  rupture  with  the  ordinary  pressure.  It  is  naturally 
an  event  of  the  second  and  third  half-centuries  of  life.  It  has  occurred 
among  the  insane  when  perfectly  quiet. 

The  anterior  portion  of  the  left  ventricular-waU  near  the  septum  is  the 
favorite  seat.  Rupture  is  rarely  recognized  before  death,  which  usually 
follows  in  the  course  of  a  few  hours. 

The  symptoms  are  precordial  pain,  a  sense  of  oppression,  dyspnea, 
pallor,  pulselessness,  and  collapse.  There  may  be  enlargement  of  the  car- 
diac area  of  dullness,  owing  to  filling  up  of  the  pericardial  sac,  associated 
with  feeble  or  absent  apex-beat. 

IRREGULAR  ACTION   OF  THE  HEART. 

General  Considerations. — According  to  Mackenzie  the  points  proven  by 
Gaskell  in  many  papers  and  set  forth  in  his  article  on  the  contraction  of  the 
cardiac  muscle  found  in  Shaefer's  Physiology,  edition  of  igoo,  have  com- 
pletely revolutionized  our  interpretations  of  the  symptoms  found  in  certain 
diseases  of  the  heart.  Gaskell  proved — First  that  the  muscle  fibers  them- 
selves have  the  inherent  power  of  secreting  a  substance  which  will  stim- 
ulate a  fiber  to  contract. 

Second. — They  have  the  power  of  receiving  a  stimulus  excitability. 


IRREGULAR  ACTION  OF  THE  HEART  611 

Third. — The  power  of  transmitting  the  stimulus  to  other  ccUf, 
conductivity 

Fourth. — The  power  of  contraction. 

Fifth.- — They  have  inherent  tonicity. 

Gaskell  also  calls  attention  to  the  fact  that  while  al'  fibers  of  the  heart 
are  endowed  with  these  properties,  they  do  net  develop  to  the  same  degree 
in  all  of  them.  Thu,  the  venous  end  of  the  primitive  heart  has  the  power 
of  stimulus  production  and  excitability  better  developed  than  other  parts,  but 
if  for  any  reason  another  portion  of  the  heart  is  rendeied  more  excitable, 
then  the  contraction  will  begin  there.  The  primitive  cardiac  tube  is  rep- 
resented in  the  mammalian  heart  by  certain  tissues.  There  is  a  very  small 
mass  of  tissue  at  the  mouth  of  the  superior  cava.  This  is  believed  to  be  the 
remains  of  the  sinus  venosus  and  has  been  called  the  sino-auricular  node. 
It  is  believed  that  the  heart's  contraction  probably  begins  at  this  point. 
Further  remains  of  this  tissue  are  found  farther  down,  arising  in  the  right 
auricle  and  passing  across  the  auricular  ventricular  septum  to  be  distributed 
in  the  ventricles. 

This  bundle  of  tissue  now  known  as  the  bundle  of  His,  "arises  from  a 
node  of  tissue,  the  A.  V.  node,  situated  in  the  right  auricular  wall  near  the 
mouth  of  the  coronary  sinus,  passes  over  the  auricular  ventricular  septum 
below  the  fibrous  body  and  under  the  septal  cusp  of  the  tricuspid  valve." 
It  divides  on  the  septum  and  is  continued  on  the  ventricles. 

Gaskell,  Erlanger  and  others  have  shown  experimentallj^  that  the 
bundle  conveys  the  stimulus  from  the  auricles  to  the  ventricles,  and  Mac- 
kenzie believes  that  if  it  chance  that  the  bundle  be  rendered  more  excitable 
than  the  rest  of  the  tissue,  then  it  will  start  a  contraction  independently  of 
the  sinus  rhythm. 

While  the  functions  of  the  heart  muscle  allow  it  to  perfonn  its  movements 
independently,  nevertheless  nervous  influence  has  a  great  power  in  affecting 
the  action  of  the  various  fibers. 

Mackenzie's  groupings  of  the  various  types  of  irregularity  are  adopted 
and  followed,  retaining  the  division  of  nervous  palpitation  for  clinical 
reasons  only. 

Increased  Frequency  of  the  Heart  Beat. — The  word  tachycardia  is 
loosely  applied ;  some  writers  calling  any  sustained  action  of  the  heart  above 
1 20  a  tachycardia.  We  will  limit  the  term  after  Mackenzie  to  paroxysmal 
tachycardia,  an  organic  condition.  The  normal  numiber  of  heart  beats  varies 
with  individuals  in  different  ages  and  under  certain  circumstances.  The 
average  in  infancy  is  from  130  to  140  per  minute;  in  middle  life  from  70  to  80. 
At  fifty  it  gradually  increases.  Normally  the  heart  beat  is  increased  by 
excitement,  fright  or  exertion.  As  to  the  latter,  an  increase  of  ten  beats 
when  the  individual  rises  from  a  prone  position  is  perfectly  normal;  an 
increase  of  twenty  or  more  would  be  decidedly  abnormal,  especially  if  the 
increase  were  sustained  for  some  time.  If  a  heart  beat  which  is  normally 
seventy  is  raised  to  ninety  or  over  when  the  patient  walks  upstairs  and 
especially  if  the  acceleration  continues  some  time,  it  usually  means  that  the 
heart  muscle  is  lacking  in  power  and  the  heart  is  responding  in  number  of 
beats  instead  of  strength.  The  judgment  as  to  whether  an  increase  is 
abnormal  or  normal,  however,  must  depend  in  a  large  measure  upon  the 


612  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

usual  performance  of  each  individual  heart.  If  the  rate  after  a  very  mod- 
crate  exercise  is  that  which  would  naturally  be  expected  after  very  violent 
exercise,  certainly  the  condition  must  be  abnormal. 

The  causes  of  this  increased  frequency  on  exertion  are  very  numerous, 
myocarditis,  dilatation  as  the  result  of  valvular  disease,  any  exhausting 
disease  such  as  fevers  and  the  anemias,  the  abuse  of  alcohol  or  tobacco 
and  sexual  excess,  are  among  the  most  common. 

Perhaps  the  most  dangerous  mistake  is  to  consider  an  abnormally 
rapid  heart  where  no  evident  cardiac  lesion  is  found  as  nervous  or  neurasthenic. 
Doubtless  some  few  cases  are  entirely  extrinsic,  but  many  such  cases  are 
due  to  a  weakened  heart  muscle,  the  result  of  such  a  dyscrasia  as  tuberculosis. 
Certainly  many  cases  of  tuberculosis  have  among  their  first  symptoms 
nervous  disturbances  accompanied  by  a  rapid  heart.  Exophthalmic  goiter 
has  often  a  rapid  heart  action  as  its  very  first  symptom,  this  rapidity  of 
action  being  sometimes  accompanied  by  a  relatively  high  systolic  blood 
pressure  and  low  diastolic  pressure. 

Treatment. — Treatment  of  abnormal  frequency  of  the  heart  beat  will  de- 
pend absolutelj^  upon  the  cause;  that  of  nervous  palpitation  wiU  be  dis- 
cussed. If  the  case  is  one  of  organic  valvular  disease,  the  treatment  is  that 
detailed  for  that  condition ;  if  due  to  alcoholism,  abstinence  from  alcohol  will 
in  great  measure  slow  the  heart;  even  the  rapid  heart  of  tuberculosis  and 
exophthalmic  goiter  wUl  respond  to  proper  treatment  for  these  conditions. 

Diminished  Frequency  of  the  Heart's  Action. — Bradycardia,  like  its 
antithesis,  tachycardia,  is  loosely  applied.  Before  a  case  is  considered  to 
be  a  true  slowing  of  the  heart's  action  itself  care  must  be  taken  to  distinguish 
between  a  slow  pulse  and  a  slow  heart.  A  radial  pulse  may  be  fort}^  due  to 
abortive  systole  or  missed  beat,  and  the  heart  itself  be  eighty  or  more. 

Convalescents  from  acute  fevers  such  as  typhoid  and  diphtheria  may 
have  an  extremely  slow  pulse.  Certain  poisons  such  as  that  affecting  an 
individual  with  jaundice,  chronic  Bright's  disease,  cause  a  slow  pulse. 
It  occurs  in  certain  diseases  of  the  heart  such  as  Stokes-Adams  syndrome, 
where  there  is  abnormal  conduction  of  the  stimulus  from  the  auricle  to 
the  ventricle. 

Finally,  slow  pulse  may  occur  during  labor  and  as  the  result  of  advanced 
age. 

There  seems  to  be  no  successftd  treatment  except  in  those  cases  due  to 
toxic  agents,  where  the  mthdrawal  of  the  poison  will  allow  the  normal 
rhythm  to  assert  itself. 

Irregular  Action  of  the  Heart.  Arrythmia. — Gaskell  has  shown  by  ex- 
perimentation, as  before  stated,  that  while  the  contractions  of  the  heart 
muscle  begin  normally  at  the  sinus,  they  may  begin  at  any  point  in  the 
heart  which  is  more  excitable  than  this  usual  point.  This  fact,  proven  ex- 
perimentally by  Gaskell  and  his  followers,  gives  rise  to  the  various  forms  of 
cardiac  irregularity.  It  must  be  insisted  at  the  beginning  that  the  mere 
fact  of  irregular  cardiac  action  does  not  carry  with  it  any  bad  prognosis. 
Other  characteristics  of  the  heart  beat  are  much  more  important.  In 
certain  young  individuals,  such  for  instance  as  those  recovering  from  an 
infection,  there  is  no  danger  in  the  mere  irregularity.  When  the  extra 
stimulus  occurs  at  the  origin  of  the  cavas,  the  heart  is  subjected  to  what 


EXTRA  SYSTOLE  613 

Mackenzie  styles  the  sinus  irregularity.  It  occurs  frequently  in  the  }-oun}^ 
after  fevers  and  during  slow  respiration. 

It  occurs  as  a  rule  as  the  result  of  some  irregularity  of  action  of  the 
vagus.     Its  symptoms  are  irregular  pulse,  frequently  altered  by  respiration. 

The  heart  sounds  are  clear  and  sharp.  There  is  no  murmur.  The 
tracings  show  that  the  auricles  are  affected  as  are  the  ventricles,  and  there- 
fore there  is  no  trouble  with  the  conducting  bundle,  there  is  no  trouble  with 
the  heart  itself. 

Extra  Systole. — Mackenzie  would  limit  this  term  to  those  primitive 
contractions  of  auricle  or  ventricle  in  response  to  a  stimulus  from  some 
abnormal  point  of  the  heart,  but  where  otherwise  the  fundamental  or  sinus 
rhythm  of  the  heart  is  maintained.  He  believes  that  this  stimulus  takes 
place  somewhere  in  the  course  of  the  remains  of  the  primitive  tube,  in  the 
auriculo-venticular  bundle  beyond  the  auricular  ventricular  node  (ven- 
tricular) in  the  past  incorporated  in  the  auricle  (auricular) ,  or  in  the  auricular 
ventricular  node  itself  (nodal).  This  symptom  is  often  marked  to  the  pa- 
tient, who  is  conscious  that  his  heart  is  dropping  a  beat.  He  is  frequently 
much  disturbed,  mentally.  On  examination,  the  pulse  often  intermits,  this 
intermission  being  due  to  an  abortive  attempt  at  systole  of  the  heart  which 
does  not  reach  the  radial  pulse.  This  extra  systole  often  being  followed 
by  a  cessation  of  the  heart's  action  through  one  cycle.  Engleman  explains 
this  on  the  ground  that  the  ventricle  is  so  exhausted  by  the  abortive  attempt 
that  it  fails  to  respond  to  the  next  normal  stimulus,  to  contraction.  Mac- 
kenzie believes,  however,  that  in  man  it  is  not  the  ventricle  which  is  refrac- 
tory and  refuses  to  beat,  but  the  primitive  bundle  is  refractory  and  refuses 
to  conduct  the  stimulus. 

Examination  of  the  heart  itself  will  show  a  regular  first  sound  followed 
by  a  short  abortive  systole.  The  first  is  followed  by  the  radial  pulse,  the 
second  is  not.  This  condition  is  not  in  itseh  serious,  it  simply  means  that 
an  abnormal  stimulus  is  given  to  the  heart,  usually  through  some  fault  in 
the  bundle  or  conducting  apparatus.  It  is  not  always  the  result  of  cardiac 
degeneration.  When  there  is  no  other  symptom  than  an  irregularity,  no 
especial  fear  need  be  felt. 

Treatment. — Assurance  to  the  patient  that  the  symptom  is  usually  with- 
out danger.  Avoidance  of  irregular  living,  undue  exertion  and  other  un- 
hygienic acts  which  give  rise  to  undue  cardiac  stimulation  are  important. 
Removal  of  all  sources  of  worry  and  graduated  exercise  is  ad\'ised. 

Nodal  Rhythm. — Paroxysmal  tachycardia — continuous  irregularity  of  the 
heart. 

This  condition  embraces  the  greater  number  of  cases  of  cardiac  irregu- 
larities, and  is  present  in  practically  all  severe  cardiac  failures.  Macken- 
zie believes  most  of  the  cases  are  the  result  of  rheumatism  where  deposits 
are  found  in  many  parts  of  the  cardiac  muscle  and  often  along  the  auric- 
ulo-ventricular  bundle.  It  often  occurs  where  there  is  disease  of  the  coro- 
nary arteries,  giving  rise  to  cardio- sclerosis.  In  these  cases  the  ventricle 
and  auricle  beat  together  or  the  ventricle  slightly  precedes  the  auricle.  In 
certain  cases  the  rapidity  of  the  heart  is  not  increased,  but  frequently  the 
patient  finds  himself  unable  to  do  his  usual  work  without  distress.  Some- 
times, however,  edema  and  dyspnea  supervene  and  the  patient  becomes 


614  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

incapacitated.  The  prognosis  depends  altogether  upon  the  condition  of  the 
cardiac  muscle.  The  treatment  is  that  advised  in  decompensation  from 
valvular  disease. 

■  In  other  cases  there  is  great  rapidity  of  the  heart  beat.  There  is  fibrilla- 
tion of  the  auricle.  The  patient  at  first  is  simply  aware  of  a  rapid  pulse. 
Gradually,  however,  he  becomes  unable  to  do  his  usual  work.  Cyanosis, 
dyspnea,  and  ed;ma  supervene.  Under  proper  treatment,  rest  followed 
by  proper  exercise,  the  heart  may  regain  much  of  its  strength,  followed 
sooner  or  later  by  another  breakdown.  In  the  cases  due  to  rheumatism 
digitalis  is  of  value.     In  fibroid  heart  it  is  valueless. 

True  Paroxysmal  Tachycardia. — (Delirium  cordis.)  This  is  the  condi- 
tion represented  by  the  class  of  cases  which  for  the  greater  part  of  the  time 
seem  to  be  in  peifect  health  with  no  symptoms  directed  to  the  heart,  but 
which  are  suddenly  seized  with  cardiac  action.  If  the  heart  is  examined 
between  the  attacks,  either  no  abnormality  is  noticed  or  there  may  be  a 
condition  represented  by  feeble  first  sound  without  any  other  apparent 
disturbance.  Sometimes  the  attacks  occur  in  individuals  with  well-marked 
valvular  lesions. 

The  attack  is  characterized  first  of  all  by  sudden  severe  rapid  heart 
action.  This  may  give  the  individual  little  or  no  distress.  It  maj^  la.t  for 
a  few  minutes  or  for  days.  Sometimes  there  is  absolutely  no  dilatation,  at 
others  a  dilatation  lapidly  or  slowly  develops  with  all  the  accompanying 
distress.  Sometimes  during  the  attacks  a  well-marked  muimur  develops, 
at  others  nothing  is  heard  except  the  rapid  heart  beat.  The  exciting  cause 
is  not  certain.  The  attack  may  ccme  during  the  night,  awakening  the 
patient  from  sleep.  It  may  come  apparently  as  the  result  of  indigestion. 
It  rarely  follows  exertion,  though  in  one  of  our  cases  a  rather  prolonged 
series  of  weeks  of  overwork  have  preceded  practically  all  the  attacks. 

The  prognosis  depends  upon  the  integrity  of  the  heart  muscle.  The  at- 
tack is  not  necessarily  of  serious  import.  One  case  on  our  record  had  many 
of  these  attacks,  lasting  from  an  hour  or  two  to  two  or  three  days.  He  died 
at  76,  his  arteries  and  heart  at  the  time  of  death  showed  no  macroscopic 
change. 

The  treatment  is  unsatisfactory.  One  case  on  record  could  stop  an  attack 
by  swallowing  ice-cold  water.  Most  attacks  under  our  care  have  responded 
to  a  hypodermic  of  morphin.  The  latter  remedy  is  somewhat  dangerous, 
however,  on  account  of  the  fear  of  causing  a  morphin  habit.  Digitalis  is 
valueless  in  the  attack. 

Heart  Block.  Stokes-Adams'  disease,  ventricular  rbytlnn. — In  cer- 
tain cases  of  arrj'thmia,  the  irregular  action  of  the  heart  is  due  to  faulty 
conducting  power  of  the  bundle,  instead  of  irregular  stimulation  as  in  the 
classes  described  in  the  preceding  paragraphs.  This  lack  of  power  of  con- 
duction may  be  due  to  a  simple  delay  in  the  conduction  of  the  stimulus;  to  an 
interruption  of  the  stimulus;  or  to  a  complete  blocking  of  the  stimulus. 

These  variations  due  to  interference  of  the  bundle  have  been  frequently 
demonstrated  experimentally  by  Gaskell,  Erlanger  and  others,  and  have 
been  described  by  Mackenzie  (and  many  others) .  Clinically,  the  cases  can 
be  fairly  well  recognized  by  obser\ang  the  radial  pulse  and  the  jugular 
pulse.     The  radial  pulse,  representing  the  ventricular  systole,  beats  slowly, 


NER  VO  US  PA  LP  I TA  TIOX  615 

varying  from  20  to  40  per  minute.  The  jugular  pulse  is  seen  to  beat  much 
more  rapidly.  This  diagnosis  can  be  absolutely  confirmed  by  the  use  of  the 
polygraph  which  shows  the  slow  ventricular  beat  and  the  more  rapid  auri- 
cular beat. 

The  cases  where  the  ventricular  beat  is  in  response  to  a  delayed  stimulus 
from  the  auricle  can  be  distinguished  by  means  of  a  poh'graph  tracing  from 
those  cases  in  which  there  is  entire  failure  of  the  bundle  to  conduct  any 
stimulus  from  the  auricle  to  the  ventricle.  The}'  can  be  also  distinguished 
by  clinical  signs. 

The  cause  of  this  condition  in  man  is  invariably  due  to  some  sclerotic 
change  of  the  heart  muscle,  frequently  accompanied  by  sclerosis  of  the  coro- 
nary arteries,  usually  rheumatic  or  syphilitic.  Stengel  reports  a  typical  case 
of  complete  heart  block  with  autopsy  where  the  bundle  was  destroyed  by  a 
salerotic  area.  There  are  cases  of  heart  block,  according  to  Mackenzie,  in 
which  the  heart  block  is  sho\vn  to  be  due  to  vagus  stimulation  or  to  digitalis, 
but  these  cases  are  temporary  and  not  permanent. 

Mackenzie  sounds  a  warning  against  the  persistent  use  of  digitalis  where 
the  heart  begins  to  drop  a  beat  under  its  influence.  The  complete  syndrome 
of  Adams-Stokes'  is  characterized  as  follows  in  a  case  observed  b}'-  one  of  us. 
The  case  during  the  quiescent  stage  was  marked  by  a  slow  radial  pulse  cor- 
responding to  the  action  of  the  ventricle.  During  this  time  there  was  rapid 
pulsation  in  the  jugulars.  During  the  life  of  the  patient  she  had  many 
epileptic  form  seizures  always  preceded  by  an  unusually  slow  pulse.  It  was 
never  our  privilege  to  observe  the  case  during  an  attack,  but  her  attendant 
always  noted  a  disappearance  of  the  radial  diuing  the  unconscious  stage. 

Stengel,  in  the  case  quoted  above,  noted  the  absence  of  the  ventricular 
systole  for  one  minute  at  a  time.     The  patient  was  thought  to  have  died. 

The  prognosis  in  these  cases  is  bad  because  of  the  certain  myocardial 
change  which  the  condition  indicates. 

The  treatment  is  summed  up  in  the  advice  so  to  watch  the  life  of  the 
patient  that  sudden  strain  upon  the  heart  is  avoided;  anger;  undue  sexual 
excitement ;  overexertion,  particiolarly  walking  in  a  high  wind,  should  be 
avoided.  Care  should  be  taken  to  avoid  indigestible  food,  as  an  attack  of 
indigestion  may  bring  on  a  complete  failure  of  the  heart  to  act. 

Drugs  are  of  little  value.  Digitalis  is  not  only  useless,  but  may  do  posi- 
tive harm. 

NERVOUS  PALPITATION. 

Definition. — By  this  is  meant  an  unnaturally  frequent,  regular,  or  ir- 
regular beating  of  the  heart,  of  which  the  patient  is  uncomfortably  con- 
scious, but  which  is  unattended  by  any  organic  disease  of  the  organ.  This 
does  not  mean  that  there  may  not  be  functional  or  accidental  murmurs. 
Such  murmurs  are  always,  however,  systolic,  a  diastolic  nmrmiir  always  indicat- 
ing organic  disease. 

Etiology. — There  are  numerous  causes  of  palpitation.  In  the  first 
place,  it  is  much  more  frequent  in  women  than  in  men.  Again,  it  is  prone 
to  occur  at  the  time  of  puberty  in  girls,  and  at  the  menstrual  period  and 
climacteric  in  women.     Indigestion  is  a  very  frequent  causal  agent.     Mental 


616  DISEASES  OF  HEART  AXD  BLOOD   VESSELS 

emotion,  including  fright,  anxiety,  and  grief,  diseases  of  the  uterus  and  stom- 
ach, sexual  excesses,  overwork,  are  all  active  etiological  elements.  The 
"irritable  heart"  described  by  Da  Costa,  based  on  obser\'ations  made  on 
soldiers  in  the  late  Civil  War  in  America,  has  for  its  most  striking  symptoms 
palpitation.  Overwork  and  excitement  were  its  chief  causes,  abetted  by  ex- 
haustion from  illness. 

Symptoms. — The  "beating"  referred  to  is,  of  course,  the  chief  symp- 
tom. It  varies  greatly,  however,  in  degree  and  duration.  At  times  there 
is  a  mere  fluttering,  lasting  for  a  few  minutes.  At  other  times  the  pulse-rate 
may  reach  i6o  or  more  and  be  scarcel^^  countable.  The  rapid  heart-action 
is  sometimes  associated  with  a  sense  of  weakness  or  "goneness"  in  the 
epigastrium,  and  sometimes  with  nausea.  The  face  is  usually  pale,  but  is 
sometimes  flushed.  The  physical  signs  usually  add  nothing  to  the  undue 
beating  noted  on  auscultation,  though,  as  alreadj^  mentioned,  there  may  be 
functional  murmurs  systolic  in  time  at  the  base  of  the  heart,  more  rarely 
at  the  apex.  The  normal  heart-sounds  may  be  somewhat  sharper  and 
clearer,  or  they  may  be  more  blurred. 

Diagnosis. — The  conditions  with  which  nervous  palpitation  may  be 
confounded  are  myocarditis  and  fatty  degeneration  of  the  heart  and  dila- 
tation, the  symptoms  of  which,  it  will  be  remembered,  are  similar;  or  one 
of  the  arrhythmias  before  described,  where  there  is  organic  disease  in  the 
conducting  apparatus  of  the  heart. 

In  all  these  conditions  the  history  of  the  case  and  the  physical  examina- 
tion must  decide  the  diagnosis.  Careful  tracings  of  the  jugular  pulsations  as 
compared  with  the  radial  pulse  will  throw  much  light  upon  the  condition. 
A  diagnosis  of  nervous  palpitation  must  never  be  made  unless  organic 
changes  in  the  heart  can  be  absolutely  excluded.  Mackenzie  includes 
these  cases  in  his  x  disease  and  classes  them  as  due  to  sinus  stimulation.  It 
has  eeen  thought  worth  while  to  retain  the  name  nervous  palpitation  to  mark 
these  cases  due  purely  to  causes  outside  the  heart  itself.  The  nervous  affec- 
tion is,  however,  a  less  serious  one,  characterized  by  intermissions  during 
which  the  heart  is  quiet.  Its  subjects  are  also  of  the  anemic  nerv^ous  type, 
whose  histor}'  greatly  aids  the  diagnosis,  and  they  are  commonly  younger. 

Treatment. — This  is  by  rest,  nerve  sedatives,  and  a  suitable  moral 
treatment  of  encoiuraging  words  and  a  confident  manner.  A  few  more  grains 
of  sodium  bromid,  repeated  every  hour,  maj^  be  useful.  When  the  patient 
is  weak  and  anemic,  he  should  be  built  up  and  strengthened  by  iron,  quinin, 
and  strychnin. 

ANGINA  PECTORIS,  OR  STENOCARDIA. 

Definition. — Angina  pectoris  is  a  symptom  complex  referred  to  the  heart, 
characterized  by  pain  sometimes  mUd,  sometimes  intensely  severe,  situated 
beneath  the  lower  end  of  the  sternum,  over  the  heart,  and  sometimes  con- 
ducted to  the  shoulder  and  to  the  arm,  usually  the  left.  Sometimes  the  at- 
tack is  accompanied  bj'  a  severe,  painful  contraction  of  the  chest. 

Etiology. — Mackenzie  believes  that  these  attacks  of  pain  are  always  due 
to  exhaustion  of  the  contractile  function  of  the  heart  muscle.  The  lesions 
of  the  heart  which  accompan}'  some  of  these  cases  are  so  varied  that  it 


ANGINA  PECTORIS  617 

seems  correct  to  assume  that  this  is  the  underlying  cause.  Obstructive  dis- 
ease of  the  coronary  arteries,  aortic  stenosis  or  insufficiency,  pressure  by  a 
tumor  or  other  cause,  dilatation  or  enlargement  of  the  heart  beyond  the 
capacity  of  the  coronary  arteries  to  nourish  are  the  lesions  most  frequently 
found.  Of  these  endarteritis  of  the  coronary  is  the  most  common.  Excessive 
use  of  tobacco  has  been  accredited  with  the  direct  effect  of  causing  angina.  The 
exciting  cause  of  the  attack  is  usuall}''  some  overexertion  or  mental  emotion 
calling  for  some  additional  effort  from  an  already  crippled  ischemic  heart. 
These  events  are  more  apt  to  produce  this  effect  after  a  meal  because  a  full 
stomach  encroaches  on  the  heart.  The  taking  of  food  alone,  even  in  moder- 
ate amount,  may  excite  an  attack.  Still  more,  excessive  eating  and  indiges- 
tion, however  caused,  become  exciting  causes.  It  is  much  more  common  in 
men  than  in  women.  Aortitis  affecting  the  root  of  the  vessel,  general 
arteriosclerosis  and  high  blood  pressure  are  very  common.  The  induaduals 
who  are  most  commonly  affected  are  business  men  living  under  great  strain, 
eating  immoderately  or  improperly. 

Diagnosis. — Sometimes  many  of  the  patients  who  apply  have  an  oppres- 
sion immediately  under  the  xiphoid,  usually  following  exertions  and  accom- 
panied by  expulsion  of  a  large  amount  of  gas  from  the  stomach.  They  be- 
lieve themselves  to  be  suffering  from  indigestion.  Other  cases  have  a  more 
severe  distress  amounting  to  an  actual  pain  in  the  cardiac  region,  trans- 
mitted toward  the  left  shoulder.  Still  other  cases  are  suddenly  seized  with 
an  excruciating  pain  in  the  region  of  the  heart,  a  numbness  in  the  left  shoul- 
der, arm  and  hand,  and  a  feeling  of  impending  death.  Sometimes  the  face 
is  pale,  sometimes  it  is  ashy  in  color;  beads  of  perspiration  often  stand  out 
on  the  face  during  these  attacks.  The  duration  of  the  attack  is  from  a  few 
seconds  to  many  minutes.  The  lighter  attacks  disappear  immediately  upon 
the  patient  resting  from  the  act  that  he  was  doing  when  the  attack  began. 
Often  the  attack  ends  by  belching  air,  the  air  which  is  expelled  is  the 
result  of  the  patient's  having  sticked  in  air  during  the  attack. 

Diagnosis. — The  commonest  condition  with  which  the  mildest  forms  of 
angina  pectoris  is  confvised  is  indigestion,  pain  in  the  upper  epigastrium. 
Belching  of  gas  at  times  with  relief  gives  color  in  the  eyes  of  the  laity  to  the 
thought  of  indigestion,  but  to  the  physician,  the  age  of  the  patient;  the 
history  of  the  usuallj'  strenuous  life;  high  blood  pressure;  slight  increase  of 
heart  dullness  with  a  valve-like  first  sound  together  with  the  fact  that  the 
attack  occurs  almost  always  with  exertion  or  on  excitement,  especially  if 
the  pain  is  conducted  toward  the  shoulder  and  arm,  mark  the  case  as 
one  of  true  angina.  In  certain  nervous  individuals,  attacks  simulating 
angina  pectoris  occur.  These  attacks,  if  they  are  simply  hysteria,  usually 
occur  in  females,  last  much  longer  than  the  attacks  of  true  angina  and  do 
not  give  the  feeling  of  impending  death.  The  physical  signs  above  given 
are  wanting.     Such  cases  have  been  called  pseudo-angina. 

Prognosis. — Prognosis  in  angina  pectoris,  even  in  its  mild  form,  is 
grave,  because  of  the  extremely  frequent  grave  cardiac  lesions  which  are  its 
cause.  On  the  other  hand,  in  cases  which  occur,  as  Mackenzie  has  pointed 
out,  from  the  exhaustion  of  the  heart  muscle,  brought  about  by 
overuse  of  tobacco,  by  worry,  by  work  and  frequent  pregnancies,  with  the 
absence  of  arterial  degeneration,  the  prognosis  is  not  very  grave. 


618  DISEASES  OF  HEART  AXD  BLOOD  VESSELS 

Treatment.  Prevention. — It  should  be  ]xjintcd  out  to  men  with  respon- 
sibilities that  worry  over  their  work;  eating  unusually  and  improperly; 
undue  indulgence  in  alcoholics ;  in  other  words,  overworking  the  machinery 
of  the  body,  is  fairly  sure  to  bring  about  premature  arterio-sclerosis,  which, 
if^it  attacks  the  coronary  arteries  as  it  well  may,  is  certain  to  bring  about 
degeneration  of  heart  muscle,  which  in  turn  may  bring  about  angina 
pectoris. 

Treatment  of  mild  attacks  may  be  summed  up  in  hygienic  regtdation 
of  the  individual  life,  cessation  of  the  acts  which  are  bringing  about  the 
degeneration  of  the  muscle;  proper  food;  moderate  eating  and  avoidance 
of  alcoholics.  The  very  mildest  attacks  usually  pass  away  quickly  by  the 
individual's  standing  or  sitting  still.  If  the  case  is  more  severe,  the  inhalation 
of  the  contents  of  a  Pearl  of  Amyl  wiU  often  break  up  the  very  severe  attacks, 
the  administration  of  chloroform  or  the  hypodermic  injection  of  morphin 
is  indicated,  as  well  as  the  use  of  nitrite  of  amyl  or  nitroglycerin.  If  the 
cases  are  the  result  of  conditions  not  bringing  about  cardiac  degeneration, 
the  correction  of  the  habits  of  patient  and  method  of  living  will  stop  them 
entirely.  The  treatment  of  the  attack  itself  is  the  same  as  that  due  to 
organic  heart  disease. 

Many  cases,  whether  severe  or  mild,  succumb  during  the  attack. 

DISEASES  OF  THE  BLOOD-VESSELS. 

ARTERIO-SCLEROSIS. 

Synonyms. — Angio-sclerosis;    Endarteritis    chronica    deformans;    Atheroma 
of  the  Blood-vessels;  Arterio-capillary  Fibrosis. 

Definition. — An  inflammatory  thickening  of  the  waUs  of  blood-vessels, 
chiefly  of  arteries,  beginning  in  the  intima,  but  extending  also  to  the  media 
and  adventitia,  associated  also,  more  or  less,  with  degenerative  changes. 

Endarteritis  obliterans  is  an  inflammation  of  the  endarterium  which, 
partly  by  its  immediate  product  and  partly  by  thrombosis  and  the  organi- 
zation of  the  resulting  clot,  produces  comj^lete  obliteration  of  the  artery 
with  rcstdting  gangrene. 

Etiology. — There  is  a  tendency  to  atheroma  in  the  arteries  of  the  old,  as 
an  evolution  process  quite  independent  of  exciting  causes.  This  tendency 
also  varies  greatly  in  different  families,  being  very  strong  in  some  and  absent 
in  others.  Men  are  more  frequent  subjects  than  women.  There  are  many 
exciting  causes,  among  which  are  especially  overeating  and  drinking,  with 
consequent  accumulation  of  irritating  matters  in  the  blood,  syphilis,  the 
gouty  poison,  and  lead.  Chronic  Bright's  disease  and  diabetes  mellitus 
are  especially  frequently  succeeded  by  it;  more  rarely  acute  articular 
rheumatism.  In  the  latter  the  rheumatic  poison,  whatever  that  may  be, 
is  probably  the  responsible  agent,  and  in  Bright's  disease  it  may  be  retained 
cxcrementitious  matter.  In  diabetes  it  is  the  sugar  in  the  blood.  Two 
classes  of  cases  may,  however,  be  associated  with  Bright's  disease,  in  one 
of  which  the  arterio-sclerosis  is  general  and  primary,  causing  interstitial 
nephritis,  and  in  the  other  it  is  secondan,',  the  result  of  Bright's  disease. 
One  set  of  observers  regard  all  cases  of  interstitial  nephritis  as  secondary. 


ARTERIOSCLEROSIS  619 

Among  these  vSir  William  Giill  and  Henry  D.  Sutton,  of  England,  and 
Arthur  V.  Meigs,  of  Philadelphia,  have  been  conspicuous  by  their  writings. 
Still  another  cause  of  arterio-sclerosis  is  increased  arterial  tension  due  to 
prolonged  muscular  exertion.  The  toxins  in  the  blood  of  the  various  acute 
infectious  diseases  may  also  cause  endarteritis  and  sclerosis. 

Morbid  Anatomy. — The  aorta  is  the  most  frequent  and  conspicuous 
seat  of  the  changes  ascribed  to  chronic  endarteritis,  but  the  carotids,  sub- 
clavians,  brachials,  radials,  and  ulnars,  the  iliacs,  femorals,  and  especially 
the  arteries  of  the  brain  and  coronary  arteries  of  the  heart,  are  frequently 
involved.  The  arteries  to  viscera,  like  the  stomach  and  liver,  are  rarely 
affected,  whUe  the  pulmonary  arteries  take  an  intermediate  place.  On  the 
other  hand,  the  latter  are  sometimes  invaded  to  the  exclusion  of  the  aorta. 
Whatever  invites  high  tension  in  the  lesser  circulation  tends  to  produce 
sclerosis  in  these  vessels.     The  portal  vein  may  also  be  invaded. 

Appearances  differ  in  arteries  of  different  sizes.  Those  in  arteries  of 
moderate  size  are  best  studied  in  the  superficial  vessels.  They  are  tortuous, 
stand  out  conspicuously,  and  feel  hard  to  the  finger,  under  which  they  may 
be  made  to  roll.  These  features  are  often  recognizable  in  the  temporals  and 
less  plainly  in  the  radials.  The  smaller  arteries  and  veins  with  transparent 
walls,  especially  in  the  brain,  exhibit  to  the  naked  eye  white  patches  which 
are  the  seat  of  the  atheroma.  On  slitting  them  open,  the  inner  surface  of 
these  and  other  arteries  will  be  found  to  have  lost  its  natural  smoothness, 
to  be  rough  and  uneven,  while  the  lumen  is  more  or  less  encroached  upon. 

Minutely  examined,  the  appearances  vary  with  the  stage.  The  first 
stage  is  that  of  cellular  infiltration,  represented  by  the  translucent  yellowish 
areas  of  intima  thickened  to  three  or  four  times  its  natural  thickness.  Later 
these  young  cells  are  in  part  converted  into  connective  tissue,  causing  the 
primary  hardness  of  the  vessel-walls.  In  the  second  stage  the  cells  of  the 
connective  tissue  and  the  surface  cells  of  the  intima  undergo  fatty  degenera- 
tion, and  the  intercellular  substance  liquefies.  In  the  third  stage,  which  is 
not  reached  in  the  smaller  arteries,  or,  indeed,  usually  in  those  below  the 
aorta,  there  occurs  a  further  liquefaction  with  the  formation  of  the  so-called 
atheromatous  abscess,  whose  contents  are  not  pus,  but  the  well-known 
atherom-pulp,  representing  the  debris  of  fatty  degenerated  cells,  including 
fat  drops  and  cholesterin  crj^stals.  Alongside  of  the  atheromatous  patches 
appear  also  plates  or  scales  of  calcareous  infiltration  of  the  intima,  produced 
by  a  deposit  of  lime  salts  in  the  intercellular  substance  of  the  deeper  layers. 
The  atheromatous  abscess  sometimes  undermines  the  intima,  forming 
sinuous  cavities,  and  after  evacuation  there  results  the  atheromatous  ulcer. 
Both  the  calcareous  plates  and  ulcers  furnish  inequalities  which  favor  throm- 
bosis. In  the  later  stages  of  the  more  diffuse  form  of  arterio-sclerosis, 
especially  studied  by  Councilman,  the  media  or  muscular  coat  and  the 
adventitia  are  also  invaded,  the  former  mainly  by  atrophic  changes,  along- 
side of  which,  at  times,  is  a  homogeneous  hyaline  infiltration.  In  this  form 
the  capillary  walls  are  also  thickened,  especially  those  of  the  glomeruli  of  the 
kidneys,  in  seme  of  which  the  vessels  become  obliterated. 

A  calcareous  infiltration  of  the  muscular  coat  without  previous  inflam- 
mation may  be  found  in  old  age  in  arteries  like  the  radial,  crural,  and  tem- 
poral.    Still  another  primary  degeneration  is  the  fatty  erosin  of  Virchow, 


620  DISEASES  OF  HEART  AXD  BLOOD  VESSELS 

extending  through  the  intima  and  media  as  a  transverse  fissure  thought  to 
be  the  starting-point  at  times  of  dissecting  aneurysm. 

Effect  of  Arterial  Sclerosis. — The  effect  of  these  changes  is  to  produce 
rigidity  and  narrowing  of  the  vessel,  a  loss  of  the  propulsive  power  residing 
in  the  elastic  coat,  a  slowing  of  the  current,  and  increased  intravascular 
resistance.  These  events  tax  the  compensating  power  of  the  left  ventricle, 
which  therefore  hypertrophies.  This  hypertrophy  keeps  up  as  long  as  its 
nutrition  is  maintained. 

But  another  effect  of  obstructed  circtdation  is  defective  local  nutrition, 
some  of  the  consequences  of  which  have  already  been  considered  in  the  study 
of  the  fibroid  heart.  Similar  interstitial  overgrowi;h  and  contraction  may 
be  met  in  the  Iddne}-  and  have  been  referred  to.  Localized  softening  of  the 
brain  also  succeeds  upon  atheroma,  though  this  event  is  usually  preceded 
by  thrombotic  obstruction  favored  by  the  sclerosis.  A  more  frequent 
accident  to  the  brain  is  rupture  of  one  of  these  atheromatous  vessels,  suc- 
ceeded by  the  sj^mptoms  of  apoplex}^  and  hemiplegia.  Such  rupture  may 
be  preceded  by  an  aneurysmal  dilatation.  Finally,  aneurysm  of  the  larger 
vessels  has  for  its  almost  indispensable  condition,  except  in  traumatic  cases, 
atheroma  of  the  dilated  vessel.  Both  events — the  primary  atheroma  and 
the  subsequent  dilatation — are  favored  by  the  increased  intravascular 
pressure. 

Symptoms. — Superficial  vessels  in  a  state  of  atheroma  are  easily  de- 
tected, as  for  example  in  the  temples,  by  their  dilated,  tortuous  outline  in 
which  pulsation  is  sometimes  apparent;  in  other  situations,  as  at  the  wrist, 
antebrachial  and  popliteal  spaces,  they  may  be  recognized  more  or  less  by 
the  touch.  Distinction  should  be  made  between  simple  increase  of  tension 
and  thickening  of  vessel-walls,  though  the  two  are  constantly  associated. 
The  vessel  in  both  instances  is  hard  and  requires  some  force  to  compress  it, 
and  between  beats  it  is  still  full  and  can  be  rolled  under  the  finger,  but  the 
artery  with  the  thickened  wall,  if  firmh-  enough  compressed  to  obliterate 
the  blood  current,  can  stUl  be  felt  beyond  the  seat  of  compression.  In 
many  instances,  on  the  other  hand,  the  changes  escape  detection  until  a 
fatal  apoplexy  gives  notice  of  their  presence.  In  most  of  these  cases,  how- 
ever, if  attention  had  been  directed  to  the  patient,  the  previously  described 
condition  of  the  arteries  would  probably  have  been  recognized,  while  a 
certain  degree  of  hj'pertroph}'  of  the  left  ventricle  would  also,  perhapi ,  have 
been  detected.  It  does  not  follow,  however,  that  the  absence  of  atheroma 
in  one  place  implies  its  absence  in  another,  since  fatal  rupture  of  an  arterj' 
in  the  brain  has  occurred  when  there  has  been  no  sign  of  sclerosis  in  the 
radials.  It  should  not  be  forgotten  that  prolonged  cardiac  hypertrophy 
and  the  increased  tension  incident  to  it  may  produce  atheroma,  or  the  two 
may  be  the  result  of  the  same  cause — as,  for  example,  contracted  kidney. 

The  clinical  symptom  of  general  arterio-sclerosis  is,  first  of  all,  an 
anemia;  which  simulates  in  appearance  very  closely  that  present  in  malig- 
nant disease.  Stengle  has  called  attention  to  this  peculiar  anemia.  The 
individual  is  breathless,  cannot  take  any  sustained  action  without  distress. 
Frequently  there  is  low  blood  pressure,  sometimes  high  blood  pressure. 

Depending  upon  the  organ  most  affected,  the  patient  has  in  addition 
sj-mptoms  referable  to  that  organ.     If  the  arteries  of  the  brain  are  most 


ARTERIAL  TENSION  621 

affected,  he  has  vertigo;  fleeting  palsies,  headaches  and  often  faintness.  If 
the  heart  is  most  affected  he  has  cardiac  symptoms.  Intermittent  claudica- 
tion is  the  result  of  faulty  blood  supply  to  the  muscles  of  the  legs  due  to 
arterio-sclerosis. 

Certain  cases  where  the  kidney  is  most  affected,  the  renal  symptoms 
are  in  the  foreground.  Certain  cases  of  arterio-sclerosis  of  the  vessels  of 
the  cord  give  rise  to  symptoms  not  unlike  those  of  tabes.  The  blood  pres- 
sure is  not  as  a  rule  very  high,  although  it  may  be  high,  due  simply  to  the 
general  condition. 

Abdominal  Arterio-sclerosis. 

Osier  calls  attention  to  the  fact  that  there  are  certain  cases  of  true 
angina  pectoris  with  abdominal  pain,  which  may  be  due  to  anginoid-spasm 
of  the  sclerotic  abdominal  vessels. 

Arterial  Tension  as  a  Symptom. 

H3rpertension. — All  individuals  with  arterio-sclerosis  have  a  plus 
arterial  tension,  but  not,  as  before  stated,  a  very  high  pressure,  which  is  a 
constant  symptom  of  other  conditions ;  for  instance  the  blood  pressure  of  a 
man  of  30  is  125-130;  but  after  this  age  when  arterio-sclerosis  is  the  rule, 
the  pressure  is  always  plus,  being  140,  150  or  even  160,  being  perfectly 
normal  for  persons  of  more  advanced  age.  The  higher  blood  pressure, 
160  and  over,  is  the  result  of  many  different  conditions,  the  most  common 
of  which  (as  Janeway  and  others  have  so  well  pointed  out)  is  chronic  inter- 
stitial nephritis.  The  question  which  is  pr'mary,  the  nephritis  or  the 
tension,  will  not  be  discussed  here.  But  Janeway  has  shown  by  a  long 
series  of  autopsies  that  cases  which  during  life  had  hj'pertension  as  one 
of  the  main  symptoms  usually  had  more  or  less  sclerosis  of  the  kidneys  at 
autopsy. 

When  the  heart  begins  to  fail  in  these  conditions,  the  blood  pressure 
drops.  Usuall)^  high  blood  pressure  is  a  symptom  of  a  failing  compensation 
in  damaged  hearts;  and  under  these  conditions  is  compensatory  and  nec- 
essary to  the  patient's  well  being.  Certain  cases  of  anemia  of  the  brain  are 
accompanied  by  high  pressure  and  here  it  is  a  danger  signal.  Toxemia  of 
pregnancy  has  one  of  its  initial  symptoms  in  high  blood  pressure,  and  here 
too  the  high  pressure  is  a  danger  signal.  Lead  poisoning  is  another  condition 
in  which  there  is  a  high  blood  pressure  due  to  a  circulating  poison. 

Low  blood  pressure  is  seen  in  all  the  asthenic  states,  in  m.any  of  the  acute 
conditions;  in  heart  disease  where  the  tonicity  of  the  muscle  is  entirely 
wanting,  in  certain  cases  of  cardio-sclerosis  where  the  heart  muscle  is  very 
weak. 

Cardiac  hypertrophy  is  not  always  demonstrable  to  percussion,  as  the 
enlarged  heart  may  be  covered  by  an  emph^^sematous  lung,  also  often 
present  in  the  aged,  in  whom  atheroma  is  most  prone  to  occur.  On  the 
other  hand,  the  usual  sharp  accentuation  of  the  aortic  second  sound  is 
present  if  the  hypertrophy  has  not  given  way  to  dilatation  of  fibroid  indura- 
tion. Cardiac  murmurs  do  not  occur  unless  the  atheroma  invades  the  valves 
to  produce  insufficiency,  stenosis,  or  roughening  of  the  aortic  orifice  or  aorta 


G22  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

near  the  orifice.  This  is  not  so  very  rare  in  old  person!!,  apart  from  the 
relative  insufficiency  due  to  aortic  dilatation. 

Treatment. — Treatment  is  mainly  the  removal  of  conditions  causing  it, 
such  as  too  free  living,  gout,  lead-poisoning,  and  syphilis;  together  with 
rest  and  quiet,  the  avoidance  of  excitement,  also  aperients  to  lower  the 
arterial  tension,  a  slight  increase  of  which  is  often  the  last  straw  required 
to  produce  an  apoplexy.  The  iodid  of  potassium  has  received  general 
endorsement,  though  from  different  points  of  view.  Thus  Vierordt  gave 
the  iodids  on  the  assumption  that  they  promote  resolution  of  the  sclerotic 
product;  Huchard  and  Balfour  on  the  ground  that  they  dilate  the  arterioles 
and  thus  lower  the  blood  pressure. 

More  recent  studies  by  Boehm,  Prevost,  Corin,  Stockman,  James 
Burnet  and  Rolleston,  go  to  show  that  the  iodids  do  not  reduce  blood 
pressure,  yet  they  admit  that  the  drug  is  useful  in  arterio-sclerosis.  Burnet 
claims  that  a  further  effect  of  the  iodids  is  to  increase  elimination,  thus 
removing  certain  irritant  constituents  of  the  blood. 

As  such,  they  ought  to  be  useful  in  arterial  sclerosis  and  probably  are. 
Moderate  doses  should  be  continued  a  long  time.  In  conjunction  with  this 
the  usual  cardiac  tonics  should  be  employed  with  a  view  to  promoting  a 
proper  circulation  of  the  blood. 

ANEURYSM. 

Definition. — An  aneurysm  is  a  more  or  less  circumscribed  dilatation  of 
a  blood-vessel.  Aneurysm  is  known  as  true  or  false.  A  tme  aneurysm  is 
one  in  which  any  or  all  of  the  coats  of  the  blood-vessel  share  in  the  dilata- 
tion, though  one  or  two  may  disappear  later  in  the  course  of  its  growth. 
A  false  aneurysm,  on  the  other  hand,  is  one  in  which  the  coats  of  the  artery 
have  disappeared  to  a  greater  or  less  extent  and  in  which  the  walls  of  the 
sack  are  composed  of  the  surrounding  tissues  or  newh-  formed  fibrous 
tissue. 

I.  Aneurysm  may  be  saccular,  fusiform,  cylindrical  and  cirsoid,  ser- 
pentine, or  there  may  be  arteriectasis.  The  "cirsoid"  aneur>-sm  is  one  in 
which  a  blood-vessel  of  medium  size  and  its  branches  are  irregularlj^  dilated 
and  contorted  like  a  varicose  vein.  In  an  arteriectasis  there  is  a  dilatation 
of  the  entire  artery.  Saccular  and  fusiform  aneurysms  are  the  more  fre- 
quent. The  "neck"  of  an  aneurysm  is  a  constricted  portion  by  which  a 
saccular  aneurysm  is  attached  to  the  main  trunk. 

(a)  Traujnatic  aneur>'sm.  In  tratunatic  aneurj^sm  the  initial  event  is 
some  injury  from  without  to  one  or  more  of  the  coats  of  the  vessels,  as  the 
result  of  which  the  resistance  to  intravascular  pressure  is  diminished  and  a 
protrusion  of  the  intima  through  the  yielding  media  takes  place,  the  latter 
being  the  most  passive  of  all  the  coats.  The  simplest  illustration  of  this 
form  of  aneiu"ysm  is  the  antebrachial  aneurj'sm  caused  by  accidental 
wounding  of  the  brachial  artery  in  venesection  of  the  median  vein.  The 
blood  pushes  out  the  intima  and  antebrachial  fascia  and  forms  a  sac  com- 
municating with  the  artery  through  the  wound. 

A  second  form  of  traumatic  aneurs'sm  is  the  aneurysmal  varix  or  anas- 
tomotic aneurysm,  in  which  the  blood  from  the  wounded  arterj'  passes 


ANEURYSM  OF  THE  AORTA  623 

directly  into  the  adjacent  vein  through  the  wound  made  at  the  same  time, 
causing  a  dilatation  of  the  vein.  This  is  resisted  by  the  valves,  which, 
however,  give  way  to  the  extent  of  two,  three,  and  even  more  pairs  before 
the  current  is  successfully  resisted. 

(b)  Dissecting  aneurysm  is  one  in  which,  in  consequence  of  a  perfora- 
tion through  the  intima  and  media,  the  blood  dissects  between  them  and 
the  adventitia.  They  are  frequent  in  the  aorta.  The  blood  max-  dissect 
from  this  point  around  the  arch  of  the  aorta,  even  as  low  as  the  diaphragm, 
before  it  returns  to  the  lumen  of  the  vessel. 

Etiology. — The  aneurysm  most  frequently  encountered  by  the  physician 
is  the  saccular  and  fusiform  form.  Its  most  frequent  essential  cause  is 
endarteritis  and  its  consequences,  including  the  more  acute  stage  of  cellular 
infiltration,  as  well  as  atheroma.  The  coats  thus  weakened  }-ield  to 
the  intravascvilar  pressure.  The  intima  is  capable  of  a  considerable  de- 
gree of  expansion  without  rupture,  while  the  media  is  entirely  passive 
and  yields  verj'  soon  to  the  distending  force.  The  adventitia  alone  seeks 
to  guard  the  sac  against  rupture  by  reactive  overgrowth.  The  causes  of 
endarteritis,  already  discussed,  such  as  syphilis,  alcohol,  and  other  toxic 
substances  variously  introduced  into  the  blood,  are  responsible  for  the  more 
usual  forms  of  arterio-sclerosis  which  furnish  the  initial  lesion  of  aneur\'sm. 
But  weakening  of  the  coats  is  caused  also  in  the  smaller  vessels  by  emboli, 
after  the  lodgment  of  which  the  proximal  part  of  the  vessel  often  becomes 
dilated.  Such  embolus  may  excite  an  endarteritis,  or  may  occasion  direct 
violence  to  the  vessel-walls  if  it  be  hard  or  sharp,  as  is  often  the  case  with 
a  fragment  of  a  calcified  valve.  Muscular  compression  exerted  by  muscles 
in  certain  stiuations  may  also  produce  it.  Such  maj-  be  the  origin  of  pop- 
liteal aneurysms  so  frequent  in  footmen,  who  maintain  a  rigidly  erect  posi- 
tion. 

Aneurysm  is  a  disease  of  men  rather  than  women.  It  is  rareh-  seen 
until  after  the  40th  year  of  life. 

Aneurysm  of  the  Thoracic  Aorta. 

Thoracic  aneurysm  occurs  in  the  arch  of  the  aorta,  in  its  ascending 
transverse  and  descending  portions,  and  in  the  thoracic  aorta  below  the 
arch.  Such  aneurysm  may  but  slightly  exceed  the  normal  caliber  of  the 
vessel,  or  it  may  be  six  inches  (12  cm.)  or  more  in  diameter. 

The  greater  frequency  of  aneurysm  in  the  male  sex  and  during  early 
middle  life  is  recognized.  To  the  preexisting  conditions  of  atheroma  there 
may  be  added  the  effect  of  extreme  exertion  in  lifting,  or  muscular  strain 
of  any  kind,  the  effect  of  which  is  always  to  increase  intravascular  pressure. 
Partly  because  they  are  points  of  least  resistance,  and  parth'  because  they 
are  in  the  line  of  successive  impingement  of  the  whirling  blood  stream, 
there  are  certain  points  of  selection  in  the  aorta  which  are  quite  constant 
seats  for  beginning  aneurysm. 

Symptoms  of  Thoracic  Aneurysm. — Apart  from  the  physical  signs,  the 
most  important  of  the  symptoms  due  to  thoracic  aneurysm  are  the  results  of 
pressure  of  the  growing  aneurysm,  hence  they  are  called  pressure  symptoms. 

The  first  of  these  is  pain,  which  may  be  sharp  and  acute  when  nerves 


624  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

are  directly  involved,  cr  dull  and  boring  when  the  result  of  pressure  on  bone. 
In  the  latter  case,  too,  it  is  localized;  in  the  former  it  may  extend  all  over 
the  chest  and  down  the  arms,  simulating  angina  pectoris.  It  may  be  uni- 
lateral. It  may  occur  in  aneurysm  of  any  part  of  the  arch,  but  is. more 
frequent  in  that  of  the  ascending  limb. 

Shortness  of  breath,  especially  on  exertion,  is  a  frequent  symptom.  It 
may  be  due  to  pressure  of  the  aneurysm  on  the  trachea,  or  on  a  bronchus, 
especiallj'  the  left.  Dyspnea  may  be  increased  on  changing  position 
Dysphagia  from  pressure  of  the  tumor  on  the  esophagus  is  a  frequent  symp- 
tom, especially  in  aneurysm  of  the  descending  aorta,  anywhere  in  the 
thorax.     Dysphagia  is  sometimes  associated  with  broncho-esophageal  fistula. 

Cough  and  alterations  in  the  voice  are  important  sj^nptoms.  The  latter 
include  hoarseness,  aphonia,  and  stridor.  Some  of  these  symptoms  may 
be  produced  by  direct  pressure  on  the  trachea  itself,  others  by  pressure 
upon  the  left  recurrent  laryngeal  nerve.  A  stridulous  voice,  unaccompanied 
by  dysphagia  or  aphonia,  was  early  pointed  out  by  Thomas  Jollifie  Tufnell 
as  indicating  that  the  pressure  in  on  the  right  side  of  the  trachea  and  does 
not  affect  the  esophagus  or  recurrent  laryngeal  nerve.  Cough  may  be 
caused  by  tracheal  pressure  or  by  a  resulting  tracheo-bronchitis  with  copious 
thin  or  mucous  expectoration,  sometimes  bloody.  The  cough  is  often 
brassy  in  character. 

On  the  other  hand,  hoarseness,  aphonia  and  various  degrees  of  paraly- 
sis of  the  vocal  cord  are  due  to  paralysis  of  the  recurrent  laryngeal  nerve, 
commonly  the  left,  which  passes  around  the  arch  of  the  aorta  and  is,  there- 
fore, more  likely  to  be  involved  than  the  right.  The  paralytic  phenomena 
may  be  present  without  other  laryngeal  symptoms,  hence  any  alteration 
of  voice  in  a  person  exhibiting  palpitation  or  dyspnea  calls  for  a  laryn- 
goscopic  examination.  When  paralysis  is  total  on  the  left  side,  such  exami- 
nation may  show  little  alteration  in  the  position  of  the  vocal  cords  in  ordin- 
ary breathing,  or  the  left  may  be  a  little  nearer  the  median  line.  On  deep 
inspiration  the  right  vocal  cord  is  well  abducted,  the  left  remaining  quiescent 
in  the  so-called  cadaveric  position,  midway  between  that  of  inspiration  and 
phonation.  The  attempt  at  phonation  is  more  or  less  abortive.  Diuing 
it,  the  right  vocal  cord  may  go  to  the  median  line,  leaving  a  small  opening 
between  it  and  the  motionless  left  cord,  or  it  may  even  cross  the  line  to  its 
paralyzed  neighbor. 

Partial  recurrent  paralysis  results  if  only  the  twigs  distributed  to  the 
abductor  muscle — i.  e.,  the  posterior  cricoarj-tenoid — are  involved  in  the 
pressure.  There  ensues  gradually  a  permanent  shortening  or  "paralytic 
contracture ' '  of  the  antagonistic  adductors  of  the  same  side,  and  the  affected 
cord  is  drawn  by  this  into  a  position  of  constant  phonation — that  is,  to  the 
median  line.  The  result  is  that  the  voice  may  be  entirely  natural,  the 
paralyzed  cord  being  in  the  position  of  adduction,  while  its  tension  is 
mainly  regulated  by  the  external  branch  of  the  superior  laryngeal  nerve, 
the  sensory  nerve  of  the  larynx  which  is  uninfluenced  in  aortic  aneurysm.' 
In  these  cases  quiet  breathing  is  also  unimpeded. 

These  phenomena  imply,  of  course,  a  destructive  lesion  of  the  nerve, 
the  result  of  pressxire,  which  may  be  preceded  by  a   primary    neuritis. 

^  For  the  muscles  involved  see  Diseases  of  the  Larynx. 


ANEURYSM  OF  THE  AORTA  625 

Such  neuritis  and  resulting  irritation  of  the  entire  pneumogastric  may  ac- 
count for  certain  attacks  of  extreme  dyspnea  sometimes  experienced  by 
subjects  of  aortic  aneurysm.  Associated  with  the  neural  degeneration  is  also 
found  atrophy  of  the  left  posterior  cricoarytenoid  or  abductor  muscle,  while 
the  adductors,  the  lateral  cricoarytenoids  and  the  arytenoid  remain  nearly 
intact.  Constant  dyspnea  is  more  likely  to  be  due  to  direct  compression 
of  the  trachea. 

Other  nerves  may  also  be  compressed,  especially  the  intercostal,  vagus, 
and  sympathetic.  By  compression  of  the  intercostal  nerves,  pain  may  be 
caused;  of  the  vagus,  vomiting;  and  of  the  sympathetic,  inequality  of  the 
pupils  and  unilateral  sweating. 

Pressure  of  the  aneurysm  on  a  bronchus  may  lead  to  retention  of  secre- 
tion and  fetid  bronchitis  and  bronchiectasis,  and  favor  the  inoculation  of 
tuberculosis,  thus  accounting  for  the  frequent  association  of  tuberculosis 
of  the  lungs  and  aneurysm,  or  the  whole  lung  may  be  collapsed. 

Spitting  of  Mood  is  an  occasional  symptom,  which  may  be  the  fore- 
runner of  larger  and  more  dangerous  hemorrhage. 

Still  rarer  is  pressure  on  the  thoracic  duct,  causing  emaciation,  though 
this  symptom  is  more  frequently  due  to  mediastinal  tumor. 

Physical  Signs. — Inspection  does  not  always  discover  changes,  but  if 
the  sac  grows  outwardly,  sooner  or  later  a  swelling  makes  its  appearance, 
to  the  right  of  the  sternum  if  in  the  ascending  limb,  possibly  raising  a  rib 
or  the  end  of  the  clavicle;  above  and  behind  the  sternum  if  in  the  transverse 
portion,  raising  the  manubrium  or  boring  its  way  through  it;  and  to  the 
left  of  the  sternum  if  in  the  descending  limb  of  the  arch.  As  the  tumor  pro- 
trudes, the  skin  becomes  smooth,  shining,  and  tense  over  it,  and  may  be- 
come gangrenous  previous  to  rupture.  Such  a  tumor  may  pulsate  or  not. 
Should  elasticity  of  the  sac  be  lost,  either  as  the  result  of  calcification  or  the 
lining  of  the  sac  with  successive  layers  of  coagulum,  such  dilatation  becomes 
impossible,  and  pulsation  does  not  occur.  The  pvilsation  is,  however,  of 
great  importance  to\the  diagnosis.  When  present,  it  is  synchronous  with 
the  systole  of  the  ventricles.  The  heart  itself  is  sometimes  displaced  down- 
ward, as  seen  from  the  lowering  of  the  apex  sometimes  as  low  as  the  sixth 
interspace  and  outside  the  mammillary  line.  Hypertrophy  of  the  left  ven- 
tricle rarely  occurs,  and  when  present,  is  not  nearly  so  extreme  as  in  aortic 
valve  disease. 

If  the  aneurysmal  tumor  press  upon  the  great  veins  of  the  neck,  there 
may  be  venous  engorgement  and  edema  on  one  side  of  the  neck  or  both, 
according  as  the  innominate  vein  of  one  side  only  is  compressed  or  the 
descending  cava  itself.  The  aneurysm  may  rarely  rupture  into  the  descend- 
ing cava,  resulting  in  a  form  of  varicose  aneurysm,  producing,  in  addition 
to  the  ordinary  signs  of  aneurysm,  sudden  distention  of  the  veins  in  the 
upper  half  of  the  body,  edema  of  the  face,  hands,  and  arms,  cyanosis, 
systolic  venous  pulse,  and  purring  thrill. 

Eye  Symptoms. — The  pupil  may  be  contracted  or  dilated  depending 
upon  whether  the  sympathetic  is  irritated  or  destroyed. 

There  may  be  unilateral  sweating  or  flushing  depending  upon  the  same 
cause. 

Palpation  also  recognizes  the  impulse  of  the  aneurysm  if  it  is  visible. 


626  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

and  sometimes  when  it  is  not  visible.  This  beating  is  peculiar,  being  expan- 
sile, and  differs  thus  from  the  rising  of  a  tumor  over  a  ptdsating  blood-vessel. 
A  thrill  is  also  often  felt,  a  vibration  in  the  walls  of  the  sac  caused  by  the 
whirl  of  the  blood  in  it .  It  is  by  no  means,  however,  invariable,  and  it  ma>- 
come  and  go.  Very  great  tenderness  is  sometimes  present  over  the  seat  of 
the  protruding  aneurysm.  Palpation  may  also  recognize  the  "diastolic 
shock,"  or  recoil  blow  of  the  aneurysm  on  the  closed  aortic  valve,  if  this  be 
competent — a  most  valuable  sign. 

Then,  there  is  the  tracheal  tugging  of  aneurj'sm  first  described  by  Sur- 
geon-Major Oliver,  and  further  studied  by  Ross  and  McDonnell,  in  Canada.  ^ 
It  is  generally  indorsed  as  a  valuable  sign.  This  is  a  dragging  down- 
ward of  the  larynx  with  each  systole  of  the  heart.  In  E wart's  method  the 
patient  sits  with  his  mouth  closed,  his  head  well  bent  backward,  steadied 
against  the  chest  of  the  examiner,  standing  behind  him.  The  trachea  is 
drawn  up  gently  by  inserting  the  ends  of  the  fingers  under  the  edge  of  the 
cricoid  cartilage,  when  with  each  impulse  the  larynx  is  felt  to  be  pulled  down- 
ward. Oliver  directs,  with  the  patient  in  the  upright  position,  the  mouth 
closed,  and  chin  elevated,  grasping  the  cricoid  cartilage  between  the  fingers 
and  the  thumb  pressing  it  steadily  upward,  when,  if  aneurysm  exists,  the 
pulsation  of  the  aorta  will  be  distinctly  felt.  There  is  much  danger  in  this 
last  method  of  mistaking  pulsation  of  the  carotids  for  a  tracheal  tug.  It 
may  be  the  sole  sign  of  aneurysm.  Cardarelli's  sign  of  lateral  movement 
of  the  larynx  is  similar,  with  an  obvious  difference.  It  is  said  never  to  be 
present  in  aneurysm  of  the  innominate. 

Alteration  in  the  pulse  in  distal  arteries  is  also  a  sign  of  considerable 
diagnostic  value.  The  pulse-beat  may  be  simply  delayed  as  compared 
with  the  heart-beat.  This  is  the  natural  result  of  the  intervening  sac  which 
may  receive  temporarily  a  considerable  amount  of  the  blood  required  to 
produce  the  pulse  wave.  Or  the  pulse  in  one  radial  may  be  smaller  than 
that  in  the  other.  It  is  chiefly  when  the  aneurysm  involves  the  origin  of 
blood-vessels  leading  to  the  radials,  as  the  innominate  on  the  right  and  the 
carotid  or  subclavian  on  the  left.  If  the  right  radial  pulse  is  enfeebled  or 
delayed,  the  aneurysm  will  be  on  the  right,  involving  the  origin  of  the  in- 
nominate; if  the  left  radial  is  influenced,  the  aneurysm  is  probably  in  the 
neighborhood  of  the  left  subclavian.  Great  care  should  be  taken  in  the 
examination,  and  it  should  be  made  from  the  center  to  the  periphery — that 
is,  the  carotids,  the  subclavians,  the  brachials,  and  the  radials  should  be  suc- 
cessively examined,  as  recommended  by  Sansom.  These  effects  are  vari- 
ously produced.  Thus,  the  aneurysm  may  narrow  or  distort  the  orifice 
of  the  blood-vessel  by  traction  on  it;  or  there  may  be  atheromatous  change 
in  the  branch  vessel  analogous  to  that  in  the  aorta  itself,  which  may  cause 
narrowing  of  the  orifice,  while  the  possibility  of  this  in  the  absence  of 
aneurysm,  is  also  to  be  remembered;  or  the  aneurysmal  sac  may  act  as  the 
elastic  air-chamber  in  a  pump,  diminishing  thus  the  pulsatile  force  in  the 
vessel  and  branches  beyond.  It  is  particularly  in  the  arteries  of  the  lower 
extremities,  by  aneurysm  of  the  descending  thoracic  and  abdominal  aorta, 
that  this  air-chamber  effect  is  seen,  and  the  pulse,  even  in  the  abdominal 


I"  London  Lancet,"  1S91. 


ANEURYSM  OF  THE  AORTA  G27 

aorta  and  its  branches,  has  been  thus  obUterated  by  a  large  thoracic  aneu- 
rysm.    There  may  be  a  difference  in  the  blood  pressure  on  both  sides. 

Percussion  over  the  swelling  of  an  aneurysm  invariably  elicits  im]3aired 
resonance,  varying  greatly  in  degree  and  extent.  On  the  other  hand,  the 
adjacent  lung  may  be  compressed,  producing  an  area  of  dullness  beyond 
the  tumor  itself.  One  case  on  our  records  had  complete  collapse  of  one  lung 
resembling  a  tuberculous  consolidation.  The  dullness  is  usually  in  the  right 
upper  intercostal  spaces,  especially  if  the  aneurysm  is  in  the  ascending  limb 
of  the  arch.  Aneurysms  in  the  transverse  portion  produce  dullness  in  the 
middle  line  under  the  manubrium  and  toward  the  left  of  the  sternum,  while 
aneurysms  of  the  descending  part  may  produce  dullness  in  the  left  inter- 
scapular and  scapular  regions  posteriorly.  Sometimes  the  impairment  of 
resonance  precedes  the  pulsation,  though  such,  dullness  is  of  uncertain 
significance. 

Auscultation  is  no  exception,  as  compared  with  the  other  modes  of  phys- 
ical investigation,  as  to  the  inconstancy  of  its  information,  sometimes  fur- 
nishing the  most  distinctive  signs,  while  at  other  times  it  is  totally  negative. 

The  murmur  or  bruit  heard  over  an  aneurysm  varies.  Sometimes  but 
one  murmur  is  produced — systolic,  corresponding  with  the  first  sound  over 
the  ventricles,  but  more  intense;  more  rarely  it  is  diastolic  only.  Not  infre- 
quently there  is  a  combined  or  double  murmur,  both  sj'stolic  and  diastolic, 
the  first  intense  and  prolonged,  the  second  fainter  and  shorter.  It  varies 
greatly,  being  sometimes  rough,  sometimes  soft,  and  sometimes  musical. 
The  murmur  is  not  infrequently  absent.  The  mechanism  of  these  sounds  is 
not  settled.  The  systolic  is  the  most  easily  explained.  There  can  be  little 
doubt  that  it  is  produced  by  the  inequalities  which  meet  the  entrance  of  the 
blood  into  the  sac.  The  diastolic  murmur,  when  the  aneurysm  is  at  the  be- 
ginning of  the  aorta,  will  probably  be  an  aortic  regurgitant  murmur,  due 
to  relative  insufficiency  of  the  aortic  valve.  When  the  aneurysm  is  distant 
from  the  aortic  orifice,  the  diastolic  murmur  may  be  due  to  the  recoil  of  the 
distended  sac,  propelling  the  blood  through  the  outlet  with  additional  force, 
or  the  whirling  of  the  blood  through  the  sac.  Rarely  in  these  distant 
situations  there  is  a  diastolic  murmur  only,  probably  thus  caused. 

A  much  more  constant  symptom  is  an  accentuated  aortic  second  sound, 
which  is  bell-like  in  character.  It  is  rarely  absent  in  aneurysm  of  the  arch 
where  the  aortic  valves  are  intact.  It  is  an  exaggeration  of  the  second  sound, 
recognizable  by  the  ear  and  due  to  the  elastic  recoil  of  the  aneurysmal  sac. 
"It  is  the  shock  of  the  second  sound  that  is  heard  and  the  recoil  is  felt." 
It  is  not  always  present,  and  requires  a  sound  aortic  valve  to  produce  it  in  its 
most  marked  degree.  Sir  Douglas  Powell  holds  that  it  is  best  studied  with 
the  wooden  stethoscope,  and  that  the  binaural  may  fail  to  observe  it.  Ernest 
Sansom  considers  it  best  investigated  by  the  ear  direct,  with  only  a  slight  inter- 
vening chest  covering.  It  may  be  accompanied  by  or  replaced  by  the  dias- 
tolic murmur  referred  to.  It  is  rarely,  if  ever,  present  with  mediastinal 
growths,  even  when  they  perforate  the  sternum  and  produce  pulsation. 

But  any  one  or  all  of  these  signs  may  be  wanting.  Particularly  is  this 
the  case  where  the  aneurysm  occurs  just  after  the  aorta  has  left  the  heart. 
The  most  valuable  is  the  pulsation  distinct  and  separate  from  that  of  the 
heart,  or,  as  graphically  put  by  Da  Costa,  "what  is  more  essential  is  to  find 


628  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

two  points  of  pulsation  in  the  chest — two  hearts,  apparently  each  with  its 
own  distinct  beat,  its  own  distinct  sounds."' 

The  X-ray  has  been  brought  to  bear  on  the  diagnosis  of  aneurysm,  and 
commonly  a  distinct  demonstration  of  the  tumor  can  be  made,  both  by  the 
fluoroscope  and  skiagraphy.  It  should  always  be  availed  of  when  there  are 
persistent  signs  of  pressure  in  the  chest.  Often  a  diagnosis  is  first  made  by 
the  use  of  this  method.  vSailer  and  Pfahler  have  shown  that  a  tortuous  aorta 
may  simulate  an  aneurysm. 

Aneurysm  Pointing  in  the  Back. — It  must  always  be  remembered  that 
an  aneurysm,  especially  of  the  descending  arch  or  the  descending  aorta 
itself,  may  be  nearer  the  back  than  the  front  of  the  chest  and  may  give  the 
first  physical  signs  there.  In  all  cases  where  aneurj'sm  is  suspected  the  back 
must  be  especiall}'  examined. 

In  aneurysm  of  the  Ascending  Aorta  there  is  more  apt  to  be  pain  like 
that  of  angina  pectoris,  dyspnea,  dullness  to  the  right  of  the  manubrium 
sterni  from  the  second  intercostal  space  upward,  pulsation  in  the  same 
region,  displacement  of  the  heart  downward  and  to  the  left,  delayed  pulse 
in  the  peripheral  arteries  as  contrasted  with  the  heart's  impulse,  compression 
symptoms  involving  the  sympathetic  and  the  area  of  the  superior  cava,  pres- 
sure upon  the  pvilmonary  artery  producing  a  pulmonic  systolic  murmur, 
with  hypertrophy  and  dilatation  of  the  right  ventricle  if  the  aneurysm  com- 
press the  pulmonary  artery. 

Aneurysm  of  the  Transverse  Part  of  the  Arch  furnishes  more  par- 
ticularly pulsation  in  the /055a  jugularis;  tracheal  tug;  dullness  on  percus- 
sion over  the  manubrium  and  to  its  left  in  the  first  intercostal  space;  nar- 
rowing of  the  orifices  of  the  innominate,  the  left  carotid,  or  left  subclavian, 
and  resulting  inequality  of  the  pulse  in  the  head  and  arm;  pressure  on  the 
left  innominate  vein,  with  resulting  congestion  and  edema  of  the  left  half 
of  the  neck  and  head.  It  is  when  in  this  situation  that  aneurysm  com- 
presses the  left  recurrent  laryngeal  nerve  and  causes  paralysis  of  the  left 
vocal  cord,  presses  on  the  trachea,  with  resulting  stridor  and  cough,  and  on 
the  left  bronchus,  producing  inspiratory  dyspnea. 

In  aneurysm  of  the  Descending  Limb  of  the  Arch  of  the  Aorta^ 
we  look  for  the  pulsation  behind  to  the  left  of  the  vertebral  column  oppo- 
site the  angle  of  the  scapula  or  below.  The  bruit  is  faint  or  absent.  In  the 
thoracic  aorta  below  the  arch,  in  consequence  of  the  air-chamber  effect,  we 
may  find  smallness  of  the  crural  pulse  as  contrasted  with  the  radial,  symp- 
toms of  pressure  upon  the  left  lower  azygos  or  hemiazygos  vein — i.  e., 
edema  of  the  upper  part  of  the  abdomen  and  pleuritic  effusion;  also  symp- 
toms of  pressure  on  the  esophagus  and  left  bronchus.  The  intercostal 
nerves  may  be  compressed,  producing  intense  pain  in  the  course  of  their 
distribution,  the  vertebral  column  may  also  be  eroded,  the  spinal  canal 
opened,  and  the  cord  compressed,  with  resulting  paraplegia.  If  the  aneurysm 
project  fon\-ard,  which  is  rareh'  the  case,  it  may  press  upon  and  displace 

>Da  Costa.  "  Medical  Diagnosis."  eighth  ed.,  189s.  p.  S07. 

2  The  desccndinR  part  of  the  arch  of  the  aorta  is  somewhat  arbitrarily  terminated  by  anatomists  at  the 
lower  end  of  the  fifth  dorsal  vertebra,  below  which  it  is  called  the  descending  thoracic  aorta,  which  terminates 
at  the  opening  of  the  diaphragm  in  front  of  the  last  dorsal  vertebra,  below  which  it  is  the  abdominal  aorta. 
The  symptoms  of  aneurysm  of  the  descending  part  of  the  arch  and  the  descending  thoracic  aorta  do  not 
differ  widely. 


ANEURYSM  629 

the  heart,  causing  palpitation,  or  it  may  also  compress  the  esophagus, 
causing  painful  deglutition.  It  sometimes  ulcerates  and  breaks  into  the 
esophagus.  Obscure  symptoms  of  this  variety  of  aneurysm  may  exist  for 
a  long  time  before  a  tumor  shows  itself  posteriorly  between  the  shoulders, 
which  is  unmistakable  at  this  late  stage. 

Aneurysm  of  the  Abdominal  Aorta  furnishes  a  pulsating  tumor  to 
the  left  of  the  vertebral  column,  to  the  left  and  above  the  umbilicus.  The 
bifuration  of  the  aorta  takes  place  on  the  fourth  liunbar  vertebra,  which 
point  corresponds  to  the  umbilicus.  Sometimes  a  thrill  maj'^  be  felt  and  a 
systolic  murmur  heard,  rarely  a  double  murmur.  Here,  too,  the  smallness 
of  the  crural  pulses,  as  contrasted  with  the  heart's  impulse  and  the  radial 
pulse,  may  be  observed,  while  in  some  cases  the  crural  pulses  disappear 
altogether.  The  symptoms  vary  somewhat,  according  as  the  aneurysm 
grows  backward  or  toward  the  front.  In  backward  pressure  pain  is  also  a 
striking  symptom,  and  may  be  of  two  kinds,  a  fixed  and  constant  pain  in 
the  back,  catised  by  the  pressure  of  the  tumor  on  the  solar  plexus  and 
splanchnic  nerves,  or  a  sharp  lancinating  pain  radiating  along  the  branches 
of  the  compressed  lumbar  nerves,  whence  pain  in  the  loins,  testes,  hypo- 
gastrium,  and  in  the  lower  limbs,  usually  on  the  left  side.  If  the  sac  grows 
anteriorly,  gastrointestinal  symptoms  may  be  present,  such  as  vomiting, 
gastralgia,  diarrhea,  and  even  symptoms  of  obstruction  of  the  bowel. 
Pain  is  also  present,  but  is  more  likely  to  be  fixed  in  the  loins,  epigastrium, 
or  some  part  of  the  abdomen. 

Erosion  of  the  spine  is  much  rarer  in  abdominal  aneixrysm  than  in 
thoracic.  In  emaciated  persons  the  abdominal  aorta  sometimes  pulsates 
so  plainly  that  one  is  strongly  reminded  of  aneurysm,  and  is  a  constant 
source  of  error,  but  under  these  circumstances  there  is  absence  of  the 
systolic  murmur  and  of  the  alterations  in  the  pulse  of  the  arteries  of  the 
lower  extremity,  and  none  of  the  pain  described.  Indeed,  evident  abdom- 
inal ptdsation  occurs  far  more  frequently  without  aneurysm  than  with  it. 
Abdominal  aneurysm  should  not  be  diagnosticated  unless  there  is  a  palpable 
tumior,  a  thrill  with  expansile  pulsation. 

Aneurysm  of  the  Branches  of  the  Abdominal  Aorta. — Of  these, 
aneurysm  of  the  celiac  axis  is  most  often  mentioned  and  diagnosed,  though 
not  always  correctly. 

Aneurysm  of  the  Splenic  Artery  is  sometimes  met.  Ten  cases  were 
collected  by  Lebert  out  of  39  involving  various  branches  of  the  abdominal 
aorta. 

Aneurysm  of  the  Hepatic  Artery  is  a  rare  lesion,  some  ten  or  twelve 
cases  having  been  recorded.  These  aneurysms  are  not  usually  large,  while 
the  liver  has  been  found  greatly  enlarged. 

Aneurysms  of  the  Superior  Mesenteric  Artery  have  been  found  at 
necropsies. 

Aneurysms  of  the  Renal  Artery  are  more  mmierous.  They  are 
generally  small,  but  m.ay  terminate  in  rupture  and  retroperitoneal  hemor- 
rhage. 

Aneurysm  of  the  Innominate  is  especially  indicated  by  its  murmur, 
thrill,  and  impulse  in  the  vicinity  of  the  inner  end  of  the  right  clavicle, 
which  is  sometimes  raised  by  the  resulting  tumor;  also  by  the  comparative 


630  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

absence  of  signs  of  pressure  on  the  larynx  or  esophagus.  The  differences 
in  the  right  radial  pulse  alluded  to  are  especially  present  here.  Compres- 
sion of  the  right  subclavian  and  right  carotid  diminishes  the  force  of  the 
beat  of  the  innominate  aneurysm,  but  is  without  effect  in  aortic  aneurysm. 
Nor  are  there  percussion  signs  of  enlargement  of  the  aorta. 

If  the  Subclavian  is  involved,  the-signs  arc  further  outward,  on  the 
outer  side  of  the  stemo-cleido-mastoid,  while  in  aneurysm  of  the  innominate 
they  are  found  on  the  inner  or  tracheal  side.  To  those  named  may  be 
added  symptoms  of  pressure  upon  the  subclavian  vein,  producing  swelling 
of  the  arm  and  neck;  upon  the  right  recurrent  laryngeal,  producing  defective 
speech  and  dyspnea;  on  the  sympathetic,  producing  contraction  of  the 
pupil,  and  on  the  brachial  plexus  of  nerves,  pain.  Especially  would  these 
signs  point  to  aneurysm  of  the  subclavian  if  the  pulse  of  the  carotids  is 
uninfluenced  while  the  right  or  left  radial  pulse  is  influenced. 

The  very  rare  condition  of  aneurysm  of  the  Pulmonary  Artery  may 
produce  a  swelling,  with  the  other  local  symptoms  described,  to  the  left  of 
the  sternum,  in  the  second  interspace.  A  murmur  is  less  constant  and  is 
not  conducted  into  the  vessels  of  the  neck,  while  the  superficial  pressure 
signs  are  more  conspicuous.  There  is  lividity  of  the  face,  with  dropsy,  and 
the  dyspnea  is  naturally  very  great.  There  is  no  cough  or  voice  altera- 
tion. It  is  to  be  remembered,  however,  that  the  swelling  of  an  aneurysm 
of  the  arch  of  the  aorta  may  extend  to  the  left  of  the  sternum.  Such  an 
aortic  aneurysm  may  break  into  the  pulmonary  artery. 

An  aneurysm  of  the  Heart  is  not  recognizable  by  physical  signs  and  may 
only  be  suggested  by  symptoms. 

Differential  Diagnosis  of  Aneurysm  of  the  Arch. — Further  diagnosis 
distinguishes  aneur^'.sm  of  the  aorta  mainly  from  mediastinal  tumor.  There 
may  be  the  same  percussion  signs,  though  percussion  dullness  is  usually 
more  irregular  in  mediastinal  tumor.  There  is  often  similar  pain;  there 
may  also  be  pulsation,  but  instead  of  the  expansile  piolsation  extending  in 
all  directions,  it  is  more  heaving.  Murmurs  are  not  usual  in  the  medias- 
tinal tumor.  The  ringing,  or  accentuated  second  sound — diastolic  shock — 
which  may  be  present  in  aneurysm  when  the  aortic  valves  are  intact,  or 
substituted  by  the  diastolic  murmiir  when  the  valves  are  incompetent, 
is  absent  in  mediastinal  tumor.  Tracheal  tugging  may  occur  in  mediastinal 
tumor.  Differences  in  the  pulse  or  changes  in  the  voice.  The  state  of  the 
blood-vessels  usually  associated  with  aneurysm  must  be  ascertained. 
Fever  is  often  present  in  mediastinal  tumor;  very  rarely  in  aneurysm.  A 
differential  diagnosis  is  often  impossible,  and  experts  have  held  opposite 
opinions  on  the  same  case.  Should  the  patient  develop  a  cachectic  state 
and  secondary  glandular  enlargements  appear,  presumption  is  in  favor  of 
mediastinal  disease. 

The  resemblance  of  some  of  the  sjTnptoms  of  aneurysm  of  the  ascending 
aorta  to  som<^  of  those  of  aortic  incompetency  is  verv'  close.  The  same  pul- 
sating aorta,  the  same  double  basic  murmur  with  impaired  resonance  at 
the  right  of  the  sternum,  may  be  present.  Cases  have  been  diagnosed  as 
aortic  regurgitation  vnth.  stenosis,  in  which  the  autopsy  disclosed  perfect 
semilunar  valves  with,  however,  aneurysm  and  relative  insufficiency,  which 
caused  the  diastolic  mtuTnur.     In  aneurysm  there  is  more  rarely  hypertrophy 


ANEURYSM  631 

of  the  heart  than  in  aortic  valvular  disease.  The  age  of  the  patient,  if 
under  40,  especially  the  history  of  heart  disease  in  early  life,  the  history  of 
rheumatism,  and  the  absence  of  the  causes  of  atheromatous  vessels,  point  to 
valvular  disease.  Though  there  may  be  pulsation  at  the  root  of  the  neck  in 
both,  in  aortic  incompetency  the  same  strong  pulse-beat  extends  to  the 
wrists.  Traube's  double  sound  in  the  femorals  and  popliteals,  though 
possibly  otherwise  caused,  is  still  more  frequently  associated  with  aortic 
incompetency  than  any  other  lesion.  Simple  dilatation  may,  indeed,  be 
present  in  aortic  incompetency,  but  the  pressure  signs  are  wanting.  Capil- 
lary pulse  is  absent  in  aortic  aneurysm. 

A  pulsating  empyema  on  either  side  of  the  upper  sternum  sometimes 
closely  resembles  a  pulsating  aneurysm,  and  the  illusion  is  more  complete 
because  the  pulsation  is  expansile.  Pulsating  empyemas  are  generally 
further  to  the  left  of  the  sternum  than  aneurysmal  pulsation.  Other  signs 
of  aneurysm  are  also  wanting,  unless  it  be  tenderness,  which  may  be  present. 
There  is  leukocytosis  in  empyema  and  not  in  aneurysm.  A  rare  condition 
is  a  narrowing  of  the  aorta  below  the  remains  of  the  ductus  arteriosus  at  the 
junction  of  the  arch  with  the  thoracic  aorta,  which  produces  small  delayed 
pulse  in  the  femorals,  a  thrill  and  murmur  over  the  upper  part  of  the 
sternum,  but  the  extraordinary  enlargement  of  the  collateral  vessels,  espe- 
cially the  mammary  and  epigastiic  arteries,  should  set  the  question  at  rest. 

In  acute  laryngitis  we  have  often  the  cause — exposure  to  cold— ^to  help 
us,  though  in  the  chronic  form  we  have  not.  In  laryngitis  there  is  usually 
more  huskiness  and  less  stridor  in  the  voice,  nor  is  the  cough  so  brassy,  or 
the  voice  so  uniformly  changed;  it  is  more  likely  to  alternate  with  normal 
voice.  In  aneurysm  the  voice  grows  progressively  weak  until  aphonia  re- 
sults. The  dyspnea  in  aneurysm  is  more  often  attended  mth  wheezing, 
and  is  sometimes  relieved  for  a  time  by  coughing.  Stokes  called  attention 
to  the  fact  that  in  aneurysm  the  stridor  of  the  voice  seems  to  come  from  the 
notch  of  the  sternum,  rather  than  from  the  larynx  itself.  In  aneurysm  the 
breathing  sounds  are  more  likely  to  differ  in  the  two  lungs.  Then  we  have 
the  laryngoscopic  picture.  There  is  no  swelling  of  the  cords  in  aneurysm, 
while  there  may  be  the  paralytic  phenomena  detailed.  Finally,  in  laryngitis 
there  may  be  fever.  The  x-ray  will  frequently  make  an  otherwise  impossible 
diagnosis. 

Prognosis. — Aneurysm  is  not  infrequently  found  at  necropsy  without 
having  been  suspected  and  the  aneurysmal  sac  entirely  healed.  In  other 
cases  the  fatal  termination  is  the  first  notification  of  its  presence.  When  an 
aneurysm  of  the  aorta  is  so  developed  as  to  exhibit  its  usual  signs  plainly, 
it  is  generally  sooner  or  later  fatal  in  some  one  of  the  modes  already  de- 
scribed. To  foretell  in  which  of  the  directions  pointed  out  perforation  will 
occur  depends  upon  the  accuracy  with  which  diagnosis  of  its  position  can 
be  made,  and  such  diagnosis  is  at  best  a  matter  of  probability.  Only  in 
cases  in  which  aneurysm  slowly  erodes  the  anterior  wall  of  the  chest  is  there 
a  gradual  termination.  Then  there  are  sometimes  repeated  small  hemor- 
rhages, which  gradually  reduce  the  strength  of  the  patient,  who  finally 
dies  of  exhaustion  or  of  an  ultimately  fatal  large  hemorrhage.  Perforation 
into  the  vena  cava,  pulmonary  artery,  and  right  side  of  the  heart  is  a  rare 
termination.     The   course  of   the   disease  may,    however,   be   prolonged 


632  DISEASES  OF  HEART  AXD  BLOOD-ViLSSELS 

many  months,  and  if  treatment  is  instituted  early,  it  may  contribute  to 
such  prolongation.  When  death  does  not  occur  from  sudden  hemorrhage, 
the  symptoms  may  assume  the  type  of  chronic  heart  disease,  for  which, 
indeed,  the  condition  is  sometimes  mistaken  by  the  untrained  observer. 
With  failing  heart  come  dyspnea,  palpitation,  dropsy,  and  death. 

Treatment. — We  seek  in  the  treatment  of  aneurysm  to  diminish  intra- 
vascular pressure  and  restore  the  integrity  oj  the  vessel.  The  former  may  be 
accomplished  in  a  degree  by  placing  the  patient  under  conditions  which  will 
avert  the  causes  of  such  increased  intravascular  pressure,  which  is  constantly 
cooperating  with  the  disease- of  the  artery  to  produce  further  dilatation  and 
ultimate  rupture  of  the  blood-vessel.  This  is,  of  course,  best  accomplished 
by  absolute  rest.  It  is  plain  the  less  frequently  the  heart  beats  and  throws 
the  weight  of  its  blood  against  the  weak  blood-vessel,  the  longer  wiU  that 
blood-vessel  last,  while  it  is  known  to  every  student  that  the  heart  beats  less 
frequently  in  the  sitting  than  in  the  standing  posture,  and  less  in  the  re- 
cumbent than  in  the  sitting  position.  On  the  other  hand,  it  is  evident  that 
absolute  rest  is  an  impossibility.  Yet  it  may  be  approximated  in  various 
degrees.  It  is  impossible  also  to  restore  the  integrity  of  the  vessel,  but  to 
this  end  also  measures  are  suggested  which  have  for  their  immediate  pur- 
pose coagulation  of  the  blood  in  the  vessel  and  obliteration  of  the  sac. 
That  this  sometimes  occurs  numerous  autopsies  also  attest. 

The  method  which  has  met  most  favor  is  that  now  known  as  Tufnell's 
treatment,  by  restricted  diet  and  rest  though  Valsalva  originally  suggested 
a  restricted  diet  and  practiced  frequent  venesections.  Bellingham  advised 
starvation  without  bleeding.  The  treatment  was,  however,  revived  by  the 
late  T.  JoUiffe  Tufnell  and  modified  by  G.  W.  Balfour  who  added  the  iodid 
of  potassium.  Tufnell's  treatment  consists  in  absolute  mental  and  physical 
rest  in  the  recumbent  position,  together  with  a  moderate  dry  diet.  The 
object  of  this  is  to  diminish  the  blood-pressure  and  volume  of  blood,  to 
increase  the  proportion  of  fibrin  in  the  latter,  and  to  promote  its  coagulation. 
The  diet  is  as  follows : 

For  breakfast,  two  ounces  of  bread  and  butter  and  two  ounces  of  milk; 
for  dinner,  two  or  three  ounces  of  meat  and  three  or  four  ounces  of  milk  or 
claret;  for  supper,  two  ounces  of  bread  and  two  ounces  of  milk.  Thus  it 
is  hoped  to  diminish  the  blood  volume  and  reduce  the  pressiu-e  within  the 
sac,  to  render  the  blood  more  fibrinous  and  to  favor  coagulation.  The 
proper  dose  of  the  iodid  of  potassium  is  5  to  20  grains  (0.33  to  13  gm.) 
three  times  a  day.  It  is  supposed  to  act  by  increasing  secretions,  thus 
thickening  the  blood.  To  its  efficiency  in  this  direction  we  may  add  our 
testimony.  Balfour  also  claims  that  it  lowers  the  blood  pressure  by  pro- 
moting the  flow  of  blood  through  the  arterioles.  Boelim,  Provost,  Conn, 
Stockman,  James  Burnet  and  Rolleston  deny  that  the  iodids  lower  blood 
pressure,  though  they  admit  that  the  drug  is  useful.  It  may  be  expected, 
also,  that  cases  of  s\'philitic  origin  will  be  those  especially  benefited,  but  it  is 
said  that  experience  does  not  confinn  such  expectation.  Occasional  small 
bleedings  amounting  to  a  few  ounces  contribute  to  a  favorable  result  includ- 
ing relief  of  pain.  Evidences  of  improvement  are  reduction  in  the  size  of  the 
tumor,  diminished  force  of  pulsation,  and  relief  of  pain.  The  Tufnell  treat- 
ment should  be  kept  up  for  several  months,  o^'  as  long  as  the  patient  will  sub- 


ANEURYSM  633 

mit  to  it.  It  is  said  to  be  useful  more  particularly  in  saccular  aneurysm 
communicating  by  a  small  orifice  with  the  aorta.  It  is  doubtful  whether  it  is 
worth  while  to  subject  a  patient  with  large  aneurysm  communicating  with 
the  aorta  by  a  large  orifice  to  the  inconvenience  of  such  a  treatment,  and 
whether  it  may  not  be  better  to  advise  him  to  live  a  life  as  quiet  as  possible 
and  to  await  the  inevitable,  while  we  relieve  symptoms  as  they  arise,  and 
remember  especially  that  iodid  of  potassium  is  often  one  of  the  best  remedies 
for  pain. 

A  remedy  said  to  favor  coagulation  of  blood  in  an  aneurysm  is  chlorid 
of  calcium  of  which  lo  grains  (0.66  gm.)  may  be  given  four  times  a  day. 
Acupuncture  as  a  means  of  securing  coagulation  and  contraction  of  the 
clot  was  suggested  by  Velpeau.  It  consists  in  placing  a  needle  into  the 
aneurysm  with  the  hope  that  the  blood  will  coagulate  on  it.  Filling  the 
aneurysm  with_^M^  wire  has  been  suggested  for  the  same  purpose.  The  wire 
is  introduced  through  a  hypodermic  needle,  and  a  measured  electric  current 
passed  through  the  wire.  This  measure  gives  much  relief  in  certain  cases. 
In  others  it  is  valueless.  Ligation  of  the  carotid  or  subclavian,  or  both,  has 
also  been  done  for  aneurysm  of  the  aorta  with  satisfactory  results.  It  is, 
however,  a  formidable  operation. 

No  other  internal  treatment  for  aneurysm  other  than  that  suggested — 
by  iodid  of  potassium — has  ever  been  of  any  use.  As  a  part  of  the  medicinal 
treatment  of  thoracic  anevirysm  it  should  be  added  that  where  there  is  vio- 
lent action  of  the  heart,  cardiac  sedatives  are  sometimes  indicated  to  allay 
this,  in  addition,  of  course,  to  the  enjoined  rest.  Among  these  sedatives  we 
include  aconite  and  veratrum  viride  in  extreme  cases,  also  cold  to  the  seat 
of  the  swelling  and  to  the  cardiac  region.  When  signs  of  cardiac  decompen- 
sation occur  the  case  must  be  treated  as  for  that  condition.  Digitalis  may 
then  be  given  without  fear  of  harm. 

The  treatment  of  peripheral  aneurysm,  as  of  the  popliteal  and  femoral, 
is  usually  relegated  to  the  surgeon,  who  will  treat  it  by  ligation  or  compres- 
sion. Tufnell's  method  is  also  applied  to  peripheral  aneurysm,  for  which, 
indeed,  it  was  originally  recommended. 

The  treatment  of  peripheral  aneurysm  by  compression  has  long  been  an 
acknowledged  method  for  the  purpose,  and  though  looked  upon  as  a  surgical 
procedure,  is  as  medical  as  it  is  surgical.  The  method  adopted  which  has 
been  most  successful  is  digital  compression,  which  is  exerted  by  relays  of 
students  or  others  available  for  the  purpose.  The  effect  is  that  in  the  course 
of  48  hours  coagulation  has  taken  place  and  the  aneurysm  is  cured.  Failing 
in  these  measures,  ligation  is  practiced  in  case  of  the  smaller  arteries,  but  all 
details  of  this  operation  belong  to  the  province  of  surgery. 


SECTION  V. 

DISEASES  OF  THE  BLOOD  A\W  BLOOD-MAKING  ORGANS. 

THE  ANEMIAS. 

By  anemia  is  meant  any  state  of  the  blood  in  which  there  is  a  diminution 
of  its  total  bulk,  its  red  corpuscles,  its  hemoglobin — any  one  or  all  of  these. 
The  first  is  the  condition  which  ensues  from  a  large  hemorrhage  of  any  kind, 
as  from  the  rupturing  of  an  aneurysm,  erosion  of  a  blood-vessel,  such  as 
sometimes  happens  in  ulcer  of  the  stomach  or  in  tuberculosis  of  the  lung, 
or  from  a  blood-vessel  wounded  in  any  wa3^  In  all  instances,  however, 
where  the  hemorrhage  is  not  fatal  the  original  bulk  of  the  blood  is  rapidl\' 
restored  by  the  absorption  of  water  and  salts  from  the  tissues,  while  the 
hemoglobin  and  albumin  remain  deficient  until  they  can  be  restored  by  suit- 
able nourishment.  Practically,  therefore,  anemias  resolve  themselves  for 
study  into  conditions  in  which  there  is  a  reduction  in  the  amount  of  hemo- 
globin through  a  diminution  in  the  total  number  of  red  corpuscles  or  in  the 
proportion  of  coloring-matter  in  each  corpuscle,  or  both. 

Anemias  are  further  divided  into  primary  or  essential,  and  secondary 
anemias.  The  former,  strictlj^  speaking,  include  only  those  which  are 
the  direct  result  of  a  defect  in  the  blood-making  apparatus,  while  second- 
ary anemias  are  those  due  to  loss  of  blood,  or  some  one  of  its  important 
constituents. 

Among  primary  anemias  are  included  chlorosis,  pernicious  anemia, 
leukemia,  pseudo-leukemia  or  Hodgkin's  disease,  and  splenic  anemia. 

The  secondary  anemias  are  the  direct  result  of  trauma,  accidental 
hemorrhage,  chronic  disease,  or  toxic  agents. 

SECONDARY  OR  SYiMPTOMATIC  ANEMIA. 

1.  Anemias  Due  to  Hemorrhage,  however  Caused. — Traumatic  hemor- 
rhage, postparttun  and  other  uterine  hemorrhage,  pulmonary-  hemorrhage, 
and  gastric  and  intestinal  hemorrhages  comprise  most  of  these;  ruptured 
aneurj-sms  and  purpura  furnish  others.  Parasites  invading  the  intestinal 
canal  may  be  causes  of  hemorrhage  and  consequent  anemia.  So  may 
parasites  elsewhere,  as  the  distoma  hcematobium  in  the  kidney. 

In  non-fatal  hemorrhages  from  these  causes  the  immediate  loss  of  blood 
in  hemophilia  is  rapidly  made  up  by  the  absorption  of  water  from  the  gastro- 
intestinal tract,  but  a  long  time  is  required,  even  under  favorable  circum- 
stances, before  the  corpuscles  and  hemoglobm  are  restored.  At  other  times 
regeneration  is  quite  rapid,  restoration  being  complete  in  ten  days.  The 
hemoglobin  is  always  rather  more  reduced  than  the  corpuscles,  but  both 
increase  for  a  time  pari  passu,  as  shown  in  the  appended  chart.  The  albu- 
minous constituents  are  more  rapidly  restored. 

2.  Anemias  Due  to  the  Drain  of  Chronic  Disease. — Such  are  chronic 

63-1 


ANEMIA 


635 


Bright's  disease,  suppurative  processes,  cancer,  or  prolonged  lactation, 
arterio-sclerosis,  tuberculosis,  syphilis  and  certain  intestinal  parasites  and 
chronic  diarrhea.     In  this  group  belong  the  anemias  of  malaria. 

3.  Anemia  from  Inanition. — This  results  from  starvation,  which  may 
be  the  practical  consequence  of  diseases  which  interfere  with  the  successful 
ingestion  and  assimilation  of  food,  such  as  obstruction  of  the  esophagus. 

4.  Toxic  Anemias. — Finally,  there  remain  the  toxic  anemias.  These 
are  the  result  of  the  presence  in  the  blood  of  such  substances  as  lead,  acquired 
by  painters  or  workers  in  lead-paint  factories,  type-setters,  and  type-founders  : 
also  arsenic  from  dress  fabrics,  wallpaper,  and  furniture  coverings;  mercury. 


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Fig.  117. — The  Blood  in  Secondary  Anemia.     Hemoglobin  Red,  Corpuscles  Black.     From 
Case  of  Syphilis. 


Symptoms. — The  most  commonly  recognized  symptom  of  anemia  is  a 
paleness  of  the  skin,  and  this  is  undoubtedly  present  in  the  vast  majority  of 
cases.  Yet  a  total  reliance  dare  not  be  placed  on  it,  for  it  sometimes  hap- 
pens that  the  skin  and  even  the  lips  are  pale,  and  yet  no  anemia  is  found 
when  the  blood  is  examined.  On  the  other  hand,  the  skin  and  lips  may 
have  a  good  color,  and  yet  anemia  be  actually  present.  Weakness,  faint- 
ness,  vertigo,  shortness  of  breath,  and  palpitation  are  also  symptoms. 

In  addition  to  these  are  the  hlood  changes,  which  vary  mth  the  degree 
of  anemia.  Both  corpuscles  and  hemoglobin  are  reduced,  not  always  pari 
passu,  the  hemoglobin  commonly  in  somewhat  larger  proportion.  The 
disproportionate  lowering  of  the  hemoglobin  is  explained  by  a  more  than 
natural  paleness  of  the  red  corpuscles.  Their  average  size  is  reduced,  while 
in  severe  cases  there  is  also  a  moderate  poikUocytosis.     Nucleated  red_cor- 


636  DISEASES  OF  THE  BLOOD 

pusclcs  also  make  their  appearance.  The  normoblasts  and  microblasts  are 
the  prevailing  forms.  They  exhibit,  after  staining  with  Wright's  stain,  a 
deep-blue  nucleus,  while  free  nuclei  are  occasionally  found.  Alicrocytes, 
megalocytes,  and  poikilocytes  are  present  in  advanced  cases. 

The  colorless  corjsusclcs  are  moderately  increased,  such  increase  being  rep- 
resented by  the  multinuclear  neutrophils,  while  the  small  mononticlear 
lymphocytes  are  diminished.  The  leukocytosis  gradually  disappears  with 
the  return  of  the  blood  to  its  normal  state.  Myelocytes  are  exceptionally 
present. 

Diagnosis. — In  addition  to  the  blood  changes  more  or  less  common  to  all 
of  these  causes  of  anemia,  the  same  general  symptoms  of  pallor,  lassitude, 
debility,  dyspnea,  and  faintness  which  characterize  the  essential  anemias  are 
also  present  in  less  degree. 

While  a  feature  of  secondary  anemia  is  the  nearlj^  coequal  reduction  of 
the  hemoglobin  and  corpuscles  this  is  not  true  of  all  forms.  Thus  in  lead- 
poisoning,  as  a  rule,  the  hemoglobin  is  reduced  in  larger  proportion  than  the 
red  cells,  resembling  in  this  respect  chlorotic  anemia.  Lead-poisoning  is 
further  characterized  by  a  stippling  of  the  red  cells  due  to  degeneration.  The 
history  of  the  case  in  the  presence  of  one  of  the  causes  named  is  of  itself  suffi- 
cient to  determine  the  diagnosis  in  many  cases. 

Treatment. — The  treatment  of  secondary  anemia  is  that  of  the  primarj' 
disease,  plus  certain  drugs  which  help  to  stimulate  the  blood-making  organs. 
With  the  disappearance  of  the  primary  disease  ver\'  rapid  coequal  rise  in  the 
hemoglobin  and  corpuscles  occiirs,  as  is  beautifully  showm  in  the  foregoing 
chart  (Fig.  117)-  Full  doses  of  iron  are  well  borne  in  these  cases,  and  we  have 
the  choice  of  almost  any  of  the  preparations,  including  Blaud's  pills  of  the 
carbonate,  reduced  iron,  tincture  of  the  chlorid,  Basham's  mixture,  and  the 
vegetable  salts.  Though  full  doses  are  here  indicated,  it  is  still  unnecessary 
to  give  the  massive  doses  recommended  by  some,  as  they  are  not  absorbed 
and  produce  constipation. 

THE  PRIMARY  OR  ESSENTIAL  ANEMIAS. 

These  include  chlorosis,  for  the  present  pernicious  anemia,  leulcemia, 
Hodgkin's  disease  or  pseudoleukemia,  and  splenic  anemia. 

I.  CHLOROSIS. 

Synonyms. — Morbus   mrgineus;   Green   Sickness;   Chloremia;  Chloranemia. 

Definition. — A  primary  anemia  most  frequently  met  in  young  girls, 
characterized  by  a  very  marked  relative  reduction  in  the  hemoglobin  of  the 
blood. 

Etiology. — As  stated  in  the  definition,  it  is  a  disease  of  females,  and 
especially  of  young  girls.  Moreover,  while  it  is  especially  a  disease  of 
young  girls  about  the  age  of  puberty,  it  is  also  possible  in  those  who  are 
older,  as  well  as  those  who  are  younger.  It  occurs  in  children  who  have 
not  reached  the  age  of  puberty.  Niemeyer  held  that  girls  who  menstruated 
at  13  or  14,  in  whom  there  was,  as  yet,  no  development  of  pubes  or  breasts, 
most  invariabl}'  become  chlorotic.     The  disease  occurs  the  world  over,  and 


CHLOROSIS  637 

is  apt  to  be  recurrent  in  the  same  individual.  It  is  more  common  in  blondes 
than  in  brunettes,  in  tlie  weak  and  delicate,  rather  than  the  strong  and 
vigorous.     Yet  this  general  truth  is  not  without  exception. 

Among  predisposing  causes  are  overwork,  especially  in  closely  confined 
and  ill-ventilated  rooms,  insufficient  nourishment,  and  profuse  menstruation. 
Menstrual  derangement  is,  however,  also  a  consequence  as  well  as  a  cause. 
Sustained  or  reptated  emotion,  especially  such  as  arise  from  sexual  excite- 
ment and  masturbation,  is  a  cause.  Homesickness  and  grief  are  included 
among  causes,  many  of  the  cases  occurring  in  recent  immigrants. 

The  frequent  association  of  constipation  with  chlorosis  led  Sir  Andrew 
Clark  to  suggest  that  it  might  really  be  a  copremia. 

Morbid  Anatomy. — Other  than  the  changes  in  the  blood,  to  be  con- 
sidered under  s^'mptoms,  there  is  no  essential  morbid  anatomy  in  chlorosis. 
Many  years  ago  Virchow  pointed  out  an  imperfect  development  of  the 
circulatory  apparatus  as  more  or  less  characteristic — that  the  heart  was 
small,  the  right  ventricle  sometimes  dilated,  the  aorta  and  its  larger  branches 
were  poorly  developed  and  thin  walled.  Such  a  condition,  when  present, 
is  probably  an  accidental  coincidence.  There  is  no  enlargement  of  the 
spleen  or  lymphatic  glands.  Imperfect  development  of  the  uterus  and  other 
genitalia  has  been  noticed.  The  rarity  of  fatal  termination  in  chlorosis 
may  limit  our  knowledge  of  the  morbid  anatomy,  uncertain  at  best. 

Symptoms. — Of  these,  the  hlood  changes  may  be  regarded  as  fundamental, 
though  not  absolutely  constant.  The  blood  is  pale.  This  is  due  to  a  de- 
cided reduction  in  the  hemoglobin,  with  a  moderate  reduction  in  the  size  and 
niunber  of  the  red  corpuscles — microcytosis  and  oligocythemia.  Thus, 
the  hemoglobin  value  of  each  red  disk  is  diminished.  The  usual  number  of 
red  cells  may  be  put  at  from  3,500,000  to  little  less  than  normal.  Thus, 
Thayer,  in  63  consecutive  cases  in  Osier's  clinic,  found  the  average  4,096,544, 
or  over  80  per  cent.,  and  Lembeck  found  the  maximvun  in  one  of  15  cases  to 
be  but  3,600,000.  In  a  few  instances,  however,  in  cases  of  acknowledged 
chlorosis,  there  has  been  found  a  more  decided  reduction  in  the  erythrocytes. 
One  has  been  reported  in  which  they  were  reduced  as  low  as  1,190,000  in  a 
cubic  millimeter. 

The  hemoglobin,  on  the  other  hand,  is  much  reduced,  the  average  of 
Thayer's  cases  referred  to  being  42.3  per  cent.,  which  may  be  regarded  as  a 
fair  average.  The  color  index  is  therefore  low.  This  disproportionate  fall 
in  the  hemoglobin  is  a  constant  feature,  producing  sometimes  a  recog- 
nizable diminished  intensity  of  color  when  the  blood  is  seen  en  masse.  Along 
with  the  lowering  of  hemoglobin  the  iron  of  the  blood  falls,  as  would  be  ex- 
pected, since  it  is  a  constituent  of  the  hemoglobin. 

As  to  remaining  changes,  the  red  corpuscles  may  be  undersized.  This 
may  be  said  to  be  a  more  or  less  characteristic  change  and  with  the  diminished 
coloring-matter  may  be  the  only  change.  The  red  disks  are  sometimes 
appreciably  paler  than  in  health.  They  may  be  larger  than  in  health  (meg- 
alocytes).  They  may  be  altered  in  shape,  constituting  a  small  degree  of 
poikilocytosis,  a  term  suggested  by  Quincke.  A  very  slight  degree  of 
leukocytosis  may  be  rarely  present,  an  average  of  8467  in  Thayer's  counts,  as 
contrasted  with  a  mean  normal  of  6000  in  the  cubic  millimeter,  while  the 
hlood  plaques  in  severe  cases  may  also  be  increased.     Nucleated  red  cor- 


638 


DISEASES  Of  THE  BLOOD 


puscles  arc  sometimes  met,  especially  in  the  later  stages,  represented  by  the 
smaller  forms  (microblasts)  which  sometimes  appear  in  crops.  In  this  stage 
the  corpuscles  may  assume  irregular  shapes.  Myelocytes  have  rarely  been 
met. 

The  blood  alterations  in  chlorosis  are  distinctive  enough  to  be  considered 
diagnostic,  when  considered  with  the  other  symptoms  and  the  absence  of  a 


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Hemoglobin — ^R  ed . 
Fig.  ii8. — Blood  in  Chlorosis. 


Colorless  Corpuscles — ^Blue. 


causative  disease.  The  patient  is  almost  invariably  a  girl,  generally  be- 
tween 1 6  and  20,  who,  although  she  may  have  been  overworked,  does  not 
seem  badly  nourished;  certainly  she  is  not  emaciated.  There  is  often  de- 
rangement of  menstruation,  and  sometimes  the  girl  is  hysterical. 

Most  striking,  though  not  invariable,  is  a  peculiar  pallor,  ver\-  seldom 
exhibiting  a  yello%vish-green  tinge,  extending  to  the  lips,  and  especially  the 


CHLOROSIS  639 

mucous  membranes,  and  which  is  responsible  for  one  of  the  names  of  the 
affection — green  sickness — this  green  color  is  certainly  very  rare  in  the  cases 
now  considered  chlorosis.  The  patient  is  extremely  weak,  especially  on 
exertion,  and  is  short  of  breath.  She  is  subject  to  vertigo,  palpitation  of  the 
heart,  and  even  irregularitj^  of  the  heart's  action.  Physical  examination 
will  sometimes  discover  functional  cardiac  murmurs.  Rarely,  a  compensa- 
tory hypertrophy  of  the  left  ventricle  has  been  noticed,  but  never  actual 
valvular  disease.  Sometimes  a  bruit  de  diable  or  murmur  may  be  heard 
over  the  right  jugular,  disappearing  when  the  patient  lies  down.  Epigastric 
pain  is  also  a  symptom  at  times.  It  must  not  be  forgotten  that  a  chlorosis 
late  in  life,  or  chlorosis  tarda,  does  sometimes  occur.  Fever  is  not  rarely 
present.     On  the  other  hand,  the  hands  and  feet  are  often  cold. 

Diagnosis. — The  diagnosis  is  based  chiefly  upon  the  age  and  sex  of  the 
patient,  the  peculiar  paleness  of  the  skin,  the  paleness  of  the  lips,  and  the 
decidedly  diminished  hemoglobin,  unaccompanied,  with  a  proportionate  re- 
duction in  the  number  of  erythrocytes.  The  same  lost  normal  ratio  between 
the  hemoglobin  and  the  corpuscles  is  also  a  characteristic  of  lead-poisoning, 
which  has,  however,  superadded  its  own  characteristic  symptoms,  and  is 
common  in  adult  males  and  females. 

The  epigastric  pain  mentioned  as  occurring  in  chlorosis  resembles  that 
more  common  in  ulcer  of  the  stomach.  The  anemia  which  so  constantly 
attends  ulcer  of  the  stomach,  often  in  a  high  degree  is,  however,  different 
from  that  of  chlorosis,  there  being  a  corresponding  decline  in  the  number  of 
the  erythrocjd;es  and  their  coloring-matter.  The  ordinary  symptoms  of 
gastric  ulcer  are  wanting. 

A  not  infrequent  error  of  diagnosis  in  connection  ■nith  chlorosis  is  the 
mistaking  of  it  for  a  "decline,"  a  pulmonary  consumption,  which  it  resembles 
in  the  pallor,  the  feebleness,  and  shortness  of  breath  of  the  patient.  The 
absence  of  emaciation,  of  cough,  and  of  the  physical  signs  of  consumption 
exclude  that  disease.  On  the  other  hand,  evidences  of  tuberculosis  should 
always  be  sought  where  the  symptoms  of  chlorosis  prevail.  It  is  a  grave 
error  to  consider  tuberculosis  a  chlorosis. 

Most  frequently  chlorosis  is  confounded  with  secondary  anemia,  but  the 
characteristic  features  of  chlorotic  blood  are  wanting,  and  there  is  always  a 
presence  of  some  other  disease  or  poison.  In  advanced  degrees  of  chlorosis 
the  blood  approaches  that  of  pernicious  anemia,  but  there  is  rarely  the  ex- 
treme reduction  of  red  cells  and  pernicious  anemia  is  rare  in  young^^girls 
while  chlorosis  rarely  if  ever  occurs  in  adults. 

Prognosis. — The  prognosis  is  favorable  when  the  disease  is  recognized 
and  the  proper  treatment  instituted.  There  are  few  results  more  satisfactory 
in  therapeutics  than  those  of  a  properly  treated  case  of  chlorosis.  Time  is, 
however,  necessary,  and  too  rapid  a  cure  must  not  be  promised,  several 
months  and  even  longer  being  sometimes  required. 

Treatment. — The  treatment  is  preeminently  by  iron.  The  carbonate 
in  the  shape  of  Blaud's  pill,  made  by  a  double  decomposition  between 
the  carbonate  of  potassium  and  the  sulphate  of  iron,  is  the  best,  i  to  5  grains 
(0.06  to  0.2  gm.)  being  given  at  a  dose  three  times  a  day.  It  should  be  made 
fresh.  Much  larger  doses  are  sometimes  given,  as  much  as  45  grains  (3  gms.) 
a  day.     We  repeat  that  iron  is  given  in  too  large  doses  in  the  majority  of  cases 


640  DISEASES  OF  THE  BLOOD 

for  which  is  it  prescribed.  Most  of  it  is  unabsorbcd,  and  therefore  wasted. 
Nay,  worse,  that  which  is  unabsorbed  locks  up  the  intestinal  secretions  by 
its  astringency,  produces  headache,  and  makes  the  patient  otherwise  uncom- 
fortable. But  chlorosis  is  one  of  the  few  diseases  in  which  large  doses  of 
iron  are  well  borne.  The  reason  is  plain.  It  is  the  iron-holding  constituent 
of  the  blood  which  is  wanting,  and  the  iron  is  needed  to  replace  it.  The 
blood  is,  as  it  were,  hungry  for  it.  Reduced  iron  or  one  of  the  vegetable 
salts  of  iron  may  be  given.  Next  to  iron  comes  arsenic.  The  efficiency  of 
iron  is  greatly  aided  by  union  with  arsenic,  which  should  be  given  in  increas- 
ing doses,  but  short  of  toxic  effect. 

Hydrochloric  acid  in  full  doses,  originally  suggested  by  Zander  on  the 
ground  of  supposed  deficiency  of  this  acid  in  the  digestive  fluid  in  chlorosis, 
is  useful  also  in  promoting  the  solubility  of  iron,  as  well  as  for  its  tonic  and 
antiseptic  properties. 

But  to  give  these  drugs  alone  is  not  sufficient.  In  ver\'  se\'ere  cases  rest 
in  bed  may  be  necessary  to  seciure  a  rapid  result,  and  this  must  be  associated 
with  an  abundance  of  good  food  and  fresh  air.  Daily  massage,  except  dur- 
ing menstruation,  is  also  a  useful  adjuvant.  There  is  no  condition  in  which 
the  so-called  "rest  cure"  is  more  efficient  than  in  chlorosis.  With  a  return 
of  color  to  the  Hps,  or,  better,  with  the  growing  increase  in  the  hemoglobin  as 
measured  by  the  hemoglobinometer,  the  patient  should  be  permitted  to  be 
out  of  bed  at  first  from  a  half-hour  to  an  hoiu-  only,  but  this  should  be  gradu- 
ally increased  until  she  is  up  most  of  the  day.  For  a  long  time,  however,' 
fatigue  should  be  avoided.  To  those  who  can  afford  it,  a  residence  at  the 
seaside  materially  aids  convalescence.  To  the  poor,  a  well-regulated  hospital 
treatment  is  a  boon  for  which  there  is  scarcely  a  substitute.  Many  cases 
can  be  treated  on  foot  from  the  beginning,  care  being  taken  to  avoid  fatigue. 
Symptoms  rapidly  disappear,  but  no  case  should  be  considered  cured  until 
both  hemoglobin  and  red  ceUs  are  normal. 


II.  PROGRESSIVE  PERNICIOUS  ANEMIA. 

SnygnyiMS. — Idiopathic  Anemia;  Pernicious  Anemia. 

Pernicious  or  ichopathic  anemia,  originally  described  by  Addison  in  1855 
in  his  celebrated  paper  on  "Diseases  of  the  Suprarenal  Capsules."  Interest 
in  the  subject  was  revived  by  Biermer  in  1S68,  and  since  then  it  has  been 
thoroughly  studied  anatomically  and  clinically.  It  is,  however,  still  the 
least  understood  of  all  the  anemias. 

Definition. — Pernicious  anemia  is  a  progressive  anemia  of  unknown 
cause  with  remissions.  The  red  corpuscles  and  hemoglobin  are  both  greatly 
reduced,  the  former  in  larger  proportion,  the  color  index  being  high. 

Etiology. — The  etiology  of  pernicious  anemia  is  very  obscure.  Evi- 
dence is  accumulating  in  favor  of  a  toxic  hemolytic  origin,  the  toxins  being 
the  result  of  some  one  of  the  associated  conditions.  It  is  more  common  in 
males  than  females  and  in  middle  life.  It  rarely  affects  children.  Preg- 
nancy seems  to  be  in  some  way  responsible  for  a  certain  number  of  cases. 
It  has  also  followed  lactation.  Cases  with  the  blood  picture  of  pernicious 
anemia  as  the  result  of  atrophy  of  the  stomach  have  been  reported  by  Flint, 


^mmmmmmmmmm 


IJONE  Marrows. — i.  Normal.  2.  Typical  progressive  pernicious  anemia. 
3.  Scattered  areas  of  megaloblastic  degeneration  in  progressive  pernicious 
anemia.  4.  .Aplastic  anemia. —  (Fro7>i  Lavenson's  paper  on  Aplastic  Anemia. 
Transae.  Assoc  American  Physicians,  vol.  xxi,  igo6.) 

(To  face  page  641) 


PERNICIOUS  ANEMIA 


641 


Fenwick,  Osier  and  Henry.  Intestinal  parasites,  the  bothriocephalus  latus, 
may  undoubtedly  produce  symptoms  clinically  indistinguishable  from  the 
general  anemia  which  Addison  characterized  as  "occurring  without  any 
discoverable  cause  whatever — cases  in  which  there  had  been  no  previous  loss 
of  blood,  no  exhausting  diarrhea,  no  chlorosis,  no  purpura,  no  renal,  splenic, 
miasmatic,  glandular,  strumous,  or  malignant   disease." 

Symptoms. — The  approach  of  pernicious  anemia  is  most  insidious, 
beginning  with  a  gradual  progressive  weakness.  What  is  first  interpreted  as  a 
causeless  weariness  or  languor  grows  slowly  into  an  extreme  debility,  with 
faintness  on  the  slightest  exertion,  and  thence  into  a  state  of  thorough  muscu- 
lar weakness,  which  ultimately  prostrates  the  patient,  and  he  is  too  weak  to 


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Fig.  119. — Blood  in  Pernicious  Anemia. 


rise  from  bed.  To  this  succeeds  a  state  of  mental  hebetude  and  bodily 
torpor.  Rarely  this  extreme  debility  is  substituted  by  a  remarkable  vigor. 
Nor  is  there  emaciation.  The  body  bulk  is  well  preserved.  The  shin  ac- 
quires gradually  a  lemon-yellow  hue,  whence  the  disease  has  been  mistaken 
for  diseases  of  the  liver.  The  mucous  membranes,  on  the  other  hand,  are 
blanched,  as  may  be  seen  in  the  lips,  gums,  and  mouth.  The  sclera  are  pearh' 
white. 

CardiovasctUar  symptoms  are  especially  conspicuous  in  progressive  per- 
nicious anemia.  Hemic  murmurs,  visibly  pulsating  and  throbbing  arteries, 
even  pulsating  veins,  have  been  noticed.  The  large,  but  soft,  jerky  pulse, 
resembling  that  of  aortic  regurgitation,  was  mentioned  by  Addison.  The 
capillary  ptdse  is  also  frequently  seen,  and  hemorrhage,  cutaneous  and  ret- 
inal, occur. 

Digestive  derangements  form  an  important  part  of  the  symptomatology 


642  DISEASES  OF  THE  BLOOD 

of  pernicious  anemia.  Indisposition  to  take  food  or,  rather,  a  disgust  for 
food,  nausea,  vomiting,  and  diarrhea  are  often  troublesome  symptoms. 
According  to  Hunter,  sore  mouth  and  sore  tongue  are  often  present.  Hy- 
drochloric acid  is  constantly  deficient  in  gastric  digestion  (achylia  gastrica) 
Moderate  elevation  of  temperature,  irregular  and  intermittent,  is  also  noticed, 
while  nervous  symptoms,  including  numbness,  languor,  and  even  paralysis, 
are  sometimes  present.  Paresthesia  is  especially  emphasized  as  an  early 
symptom,  even  the  earliest.  Symptoms  with  loss  of  patellar  reflexes  often 
cause  the  case  to  resemble  locomotor  ataxia. 

The  urine  exhibits  no  constant  changes,  being  sometimes  pale  and  some- 
times dark-hued.  The  dark  color  is  ascribed  by  Mott  and  Hunter  to  an  ex- 
cess of  urobilin. 

Blood  Changes. — The  changes  in  the  blood  are  more  distinctive  than  in 
chlorosis,  although  it  is  true  also  that  there  is  no  single  constant  character- 
istic feature.  It  may  be  pale  and  watery.  The  most  constant  feature  is  a 
very  decided  reduction  of  the  red  cells,  without  a  corresponding  reduction  in 
the  hemoglobin,  although  the  hemoglobin,  in  toto,  is  much  reduced.  Quincke 
found  as  few  as  143,000  corpuscles  in  a  cubic  millimeter  of  blood,  while  it  is 
not  uncommon  to  find  less  than  half  a  million.  Frederick  P.  Henry  found 
315,000  a  few  hoxirs  before  death,  and  Laache  360,000.  In  a  case  under 
Dr.  Tyson's  care  at  the  Philadelphia  Hospital,  in  1898,  the  red  disks  fell  to 
437,000,  and  the  hemoglobin  to  nine  per  cent.,  death  taking  place  two  days 
after  the  count  was  made.  The  inevitable  conclusion  from  the  average  of 
cases  observed  is  that  the  hemoglobin  value  of  each  corpuscle  must  be 
increased. 

The  changes  in  the  red  cells  point  preeminently  to  degeneration  of 
these  bodies.  Among  these  changes  is  a  variation  in  the  size  and  shape  of 
the  red  corpuscles.  Megalocytes  occur  from  ten  to  fifteen  micromillimeters  in 
diameter,  as  compared  with  a  normal  of  from  6.5  to  9.4.  The  majority  may 
be  so  enlarged.  They  are  often  also  ovoid  in  form.  Their  abundant  pres- 
ence marks  severity  in  the  disease,  but  they  are  not  essential  to  diagnosis. 
On  the  other  hand,  there  are  also  microcyies — cells  smaller  than  normal — 
and  poikilocytes — corpuscles  characterized  by  great  irregiilarity  in  shape. 
While  these  irregular  shapes  were  first  demonstrated  in  connection  with 
pernicious  anemia,  they  occiu-  in  all  severe  anemias.  Polychromaiophilia. — 
A  condition  in  which  the  erythrocytes  stain  irregularly  and  unevenly  is 
always  present  and  accompanies  the  enlargement  of  the  cell.  Basic  granu- 
lation or  granular  degeneration  of  the  red  cell,  a  variety  of  polychromatophilia 
is  very  frequent.  Degeneration  of  the  red  cells  shown  by  a  stippling  when- 
stained,  is  common. 

Nucleated  red  corpuscles  are  a  constant  constituent  of  the  blood  of  per- 
nicious anemia,  and  have  also  been  regarded  by  their  discover,  Ehrlich,  as 
almost  pathognomonic.  Two  kinds  are  found — first,  the  small,  normal- 
sized  corpuscle  wath  its  deeply  stained  nucleus  (normoblasts),  and  certain 
large  forms  with  pale  nuclei  (megaloblasts) .  They  are  not  confined  to  this 
disease.  Blood  plaques  are  either  absent  or  very  scanty.  Karyokinesis  is 
rarely  found  in  these  larger  cells,  but  when  present  in  connection  with  the 
other  changes  it  is  regarded  by  some  as  almost  pathognomonic.  Leukocytes 
are  usually  diminished  in  niunber  due  to  a  decrease  in  the  polymorphonu- 


PERNICIOUS  ANEMIA  643 

clear  leukocytes,  while  there  is  a  tendency  to  an  increase  of  the  mononuclear 
white  cells,  as  compared  with  health. 

Morbid  Anatomy. — Various  tissues  have  been  studied  in  the  effort  to 
find  a  morbid  anatomy  for  pernicious  anemia.  In  the  absence  of  lymphatic 
involvement  or  enlargement  of  the  spleen,  except  sometimes  in  small 
degree,  the  marrow  oj  bones  has  claimed  close  study.  H.  C.  Wood  de- 
scribed the  red  condition  of  the  marrow  of  long  bones  in  1871.  It  was 
further  studied  in  this  country  by  William  Pepper'  and  Tyson, ^  and  abroad 
especially  by  Cohnheim.' 

Although  the  appearances  described  by  these  observers  are  not  identi- 
cal, they  are  sufficiently  constant  to  justify  their  association  as  more  than 
accidental.  Slimmed  iip,  they  amount  to  this:  Marrow  dark  red;  consist- 
ence less  soft;  fat  vesicles  absent;  specific  lymphoid  cells  increased,  includ- 
ing marrow  cells  of  various  sizes,  containing  one  or  more  nuclei;  ntmierous 
nucleated  red  corpuscles  present,  especially  the  larger  forms,  the  giganto- 
blasts  of  Ehrlich.  These  studies  were  made  before  the  days  of  differential 
staining  and  counting.  More  recent  studies  add  neutrophiles  and  eosino- 
philes.  These  appearances  are  now  commonly  interpreted  as  due  to  an 
effort  of  the  blood-making  apparatus  to  reproduce  the  disintegrated  erythro- 
cytes. They  are  not,  however,  constant,  as  the  marrow  is  sometimes  pale 
or  yellow.  It  is  a  reproducing  process,  an  irregular  attempt  at  regeneration, 
a  hyperplasia,  as  contrasted  with  "aplastic." 

The  appended  illustrations  from  Lavenson's  paper  shows  well  the  con- 
trast between  normal  and  diseased  bone-marrow. 

The  deposition  of  iron  in  the  liver  cells  has  already  been  alluded  to. 
It  is  found  in  the  outer  and  middle  zones  of  the  lobules,  and  may  be  so 
distributed  as  to  outline  the  bile  capillaries.  It  is  regarded  by  Hunter  as 
characteristic.  The  liver  itself  is  often  fatty  and  is  sometimes  enlarged. 
The  iron  is,  in  like  manner,  sometimes  increased  in  the  kidney,  and  spleen, 
and  these  organs  are  not  otherwise  essentially  changed,  though  the  spleen 
has  been  found  reduced  in  size. 

The  heart  muscle  is  fatty,  while  the  other  muscles  are  unusually  red. 
Other  morbid  changes  are  described,  but  they  cannot  be  regarded  as  es- 
sential. Such  are  changes  in  the  ganglion  cells  of  the  sympathetic,  and 
sclerosis  of  the  posterior  columns  of  the  cord,  first  studied  by  Lichtheim.^ 
Softening  of  the  upper  part  of  the  lumbar  cord  has  also  been  reported  by 
Sir  Dyce  Duckworth. °  While  the  associated  changes  in  the  spinal  cord 
are  so  constant — 84  per  cent,  of  cases  collected  by  Cabot — that  they  cannot 
be  regarded  as  accidental,  experimental  studies  by  Burr  and  Griffith  in- 
tended to  determine  this  relation  to  pernicious  anemia  resulted  in  nothing 
definite.  Complete  atrophy  of  the  secreting  tubules  of  the  stomach  has  been 
described  by  Fenwick,  and  by  William  Osier  and  F.  P.  Henry  in  one  case 
studied  jointly  by  them. 

Diagnosis. — The  diagnosis  of  pernicious  anemia  may  be  uncertain  at 
first,  but  the  true  nature  of  the  disease  soon  declares  itself.     The  intense 

'  "Progressive  Pernicious  Anemia,"  "American  Journal  of  the  Medical  Sciences,"  October,  1895. 
2  "Die  Betheiligung  des  Knochenmarkes  bei  pernicioser  Anaemic,"   "Virchow's  Archiv,"   1877,  Ixxi, 
118-126. 

2  "Virchow's  Archiv,"  October,  1876 
*  "Congress  fur  innere  Medicin,"  1887. 
''"British  Medical  Journal,"  November  10,  1900. 


644  DISEASES  OF  THE  BLOOD 

anemia,  extreme  weakness,  digestive  derangements,  and  cardiovascular 
symptoms,  in  connection  with  blood-count  of  1,000,000  or  below,  with  a 
relative  increase,  or  at  least  no  proportionate  diminution,  in  the  hemo- 
globin, and  an  admixture  of  mcgalocytes,  microcytes,  and  poikilociiies, 
point  to  a  condition  scarcely  mistakable.  It  may  be  said,  moreover, 
that  almost  never  in  the  case  of  a  pernicious  anemia  do  the  number  of 
corpuscles  fail  to  fall  below  1,000,000.  The  large  forms  of  nucleated  red 
corpuscles  have  been  regarded  as  characteristic,  but  are  also  foimd  in 
leukemia  (see  also  diagnosis  of  Cancer  of  the  Stomach,  p.  380).  The 
marked  remission  of  the  symptoms  is  a  marked  fer.ture  of  these  cases. 

Prognosis. — The  prognosis  is  to-day  regarded  as  less  imfavorable  than 
it  was  a  few  years  ago,  since  recent  experience  has  developed  the  fact 
that  temporary  improvement  is  not  uncommon,  and  it  is  said  that  re- 
coverj'-  sometimes  takes  place.  Still,  Addison's  original  prognosis,  of  a 
termination  sooner  or  later  fatal,  is  seldom  astray. 

Treatment. — Treatment  of  pernicious  anemia  is,  moreover,  not  fruit- 
less. The  same  measures  which  are  almost  a  specific  for  chlorosis  are 
not  without  effect  in  pernicious  anemia.  Accordingly,  arsenic,  to  a  less 
degree  iron,  good  food,  and  favorable  hygienic  surroundings,  are  to  be 
adopted.  The  arsenic  treatment  has  been  followed  by  results  which 
justif}^  the  words  "temporary  cure,"  and  it  is  said  that  permanent  cure 
has  followed.  Such  temporary  cures  have  covered  a  period  of  three  j'ears. 
The  best  preparation  appears  to  be  Fowler's  solution,  in  gradually  increas- 
ing doses,  until  20  and  even  30  minims  (1.3  to  2  c.c.)  are  reached,  and  this 
three  times  a  day.  It  should  be  continued  for  a  long  time,  for  weeks  or 
months,  with  intermissions  of  a  few  days  if  unpleasant  results  appear, 
to  be  again  resumed.  Arsenic  is  not  a  specific  for  pernicious  anemia,  but 
the  results  of  its  use  are  often  surprisingly  gratifying.  Cacodylate  of 
sodixom  has  been  recommended  as  less  irritating  than  other  preparations  of 
arsenic,  being  suitable  also  for  hypodermic  use.  The  dose  is  1/2  a  grain 
(0.033  gni-).  three  times  a  day,  hypodermically  1/3  to  1/2  grain  (0.002  to 
0.033  gm.)  everj^  other  day.  Atoxyl  is  stiU  another  preparation  of  arsenic 
<:;iven  in  doses  of  1/3  to  1/2  grain  (0.022  to  0.033  g™-)  hypodermicalh-  ever^- 
other  day.  Inhalation  of  oxygen  has  also  been  recommended,  as  advised 
in  leukemia.  The  relation  between  chlorosis  and  pernicious  anemia, 
already  referred  to,  is  sustained  by  therapeutic  resvilts.  Certain  cases 
of  chlorosis  verj^  closely  resemble  pernicious  anemia,  especially  when 
not  arrested  by  treatment.  The  arsenic,  administered  as  directed,  is 
wondcrfullj'  well  borne,  nausea  and  vomiting  being  rare.  Rest  in  bed 
is  indispensable,  but  should  be  supplemented  with  massage,  if  possible. 
Food  should  be  in  easily  assimilable  shape,  such  as  beef-juice,  and  pepto- 
nized milk.  Salol  has  been  suggested  as  an  intestinal  antiseptic,  from 
the  standpoint  that  the  disease  may  be  due  to  toxins  absorbed  from  that 
canal.  From  the  same  point  of  view  lavage  of  the  large  bowel  through  an 
opening  into  the  cecum  has  been  tried  using  peroxid  of  hydrogen  and 
solutions  of  permanganate  of  potash.  Recently,  too,  William  Hunter  has 
suggested  the  use  of  antistreptococcus  serum  to  counteract  possible  general 
infection. 

Transfusion  of  blood,  which  seemed  at  one  time  to  give  promise  of 


LEUKEMIA  645 

favorable  results,  discontinued,  but  has  been  revived  and  as  much  as 
SCO  CO.  of  human  blood  injected  into  a  vein. 

0.  Huber^  employs  the  intramuscular  injection  of  blood,  and  reports  four 
cases  of  which  in  three  the  results  were  favorable,  but  advises  the 
coincident  use  of  arsenic  and  other  suitable  remedies.  He  injects  small 
quantities  of  defibrinated  blood  on  the  gluteal  region — human  blood  from  a 
person  not  suffering  from  fever  or  active  disease.  The  blood  is  defibrinated 
by  the  use  of  glass  pearls  and  filtered  through  linen,  lo  to  20  c.c.  being 
injected  every  five  to  eight  days.  It  is  thought  to  stimulate  the  body  to 
restore  the  blood  to  its  normal  composition. 

For  intravenous  injections  care  must  be  taken  to  secure  a  homologous 
serum.  Most  recently  Ehrlich's  606  has  been  employed  intravenously 
with  advantage. 

III.  LEUKEMIA. 

Definition. — A  disease  characterized  by  an  enormous  increase  in  the 
olorless  corpuscles  of  the  blood,  by  hyperplastic  changes  in  the  bone 
marrow,  the  spleen,  and  in  the  lymphatic  glands,  in  a  word  in  all  the  leuko- 
blastic  tissues. 

The  disease  has  been  called  lenkocythemia  as  well  as  leukemia,  the 
former  of  these  words  meaning  white-cell  blood,  the  latter  simply  white 
blood.  From  the  etymological  and  histological  standpoint,  leukoCTii;hemia, 
suggested  by  Hughes-Bemiett,  is  the  more  accurate  term,  but  Virchow's 
term,  leukemia,  has  become  the  one  in  common  use. 

Two  forms  are  recognized,  myeloid  leukemia  and  lymphoid  leukemia.  In 
the  former  the  marrow  cells  are  present  in  large  numbers  associated  with 
changes  in  the  bone  marrow,  while  in  the  latter  the  lymphatic  tissues  are 
also  invaded  and  lymphocytes  large  and  small  predominate  in  the  blood. 

The  extremely  rapid  course  of  certain  cases  of  leukemia  justifies  its 
division  into  an  acute  and  chronic  form,  acute  leiikemia  being,  however, 
relatively  rare.  Ebstein  was  the  first  to  call  attention  to  the  acute  form 
reporting  a  fatal  case  in  which  the  whole  duration  of  the  disease,  including 
a  prodromal  stage,  was  but  six  weeks.  Similar  cases  are  reported  by 
others.^  Fraenkel  collected  all  the  cases  to  1895,  including  ten  of  his  own. 
M.  H.  Fussell,'  A.  E.  Taylor  and  Jopson  collected  56  cases.  Mina^  in  1901, 
69  cases.  Since  this  time  many  cases  have  been  reported.  The  duration'of 
the  chronic  form  may  extend  over  years.  Leukemic  women  have  been 
repeatedly  pregnant  and  have  borne  children  at  term. 

Fraenkel  concluded  that  all  cases  of  acute  leukemia  are  lymphoid  or 
lymphatic  in  which  the  increase  of  white  cells  consists  chiefly  or  almost 
firmed.  It  would  seem,  however,  that  both  varieties  may  be  acute  or 
chronic.  The  lymphoid  va.riety  furnishing  more  acute  cases,  while  the 
chronic  is  almost  always  myeloid.^ 

Etiology. — Nothing  definite  is  known  of  the   cause  of  leukemia.     It 

1  Deutsche  Med  Wochenschrift.  June,  1910. 
'"  Wiener  klin.  Wochenschrift."  1894. 

2  "American  Medicine,"  March  5,  1904. 

<"  Wiener  med.  Rundschau,"  1901,  Nos.  37  and  38. 

^  See  R.  J.  M.  Buchanan's  paper  on  leukemia  in  the  Practitioner's  Cyclopedia  of  Medicine  and  Surgery, 
Oxford,  1912. 


646  DISEASES  OF  THE  BLOOD 

occurs  in  all  countries,  in  both  sexes,  and  all  ages,  although  it  is  more 
common  in  middle  life  and  in  males — both  forms.  Cases  have  occurred  as 
early  as  the  eighth  week  and  as  late  as  the  70th  year.  It  is  sometimes 
hereditary,  but  leukemic  women  have  borne  nonleukemic  children.  It  has 
succeeded  upon  exhausting  illness.  Malaria  has  been  assigned  as  a  cause, 
and  certainly  its  association  \vith  this  disease  has  been  seemingly  more  than 
accidental.  To  a  less  degree  this  is  true  of  syphilis.  Pregnancy  is  said  to 
favor  it,  and  to  have  been  found  in  the  lower  animals. 

The  idea  of  the  infectious  origin  of  leukemia,  advanced  by  Klebs  and 
supported  by  observations  of  Osterwold,  Rovix,  -Byrom  Bramwell,  Paw- 
lowsky,  Kelsch,  Vaillard,  and  others,  seems  well  founded,  but  no  single 
microorganism  has  been  found  associated.  A  case  has,  however,  been  re- 
ported where  an  attendant  on  a  case  of  leukemia  contracted  the  disease 
and  died.  The  frequent  association  of  levikemia  with  stomatitis  and  in- 
testinal ulceration  was  pointed  out  by  Hunterberger. 

Morbid  Anatomy. — Leukemia  has  a  definite  morbid  anatomy,  con- 
sisting in  alterations  in  the  blood  and  in  the  hemogenic  apparatus,  including 
the  spleen,  the  lymphatic  glands,  and  the  marrow  of  bones. 

The  spleen  is  almost  always  enlarged.  It  may  be  adherent  to  the  ab- 
dominal walls,  the  diaphragm,  stomach,  or  other  viscera.  The  splenic 
changes  exhibit  three  stages  in  their  development.  In  the  first,  the  spleen 
is  simply  hyperemic,  soft,  and  swollen,  sometimes  even  ruptured.  The 
Malpighian  bodies  share  in  the  hyperemia,  and  may  be  slightly  enlarged, 
but  are  overshadowed  by  the  swollen  pulp.  In  the  second  stage,  hyper- 
plastic changes  make  their  appearance  in  the  Malpighian  bodies,  and  as 
these  grow  the  pulp  is  intruded  upon.  They  may  reach  such  size  as  to  be 
recognized  by  the  naked  eye  as  spherical  gray  nodules  one  to  three  lines  in 
diameter,  or  they  may  be  elongated  or  forked  following  the  course  of  the 
blood-vessels.  The  third  stage  furnishes  the  granitic  spleen,  in  which 
white  dots  are  separated  by  dark  streaks  representing  the  destroyed  pulp 
pigmented  by  the  disintegrated  blood.  The  spleen  is  now  hard,  and  is  cut 
with  resistance.  Its  size  may  be  enormous,  and  the  organ  may  weigh 
from  two  to  18  pounds  (i  to  9  kilos.).  It  does  not  attain  as  large  size  in 
acute  leukemia  as  in  chronic,  being  palpable  in  but  65  per  cent,  of  cases. 
There  is  sometimes  dropsy  present.  The  mass  of  the  blood  may  be 
measured  (polyhemia)  the  heart  and  veins  being  distended  with  blood  clots 
amounting,  in  a  case  of  Osier's  to  620  grams  (20  ounces).  Such  blood  may 
be  whitish,  from  the  admixture  of  a  large  proportion  of  white  cells;  some- 
times the  clots  have  a  peculiar  greenish  color.  It  may  weigh  from  2  to 
18  pounds. 

The  lymphatic  enlargement  is  a  true  hyperplasia.  Not  only  do  the 
glands  enlarge,  but  new  foci  of  lymphatic  tissue  appear  in  various  organs, 
as  the  liver  and  kidneys.  All  the  more  prominent  groups  may  share  in  the 
enlargement — the  cervical,  axillar\',  inguinal,  and  perineal  glands.  The 
individual  glands  remain,  however,  soft.  The  lymphatic  follicles  in  the 
tonsils  and  in  the  tongue,  pharynx,  and  mouth  may  enlarge.  This  is  also 
occasionally  the  ca.se  wath  the  solitary  glands  of  the  intestine  and  the 
agminated  glands  of  Peyer. 

The  marrow  changes  may  be  described,  in  a  word,  as  reversion  to  the 


LEUKEMIA 


647 


embryonal  type  of  medullary  tissue.  The  fat  of  the  adult  marrow  has 
disappeared,  and  a  mass  of  lymph  cells  mingled  with  nucleated  red  cor- 
puscles in  all  stages  of  development  takes  its  place.  The  marrow  is  often 
pyoid,  or  it  may  be  dark  brown  in  color.  The  shell  of  bone  is  sometimes 
expanded.  The  lymph  cells  include  numerous  large  mononuclear  cells,  many 
inji^the  act  of  division,  also  multinuclear  leukocT,'tes.     There  are  also  nu- 


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Black — Red  Corpuscles. 


Red — Hemoglobin.  Blue — Colorless  Corpuscles 

Fig.  120. — The  Blood  in  Leukemia. 


merous  marrow-cells  or  myelocytes  and  eosinophiles,  like  those  found  in 
the  blood. 

The  liver  is  often  enlarged,  and,  according  to  von  Jaksch,^  pari  passu 
with  the  spleen,  and  it  has  this  further  peculiarity,  that  its  edges  are  rounded, 
while  in  what  he  describes  as  pseudoleukemia  infantum  the  edges  are  sharp, 
and  the  enlargement  does  not  go  hand  in  hand  with  that  of  the  spleen.     The 

See'cases  reported  by  J.  Chalmers  Camerson  and  Saenger,  Sajous,  ''Annual"  for  1891,  E. 


648  DISEASES  OF  THE  BLOOD 

liver  is  also  at  times  infiltrated  with  leukemic  patches  and  nodules,  not  un- 
like miliary  tubercles.     The  same  is  occasionally  true  of  the  kidney. 

The  thymus  gland  has  been  found  enlarged  in  some  cases  of  acute 
lymphatic  leukemia,  and  even  the  skin,  stomach,  and  gastrosplenic  omen- 
tum have  been  the  seat  of  growths,  presumably  lymphatic.  In  fact,  there 
is  no  situation  in  which  such  growths  may  not  make  their  appearance, 
although  on  the  whole  they  are  not  common,  only  thirteen  cases  of  nodules 
being  found  in  the  liver  and  ten  in  the  kidneys  out  of  139  cases  of  leukemia 
collected  by  Gowers. 

The  lungs  and  heart  alone  seem  free  from  encroachment  by  the  lym- 
phatic tissue.     The  heart  may,  however,  be  dislocated  by  a  large  spleen. 

The  alterations  in  the  hlood  constitute  really  a  part  of  the  morbid  anat- 
omy of  leukemia,  but  are  commonly  treated  under  the  head  of  symptoma- 
tology, where  we,  too,  will  consider  them.  An  increase  in  the  mass  of  the 
blood  may,  however,  here  be  mentioned.  The  heart  and  vessels  are  com- 
monly found  gorged  with  blood,  usually  coagulated,  sometimes  whitish  or 
yellow  in  color. 

Symptoms. — Myeloid  Leukemia.  The  early  sj^mptoms  of  levikemia  are 
precisely  those  of  the  other  anemias,  viz. :  Insidious  onset,  pallor,  rapid  breath- 
ing amounting  to  dyspnea  on  exertion,  weakness  and  faintness,  headache,  in- 
digestion, and  loss  of  appetite.  The  last  two  symptoms  may  precede  all 
others.  Emaciation  is  absent  at  first  but  is  ultimately  added.  Moderate 
fever,  with  rapid  pulse,  is  also  present  in  the  majority  of  cases,  the  tempera- 
ture reaching  103°  F.  (39.4°  C).  Headache,  more  or  less  continuous,  is  a 
symptom.  Enlargement  of  lymphatic  glands  or  spleen  or  both  are  generally 
easily  recognized.  The  first  intimation  of  the  presence  of  a  large  spleen  is 
sometimes  a  circumscribed  peritonitis  due  to  the  splenic  tvunor.  Hemor- 
rhages from  the  nose  and  stomach  are  common,  and  dropsical  swelling  ap- 
pears toward  the  close.  Na^al  hemorrhages  are  sometimes  fatal.  Thomas 
Oliver  reported  a  case  terminating  fatally  b%'  sudden  postperitoneal  hemor- 
rhage.^ Hematemesis  may  be  an  early  and  almost  initiator^'  fatal  symp- 
tom. Hemorrhages  into  the  skin  are  sometimes  present;  cerebral  hemor- 
rhage occurs.  Priapism  is  an  occasional  symptom;  it  is  sometimes  persist- 
ent, and  in  a  case  of  Edes  was  the  first  s^'mptom  noticed. 

The  urine  often  contains  a  small  quantity  of  albmnin,  is  highly  colored 
and  scanty,  and  deposits  a  copious  sediment  of  iiric  acid. 

Blood  Changes. — The  blood  exhibits  a  most  marked  and  diagnostic 
change  consisting  in  an  enormous  leukocytosis.  The  number  of  white  cells 
being  from  100,000  to  500,000  per  cm.  The  leukocytes  being  polj-morphus 
in  character,  myelocytes,  basophiles  and  entirely  abnormal  percentage 
relations  between  the  polymorphonuclear  and  lymphoid  cells.  There  is 
also  a  large  number  of  nucleated  red  cells. 

The  maximum  proportion  of  colorless  corpuscles  impresses  decidedly 
the  color  of  the  blood  en  masse,  making  it  pink,  or  even  the  color  of  chocolate 
and  milk.  There  is  an  increase  in  all  varieties  of  white  cells.  The  poly- 
morphonuclears (neutrophiles)  include  30  to  50  per  cent.;  large  and  small 
lymphocytes  10.6;  and  while  actually  increased  are  relatively  diminished; 
eosinophiles  4  per  cent,  and  coarse  granular  basophilic  or  mast  cells  i  to 

1  Sajous'  "Annual"  for  1890,  vol.  i.,  E,  p.  12. 


LEUKEMIA  649 

lo  per  cent.;  the  myelocytes  foreign  to  the  normal  blood  from  30  to  50 
per  cent. ;  nucleated  red  disks  pockolocytes,  and  blood  plaques  are  numerous. 

Numerous  nucleated  red  disks  axe  present,  especially  in  the  myeloid 
variety.  Cabot  says  "the  striking  point  is  the  presence  of  very  numerous 
nucleated  red  cells  even  in  the  absence  of  any  signs  of  anemia.  With  over 
4,000,000  well-formed  and  well-colored  red  cells  we  may  have  hundreds 
of  erythroblasts  in  every  cover-glass.  They  are  as  numerous  in  this  form 
of  leukemia  (myeloid)  as  in  the  worst  forms  of  pernicious  anemia,  even 
though  the  patient  be  feeling  ver;>'  well."  The  hemoglobin  falls  below 
the  normal  proportion,  so  that  the  hemoglobin  content  of  each  disk  is 
lowered.  There  is  occasional  poikolocytosis.  Reduction  of  the  red  cells 
comes  late  in  the  disease.     The  blood-plaques  may  be  slightly  increased. 

Symptoms  of  Lymphoid  Leukemia. — Lymphoid  Leukemia  may  be  acute  or 
chronic.  Acute  Leukemia  resembles  an  acute  infection.  The  patient  may 
give  all  the  symptoms  of  typhoid  fever  and  run  a  fatal  course  in  from  two 
to  three  weeks.  Only  a  blood  examination  will  make  a  certain  diagnosis. 
The  case  may  begin  with  an  inflammation  not  unlike  diphtheria  and  run 
a  fatal  course  in  two  weeks.  There  is  a  leukoc^.'tosis  the  l^Tnphocytes 
numbering  from  80  to  90  per  cent,  of  all  the  white  cells.  In  a  case  exam- 
ined by  one  of  us,  the  white  cell  count  was  but  7000  just  before  death  with 
98  per  cent,  of  large  lymphocytes.     Hemorrhages  are  conunon. 

Recent  observations^  show  certain  cases  of  infection  with  from  70  per 
cent,  to  90  per  cent,  of  lymphocytes  which  recover. 

Chronic  Lymphatic  Leukemia. — Is  chronic  in  course;  there  is  enlarge- 
ment of  all  the  lymph  glands;  a  slight  enlargement  of  the  spleen.  The 
blood  contains  a  great  excess  of  large  and  small  lymphocytes  often  90  to  95 
per  cent.     The  cases  are  arbitrarily  divided  intosmall  and  large  cell  varieties. 

That  the  alkalinity  of  the  blood  is  sometimes  diminished  is  true;  that 
it  is  ever  replaced  by  acidity  is  not  true,  as  was  at  one  time  held.  Its 
specific  gravity  is  lowered  to  1030  to  1050.  Leukemic  blood  coagulates 
slowly,  a  feature  which  has  been  ascribed  to  the  presence  of  albumoses. 

Leukanemia  is  a  term  applied  by  von  Leube  to  a  condition  of  com- 
bined leukemia  and  severe  anemia.  The  disease  lasts  for  from  a  few 
days  to  three  months.  It  may  begin  suddenly  with  fever  and  severe 
tonsillitis  to  which  are  added  weakness,  hemorrhage,  extreme  pallor  and 
rapid  decline.  There  is  often  general  glandular  enlargement  including  the 
liver  and  spleen.  The  reduction  of  hemoglobin  and  erythrocj'tes  with 
increase  of  lymphocytes  usually  the  large  form  are  conspicuous.  The  red 
cells  may  be  as  low  as  1,500,000.     The  color  index  is  high. 

The  blood  picture  is  that  of  lymphatic  leukemia. 

Diagnosis. — The  diagnosis  of  levikemia  requires  the  aid  of  the  micro- 
scope, but  with  it  it  becomes  easy.     (See  Blood  Changes.) 

Chloroma  is  a  tumor-like  hyperplasia  of  the  parent  cells  of  the  leiikocytes, 
primarily  in  the  red  marrow  of  bones,  and  secondary-  in  the  periosteum.  It 
is  now  classed  among  the  leukemias.  Chloroma  differs  from  other  forms 
of  leiikemia  in  its  marked  neoplastic  type  and  in  the  green  infiltrations  and 
metastases. 

Diagnosis. — This  can  be  made  only  by  the   aid  of  the  microscope. 

1  R.  C-  Cabot,  Amer.  Jour.  Med.  Sc,  March,  1913. 


650  DISEASES  Of  TUE  BWOD 

Tubercular  adenitis,  malignant  adenitis,  general  sarcomatous  or  carcinoma- 
tosis, chronic  spinal  enlargement  might  be  mistaken  for  leukemia  without  a 
blood  count. 

Typhoid  fever,  diphtheria,  and  pneim:aonia  have  been  the  diagnosis  in 
acute  forms,  but  the  blood  picture  described  above  will  certainly  make  the 
diagnosis.  A  differential  count  is  essential  because  frequently  a  great 
leukocytosis  occurs  in  sepsis.  We  have  notes  of  an  appendicitis  with  60000 
white  cells,  80  per  cent,  polymorphonuclear.  In  the  terminal  stages  or 
under  treatment  the  white  cells  may  be  greatly  reduced,  but  the  differ- 
ential count  will  still  make  the  diagnosis. 

Prognosis. — The  prognosis  or  leukemia  is  unfavorable,  the  best  that 
can  be  expected  from  treatment  being  the  deferring  of  the  fatal  end.  Some 
rather  remarkable  fluctuations  are  noted,  and  cases  of  cure  are  even  re- 
ported. Osier  saw  a  case  ten  years  after  the  original  diagnosis  was  made  by 
Wm.  H.  Draper.  The  lymphatic  leukemias  are  the  more  acute  and  more 
intractable. 

Treatment. — The  treatment  has  heretofore  been  mainly  with  arsenic 
and  iron,  fresh  air,  and  good  food.  Large  doses  of  arsenic — as  much  as 
30  drops  (0.92  c.c.)  of  Fowler's  solution,  reached  by  gradual  increment  have 
been  especially  recommended  and  certainly  should  be  tried. 

Treatment  by  X-ray. — The  Roentgen  ray  has  been  employed  in  the 
treatment  of  leukemia,  and  no  treatment  of  lettkemia  and  pseudoleukemia 
is  of  greater  value.  The  restilts  have  not  been  uniform,  although  on  the 
whole  they  may  be  said  to  be  sufficiently  encouraging  to  be  used  in  every 
case.  No  cures  have  been  reported,  although  frequent  remissions,  one  in 
which  there  was  no  recurrences  for  three  and  a  half  years  after  the  exposures. 
It  must  not  be  forgotten  that  marked  remissions  in  the  progress  of  leukemia 
occur  under  any  treatment.  Recent  experience  has  shown  that  the  rays 
must  be  appHed  not  to  the  spleen  but  to  the  long  bones.  Roentgenologists 
think  that  when  arsenic  and  X-ray  aj-e  used  together,  a  careful  watch  must 
be  kept  upon  the  patient.     X-ray  is  dangerous  in  acute  cases. 

Benzol  has  lately  been  given  in  doses  of  from  7  to  15  minims — case 
reports  show  diminution  of  white  cells  and  diminution  in  the  size  of  the 
spleen  with  a  general  well  being  of  the  patients. 

IV.  PSEUDOLEUKEMIA— HODGKIN'S  DISEASE. 

Synonyms. — Hodgkin's  Disease;  Lymphadenosis;  Lymphadenoma;  Malig- 
nant Lymphoma  {Billroth);  Adenie  and  Lymphadenie;  Lymphatic 
Anemia. 

Definition. — The  disease  consists  essentially  in  an  anemia  accom- 
panied by  an  enlargement  of  the  h-mphatic  glands  and  the  formation  of 
lymphatic  foci  in  the  spleen  and  occasionally  in  other  glandular  organs, 
but  associated  with  only  a  slight  increase  in  the  colorless  corpuscles  of 
the  blood.  Hodgkin's  paper,  to  which  we  are  indebted  for  our  first  definite 
knowledge  of  the  disease,  appeared  in  1832. 

Etiology. — Its  etiology  is  as  undetermined  as  that  of  leukemia.  De- 
pressing influences  of  all  kinds  are  believed  to  favor  it.     Tubercidosis  has 


HODGKIN'S  DISEASE  651 

been  associated  with  it,  but  the  conclusion  reached  after  much  discussion,  is 
that  it  is  not  tubercular.  The  presence  of  an  irritating  (infection  ?)  substance 
in  the  blood  has  been  suggested,  and  the  necessity  of  local  irritation,  asso- 
ciated with  a  lymphatic  diathesis,  has  been  insisted  upon  by  Trousseau. 
It  may  occur  at  any  age,  but  is  more  common  in  adult  life,  and  in 
males. 

Morbid  Anatomy — Its  morbid  anatomy  is,  however,  definite.  There 
is  both  lymphatic  and  splenic  involvement,  the  latter  secondary  to  the 
former.  The  tonsils,  intestinal  lymphatic  structures,  and  even  the  liver 
and  kidneys  may  be  invaded.  There  is,  moreover,  a  deposition  of  new 
foci  of  lymphatic  tissues  decidedly  more  marked  than  in  leukemia.  The 
lymphatic  enlargement  usually  begins  first  in  the  more  superficial  groups, 
as  those  of  the  anterior  and  posterior  cervical  triangles,  the  glands  of  the 
axilla,  and  the  groin,  but  the  entire  lymphatic  system  may  be  involved, 
including  the  retroperitoneal  glands,  resisting  sometimes  in  marked  ab- 
dominal enlargement.  Occasionally  the  overgrowth  is  limited  to  the 
deep-seated  glands.  Of  the  abdominal,  the  retroperitoneal  are  most 
frequently  involved,  producing  tumors  which  have  been  mistaken  for 
myomata  of  the  uterus.  The  bronchial  glands  may  also  be  involved, 
and  by  their  pressure  produce  dyspnea  and  suffocation. 

The  lymphatic  enlargement  is  a  hyperplastic  one,  shared  by  the  cel- 
lular and  trabecular  tissue  in  varying  degrees.  When  the  former 
predominates,  the  product  is  soft  and  exudes  a  milky  juice  on  section; 
when  the  latter,  it  is  firm  and  resisting.  The  individual  glands  are  not 
disposed  to  fuse  nor  to  become  adherent  to  adjacent  tissue,  differing  in 
this  respect  greatly  from  glands  enlarged  by  the  tubercular  process.  The 
enlargement  also  exceeds  that  in  leukemia. 

Histologically,  1  the  earliest  changes  as  found  in  the  smallest  glands 
consist  in  increased  vascularity  with  hyperplasia  of  the  lymphoid  cells 
and  active  proliferation  at  the  germinal  center,  together  with  proliferation 
of  the  reticular  endothelium.  Mitotic  figures  are  not  infrequent  in  the 
reticular  cells.  The  lymphoid  sinuses  contain  many  small  and  large 
mononuclear  lymphocytes,  epithelioid  cells  and  a  few  eosinophiles.  As 
the  reticultim  increases  it  grows  coarser  and  the  glands  harden.  In  the 
last  stages  almost  aU  traces  of  the  normal  structure  are  lost  and  only  here 
and  there  are  seen  fragmentary  remains  of  the  lymphoid  follicles  and  si- 
nuses. In  the  spaces  of  the  reticulum  lie  many  small  and  large  lymphocytes, 
plasma  cells  in  large  numbers,  polymorphonuclear  lymphocytes,  eosino- 
philes in  enormous  numbers,  epithelioid  cells  and  large  uninuclear  and 
multinuclear  giant  cells.  The  giant  cells,  also  often  found  in  large  num- 
bers, are  apparently  traceable  through  the  epithelioid  cells  to  the  endothe- 
liiim  of  the  reticulum.  The  various  cell  types  are  not  equally  distributed, 
lymphoid  cells  predominating  in  some  parts,  epithelioid  cells  in  others, 
and  giant  cells  and  eosinophiles  in  others  still. 

After  the  lymph  glands  the  spleen  is  more  frequently  involved.  It 
is  enlarged  in  various  degrees,   sometimes  enormously.     The  changes  in 

^  For  a  complete  and  thorough  report  of  the  histological  changes  in  the  organs  and  tissues  in  Hodgkin's 
disease,  to  which  we  are  indebted  for  much  contained  in  the  text,  the  reader  is  referred  to  the  excellent  paper 
of  W.  T.  Longcope,  "On  the  Pathological  Histology  of  Hodgkin's  Disease  with  a  Report  of  a  Series  of 
Cases,"  published  in  the  Bulletin  of  the  Ayer  Clinical  Laboratory  of  the  Penna.  Hospital.  October,  1903. 


652  DISEASES  OF  THE  BLOOD 

the  enlarged  spleen  are  quite  different  from  those  in  Banti's  disease  or 
splenic  anemia.  On  section,  it  is  found  filled  with  lymphomatous  nodules 
composed  of  a  tissue  like  that  of  the  lymph  glands.  The  earliest  changes 
are  seen  in  the  Malpighian  bodies.  They  consist  in  a  hyperplasia  of  the 
lymphoid  cells  with  early  thickening  of  the  reticular  network  and  pro- 
liferation of  the  endothelial  cells,  forming  grayish-white  masses  varying 
in  size  from  a  lentil  to  a  walnut  (1/4  inch  to  an  inch — 0.6  to  2.5  cm.),  con- 
trasting strongly  with  the  dark  red  parenchyma.  Typical  uninuclear 
and  multinuclear  giant  cells,  eosinophiles  and  plasma  cells  are  also  present, 
sometimes  abundantl3^  The  connective  tissue  increases  with  the  growth 
of  the  nodules  in  varying  proportion.  It  is  not  reparative  and  repre- 
sents an  advanced  stage  of  the  disease. 

The  hone-marrow  is  soft,  very  largely  composed  of  cells,  the  fat  being 
more  or  less  replaced  by  lymphoid  marrow.  Myelocytes  and  large  lymph- 
ocytes are  the  predominating  cells,  but  myelocytes  and  polymorphonu- 
clear leukocytes  containing  eosinophilic  granules  may  also  be  numerous, 
though  few  of  the  typical  bone-marrow  giant  cells  are  present,  while  the 
small  lymphocytes  are  not  relatively  increased.  Nucleated  red  blood- 
corpuscles  are  sometimes  present  in  small  numbers,  usually  of  the  nor- 
moblastic type.  According  to  Longcope  the  most  remarkable  deviation 
from  the  normal  consists  in  the  great  excess  of  the  eosinophilic  leukocj-tes 
and  myelocj^tes,  though  he  also  says  they  may  be  absent. 

The  liver  becomes  the  seat  of  secondary  growths  and  is  enlarged.  The 
initial  change  is  a  deposit  of  small  foci  of  lymphoid  cells,  in  which  take 
place  the  same  changes  as  in  the  spleen  and  lymph  glands.  To  this  is 
added  perilobular  cirrhosis  and  fatty  degeneration. 

vSimilar  changes  may  take  place  in  the  thymus  gland  and  the  kidney. 
Indeed,  there  is  no  organ  in  the  bodj^  in  which  they  may  not  occur,  not 
excepting  the  ner\'ous  system.  Paraplegia  has  resulted  from  pressure 
on  the  cord  by  growths  in  the  spinal  canal.  The  posterior  nares  may  be 
occluded  by  invasion  of  the  tonsils  and  the  numerous  h-mphoid  follicles 
in  the  pharynx.  In  like  manner  the  intestinal  walls  may  be-  invaded, 
producing  thickening,  while  even  serous  surfaces  do  not  escape. 

The  latest  studies  by  Fischer,  Reed,  Longcope,  Simons  and  Yanasaki 
go  to  show  that  the  process  is  inflammator}^  and  infectious,  distinct  from 
tuberculosis  and  Banti's  disease,  although  tuberculosis  may  coexist.' 

Symptoms. — The  symptoms  of  Hodgldn's  disease  are,  again,  the 
pallor,  weakness,  dyspnea,  palpitation,  dizziness,  and  other  signs  of  anemia, 
concurrent  with  or  even  sometimes  in  advance  of  the  glandular  enlarge- 
ment. There  is  quite  often  fever,  very  irregular  and  variable  in  degree, 
and  cases  have  been  observed  by  Murchison  and  De  Renzi  in  which  there 
was  paroxysmal  glandular  enlargement  coinciding  with  fever,  the  enlarge- 
ment subsiding  with  the  decline  of  fever,  but  not  reaching  the  degree 
present  prior  to  the  enlargement.  In  a  case  of  Laache's  the  glands  dimin- 
ished in  size  during  the  fever.  In  a  case  in  the  wards  of  the  Hospital  of 
the  University  of  Pennsylvania  in  which  the  glandular  enlargement  was  not 
conspicuous,  there  occurred  an  intermittent  rise  of  temperature  supposed 


1  Reed,' Dorothy  M.,  on  the  "  Pathological  Changes  in  Hodgkins'  Disease  w'ith  especial  reference  to  its 
relations  to  Tuberculosis,"  Johns  Hopkins  Hospital  Reports,  vol.  x..  1902. 


HODGKIN'S  DISEASE  653 

to  be  due  to  peritonitis ;  an  operation  did  not  show  any  peritonitis  but  great 
involvement  of  the  abdominal  lymph  glands. 

The  external  glandular  growths  are  variously  consijicuous ;  occasion- 
ally, however,  they  are  wholly  absent.  There  is  no  fixed  order  of  in- 
volvement, although  the  glands  of  the  anterior  and  posterior  cervical 
triangles  commonly  enlarged  first,  and  with  the  acme  of  their  growth  pro- 
duce a  striking  picture.  The  enlargement  is  not  uniform,  but  at  times 
remits  and  even  ceases.  It  is  said  it  may  disappear  altogether  for  a  time. 
The  glands  are  usually  soft,  sometimes  there  is  even  a  sense  of  fluctuation. 

The  glandular  enlargement  themselves  contribute  further  to  the, 
symptoms  by  there  effects.  Thus,  in  the  case  of  the  bronchial  glands 
dyspnea  from  pressure  on  bronchi  or  trachea  may  occur,  and  may  also 
be  intermittent.  Pressure  elsewhere  may  lead  to  pleuritic  or  abdominal 
effusions,  while  the  enlargement  of  nerves  in  the  growth  ma}'  cause  pain. 
Erosion  of  bone  may  result.  Bronzing  of  the  skin  has  been  found  associated 
with  enlargement  of  the  abdominal  glands.  A  purpuric  rash  is  sometimes 
present  in  Hodgkin's  disease,  due  perhaps  to  the  hydi-emic  state  of  the 
blood. 

Macroscopically,  the  blood  appears  thin  and  pale.  Minutely  examined, 
the  red  corpuscles  are  diminished  in  number,  although  not  always.  Mini- 
mum counts  make  960, ooo^  to  the  cubic  millimeter,  while  in  a  case  re- 
ported by  Henry,  ^  that  of  a  boy  of  five,  with  enormous  enlargement  of 
the  right  cervical  glands,  there  were  5,462,000  to  the  cubic  millimeter. 
Thus,  the  diminution  is  less  than  in  pernicious  anemia.  The  hemoglobin 
is,  however,  reduced  to  at  least  60  per  cent.,  furnishing  thus  one  of  the 
conditions  essential  to  anemia.  There  are  few  nucleated  red  corpuscles 
and  poikilocytes,  and  especially  microcytes.  The  leukocytes  may  be 
slightly  increased,  occasionally  decidedly  so ;  there  is  no  approximation  to 
the  leukemic  state  of  the  blood,  and  the  two  states  are  distinct  and  separate. 

Diagnosis. — The  diagnosis  requires  some  care,  as  more  than  one  con- 
dition is  attended  by  similar  glandular  outgrowths.  Chronic  and  even 
acute  adenitis  has  been  mistaken  for  the  early  manifestation  of  Hodgkin's 
disease,  while  the  converse  has  obtained  perhaps  more  frequently.  Time 
is  the  arbiter  of  such  uncertainty. 

A  group  of  tuberculous  glands  resembles  more  closely  the  disease  under 
consideration,  but  it  is  not  usually  difficult  to  distinguish  between  the 
two.  Tuberculous  glands  are  adherent  to  each  other  and  to  adjacent  tis- 
sues, while  the  lymphadenoid  growths  are  loose  and  easily  movable.  Tuber- 
culosis rarely  involves  more  than  one  group  of  glands,  is  characterized 
by  caseation  and  suppuration,  while  the  lymphadenoid  growths  almost 
never  suppurate.  Yet  the  tubercular  process  is  the  slower.  Tubercu- 
losis is  commonly  found -in  young  persons  under  20.  Hodgkin's  disease 
may  occur  at  any  age,  but  the  average  age  is  greater.  It  is  more  common 
in  males.  In  Gowers'  100  cases,  75  were  males  and  25  females;  30  were 
under  20,  34  between  20  and  40,  and  36  above  40. 

Sarcoma  also  involves  groups  of  glands,  and  in  the  beginning  the  con- 
sistence of  the  glands  is  similar  to  that  in  Hodgkin's  disease.     But  this 

'Case  reported  by  Richard  Geigel,  quoted  by  F..  P.   Henry  ("Anemia,"   Philadelphia,   1887),  from 
"Deutsches  Archiv  fiir  klinische  Med.,"  188s,  Bd.  xxxvii.,  p.  59. 
3  Op.  cil.  p.  67. 


654  DISEASES  OF  THE  BLOOD 

disease  rapidly  invades  surrounding  tissue!?,  fusing  with  them,  and  destruc- 
tive ulceration  soon  makes  its  appearance. 

Carcinoma  of  lymphatic  glands  should  also  be  mentioned  as  producing 
a  somewhat  similar  growth,  associated  with  cachexia,  but  it  is  for  the 
most  part  secondary  to  cancer  elsewhere  than  in  lymphatic  glands. 

Finally,  all  the  conditions  named  as  possible  to  be  mistaken  for  Hodg- 
kin's  disease  are  limited  to  single  groups,  while  the  latter  always  extends, 
and  the  fact  of  such  limitation  is  of  itself  sufficient  to  preclude  the  disease. 

From  leukemia  the  disease  is  easily  distinguished  by  the  leukocytosis 
characteristic  of  the  former. 

Prognosis. — While  the  prognosis  is  ultimately  fatal,  the  course  of  the 
disease  varies  greatly,  and  death  seldom  results  in  less  than  a  year.  P.  P. 
Henry  places  the  average  duration  of  life  at  two  years,  but  admits  it  is 
greatly  modified  by  such  circumstances  as  age  and  previous  health  of  the 
patient. 

Diagnosis  can  only  be  made  certainly  by  postmortem.  The  appearance 
of  the  bone  marrow  is  seen  in  the  accompanying  plate. 

Aplastic  anemia  is  a  pernicious  anemia  differentiated  from  ordinary 
pernicious  anemia  by  tendency  to  hemorrhage,  with  a  lower  color  index,  and 
with  a  smaller  degree  of  erythroblasts.  At  postmortem,  instead  of  the  red 
hyperblastic  bone  marrow,  the  bone  marrow  is  yellow,  dnd  there  is  an 
atrophy. 

Treatment. — Treatment,  too,  may  avert  the  fatal  termination  for  a 
long  time.  Extraordinary  results  in  this  respect  have  followed  the  ad- 
ministration of  arsenic,  and  even  recoveries  have  been  reported.  Large 
doses,  arrived  at  by  gradual  increment,  should  be  attained  and  kept  up 
until  some  physiological  effects  are  observed.  Such  doses  are  from  15  to  20 
minims  (i  to  1.3  c.c.)  of  Fowler's  solution.  Particularly  happ}''  results  are 
claimed  for  the  hypodermic  injection  of  arsenic.  Especially  is  this  recom- 
mended when  arsenic  is  not  well  borne  by  the  stomach.  The  cacodyllate 
of  soda  is  now  used  hypodermically,  the  dose  being  1/2  a  grain  to  3  grains. 
Supporting  treatment  of  all  kinds,  including  quinin,  cod-liver  oil,  and  the 
beso  of  food,  is  necessary. 

Operative  interference  is  sometimes  necessary  to  avert  danger  to 
life,  threatened  by  the  encroachment  of  enlarged  glands  on  vital  organs 
and  functions,  such  as  respiration.  It  has  even  been  claimed  that  the 
removal  of  a  group  of  primarily  enlarged  glands  has  cut  short  the  spread 
of  the  disease,  but  such  an  apparent  result  is  rather  an  evidence  of  error 
in  diagnosis.  In  view  of  the  fact  that  at  an  early  stage  a  diagnosis  is 
impossible,  the  removal  of  a  local  group  of  glands  should  be  recommended. 

The  X-ray  treatment  has  been  availed  of  in  treating  Hodgkin's  disease 
it  is  claimed  with  results  as  flattering  as  in  leukemia.  The  hope  of  perma- 
nent cure  has  even  been  held  out.  The  rays  are  applied  directly  to  the 
enlarged  glands.  At  times  success  is  verj'  prompt,  while  at  others  long  and 
patient  treatment  is  necessary,  as  many  as  500  applications  extending  over 
several  years  being  necessary.  When  success  occurs  it  is  desirable  to  give 
an  occasional  dose  at  inten^als  to  keep  up  the  effect. 


SPLENIC  ANEMIA  655 

Status  Lymphaticus. 

Synonym. — Lymphatism. 

Definition. — A  hyperplastic  state  of  the  lymphoid  tissue  through- 
out the  body,  including  the  lymphatic  glands,  the  spleen,  the  thymus, 
and  the  lymphoid  marrow  of  bones,  occurring  chiefly  in  children  and 
young  persons. 

This  condition  is  rare  in  this  country.  It  has  been  described  b}'  Poltau 
and  other  Vienna  physicians,  and  by  James  Ewing,  of  New  York.' 

Morbid  Anatomy. — The  lymphatic  glands  most  frequently  affected 
are  the  pharyngeal,  thoracic,  and  abdominal;  those  cf  the  cervical,  axUlary, 
and  inguinal  regions  less  frequently  and  in  less  degree,  while  the  lymphatic 
elements  of  the  tonsils  and  the  upper  pharynx,  and  the  solitarj^  and  ag- 
minated  follicles  of  the  small  and  large  intestines,  are  often  much  involved. 
The  spleen  is  moderately  enlarged,  while  the  Malpighian  bodies  stand 
but  distinctly.  The  thymus  gland  is  enlarged  and  soft,  and  on  section 
may  exude  a  milky  fluid.  The  bone-marrow  may  be  hj'^perplastic,  and 
the  yellow  marrow  replaced  b}'  red  marrow.  Along  with  these  anatomical 
changes  have  sometimes  been  found  rickets,  and,  again,  hyperplasia  of 
the  heart  and  aorta. 

Symptoms. — The  symptoms  in  addition  to  the  anatomical  changes 
noted  are  a  lowered  power  of  resistance,  sometimes  evidenced  by  sudden 
death  or  death  from  insufficient  cause.  The  subjects  are  said  to  be  poorly 
developed  and  infantile  in  appearance.  As  might  be  expected,  the  rec- 
ognition of  the  actual  condition  is  not  always  eas3^  if  it  dare  be  assigned 
a  separate  place  in  the  nosology. 

V.  SPLENIC  ANEMIA. 

Synomyms. — L'epithelionie  primitif  de  la  rate;  Splemomegalie  primitive. 

Primary  Splenomegaly  with  Anemia. 

Definition. — A  chronic  condition  in  which  there  is  progressive  en- 
largement of  the  spleen  without  marked  swelling  of  the  h^mphatic  glands, 
associated  with  more  or  less  pronounced  anemia.  The  term  Banti's  disease 
is  applied  to  its  termination  in  cirrhosis  of  the  liver  with  ascites. 

Etiology. — This  is  undetermined,  except  that  there  is  reason  to  be- 
lieve that  the  condition  sometimes  succeeds  the  infectious  diseases.  It 
is  to  be  separated  from  the  enlarged  spleen,  so  often  the  result  of  chronic 
malaria,  sometimes  associated  with  a  moderate  anemia.  It  occurs  alike 
in  old  and  young,  but  is  more  common  in  adults,  males  rather  than  females 
four  to  one. 

Morbid  Anatomy. — The  spleen  is  greatly  enlarged,  approaching  the  size 
of  the  leukemic  spleen  rather  than  the  spleen  of  Hodgkin's  disease.  It  is 
three  or  four  times  its  normal  size,  but  retains  its  normal  shape.  It  is  in- 
durated, and  its  incisures  are  deep.  Its  capsule  is  thickened  and  opaque 
in  spots  and  sometimes  adherent  to  adjacent  tissues,  often  true  of  any 
large  spleen. 

i"New  York  Medical  Journal,"  July  ro,  1897. 


656  DISEASES  OF  THE  BLOOD 

There  is  nothing  distinctive  in  the  histology  of  splenic  anemia  or  of 
Banti's  disease.  The  process  in  the  spleen  is  commonly  regarded  as  chronic 
inflammatory.  There  is  a  hyperplasia  of  all  the  splenic  elements  associated 
with  difliuse  increase  in  the  connective  tissue  and  overgrowth  of  the  retic- 
ulum., destroying  and  replacing  the  Malpighian  body,  by  a  tuberculous 
product  which  may  be  as  large  as  a  pea  and  contain  central  giant  cells. 
There  may  be  endothelioid  proliferation  and  multinuclear  epithelioid  cells 
scattered  through  sections,  and  especially  about  the  Malpighian  bodies, 
the  centers  of  which  may  also  be  the  seat  of  hyaline  degeneration.  Eosino- 
philes  may  be  present;  also  plasma  cells.  In  the  stage  known  as  Banti's 
Disease  there  is  superadded  interlobular  cirrhosis  of  the  liver  with  pigmen- 
tation, and  sometimes  chronic  dift'use  nephritis. 

There  are  no  lymphomatous  masses  in  the  spleen  as  in  Hodgkin's 
disease  or  enlarged  lymphatic  glands. 

The  bone-marrow  is  cellular,  made  up  chiefly  of  large  mononuclear 
leukocytes  and  myelocytes  some  of  which  contain  eosinophilic  granules; 
also  many  normoblasts  and  a  few  megaloblasts. 

Symptoms. — The  sjonptoms  are  analogous  to  those  of  pernicious 
anemia,  and  include  pallor,  weakness,  dyspnea,  palpitation,  associated  with 
the  signs  of:  First,  enlarged  spleen,  evidence  of  which  is  sometimes  shown 
by  ito  weight  and  the  pressure  it  exerts  before  other  sj^mptoms  show  them- 
selves. There  is  also  pain  in  the  region  of  the  spleen  which  increases 
on  pressure  and  may  radiate  toward  the  back  and  loins.  Rarely  it  mav 
be  due  to  perisplenitis,  which  may  even  invade  the  adjacent  pleura. 
Finally,  there  results  the  cachectic  state  characterized  by  emaciation, 
a  deeper  yellow  color  and  pigmentation  of  the  skin  and  mucous  membranes, 
a  tendency  to  hemorrhage  and  pyrexia,  with  a  possible  temperature  of 
102°  F.,  edema,  serous  effusions,  nausea,  and  diarrhea,  extreme  muscular 
prostration,  and  mental  hebetude.  There  is  also  said  to  be  at  times,  as 
in  lymphatic  pseudoleukemia,  an  intermittent  or  course  in  the  symptoms  to 
the  extent  of  apparent  complete  restoration  to  health  in  the  inter\'als. 

The  blood  exhibits  the  changes  one  would  expect  in  cases  in  which 
there  is  destruction  of  the  tissue  devoted  to  its  reproduction.  It  is  anemic. 
The  red  disks  are  notably  diminished,  from  5,000,000  to  as  low  as  even 
2,000,000.  The  hemoglobin  is  correspondingly  diminished,  with  low  color 
index.     There  is  marked  leucopenia. 

Hemorrhage  manifests  itself  especially  as  hematemesis,  epistaxis, 
bleeding  from  the  gums  and  even  in  the  fundus  of  the  eye.  Hematuria 
and  hemoptysis  are  infrequent;  hematemesis  is  often  excessive.  Late  in 
the  disease  there  is  ascites  due  to  cirrhosis  of  the  liver  (Banti's  disease). 

An  increase  in  the  urea  of  the  urine  has  been  noted  by  Striimpell,  and 
is  regarded  as  evidence  of  increased  proteid  metabolism. 

All  clinical  facts  go  to  show  that  the  spleen  is  responsible  in  some  way 
for  a  destruction  of  erythrocytes  and  of  their  capacity  for  carn,-ing  oxygen. 

The  duration  of  the  disease  is  from  one  to  ten  years. 

A  form  of  enlarged  spleen  described  by  Gaucher  is  known  as  the  Gaucher 
t^-pe.  The  enlarged  spleen  is  associated  with  enlarged  liver.  It  attacks 
more  than  one  member  of  a  family.  It  presents  a  grayish  red  color  on 
section  with  whitish  spots   and   streaks.     Histologically  there   are  large 


ERYTHEMIA  657 

cells  from  20  to  40  /(  in  diameter  filling  alveolar  spaces.  Gaucher  himself 
described  the  condition  as  epiiheliome  primitif  and  it  is  commonly  regarded 
an  endothelioma  and  not  a  splenic  anemia. 

Diagnosis. — The  diagnosis  of  splenic  anemia  depends  upon  the  presence 
of  splenic  enlargement  associated  with  the  phenomena  of  anemia  described, 
and  the  absence  of  glandular  enlargement,  so  conspicuous  in  Hodgkin's 
disease,  or  of  blood  changes  of  leulcemia.  Anemic  symptoms  attend  the 
chronic  malaria  so  often  associated  with  enlarged  spleen,  but  the  history  of 
malaria  in  such  cases  is  invariably  present,  while  the  degree  of  anemia  in 
malaria  is  not  so  high. 

Prognosis. — The  disease,  always  prolonged,  was  formerly  alternately 
fatal,  but  the  prognosis  has  been  modified  by  splenectomy. 

Treatment. — The  medical  treatment  is  that  for  the  other  anemias,  by 
iron  and  arsenic  and  nutritious  food.  Here  as  in  other  affections  of  the 
hemapoietic  system  the  X-ray  directed  to  the  enlarged  spleen  has  been 
followed  by  reduction  of  size  and  relief  of  pain.  In  one  of  Buchanan's  cases 
complete  restoration  to  health  after  extreme  symptoms  followed  the  ad- 
ministrations of  pituitary  extract. 

It  is  in  this  disease  that  splenectomy  has  been  so  satisfactory.  In 
Banti's  collection  it  appears  to  have  been  successful  in  three  out  of  four 
cases,  and  later  statistics  seem  to  confirm  this  statement.  Banti  recom- 
mended splenectomy  in  all  cases  except  profound  cachexia  and  in  pseudo- 
leukemic  hypertrophy  of  lymphatic  glands.  He  considers  ascites  indicates 
checexia. 

ERYTHEMIA. 

Synonyms. — Vaquezs  Disease;  Polycythemia  vera.  Polycythemia  with 
splenic  tttmor.     Osier's  Disease. 

Definition. — A  disease  characterized  by  an  increase  in  the  number  of 
red  blood  cells,  a  plethoric  state,  enlargement  of  the  spleen  and  at  times 
cyanosis.  It  has  been  studied  by  Vaquez  in  1892  Rendu  and  Widal, 
Cabot,  McKean,  Saundly  and  Russell;  in  1903;  by  Osier  who  stimulated 
interest  in  it;  by  Mackey  and  Anders  in  1907,  Stachelin  in  191 1  and  Lucas 
in  1 91 2.  The  last  collected  149  unquestionable  cases,  in  an  exhaustive 
paper  recently  published.^ 

Pathology. — The  disease  is  regarded  as  a  lesion  of  the  erythroblastic 
tissue  of  the  bone  marrow  as  leukemia  is  of  the  leucoblastic  tissue.  It  is 
analogous  to  the  hyperglobism  of  higher  altitudes  in  which  there  is  also  in- 
creased activity  of  the  erythroblastic  bone  marrow  compensatory  to  lack 
of  oxygen  in  the  air.  There  is  increased  viscosity  of  the  blood,  which  favors 
stasis  and  capillary  engorgement.  Rarely  there  is  cheesy  tuberculosis  of 
the  spleen. 

Symptoms. — The  most  important  symptoms  are  polycythemia,  a  con- 
gested state  of  the  capillaries  and  veins,  and  enlargement  of  the  spleen. 
The  congestion  may  extend  to  the  conjunctiva.  In  cold  weather  the  con- 
gested appearance  gives  way  to  cyanosis,  very  striking  in  the  face  and  hands, 

'  Lucas,  Erythremia  or  Polycythemia  with  Chronic  Cyanosis  and  Splenomegaly.     Archives  of  Interna 
Medicme,  1902. 


658  DISEASES  OF  THE  BLOOD 

but  subject  to  change  of  position.  The  enlargement  of  the  spleen  is  moder- 
ate while  the  organ  is  also  hard  and  firm  and  painless. 

The  change  in  the  ntunber  of  blood  discs  is  remarkable,  the  polycythemia 
ranging  from  seven  to  twelve  and  even  13  millions  per  cubic  millimeter, 
while  the  hemoglobin  ranges  from  139  to  160  per  cent.  The  color  index 
is  low,  the  specific  gravity  high.  The  red  cells  are  but  little  changed.  In 
most  cases  there  is  a  moderate  or  decided  leucoc\'tosis.  In  a  few  instances 
the  white  cells  are  reduced  in  number. 

There  is  headache,  flushing  and  vertigo,  constipation  and  usually  al- 
buminuria. The  blood  pressure  is  high  in  the  majority  of  the  cases,  but 
observes  no  law.  There  may  be  hemorrhage  into  the  skin  and  mucous 
membranes.  Recurring  ascites  was  present  in  two  of  Osier's  cases.  Osier 
regards  as  a  variety  Geisbockss  cases  of  polycythemia  hyperionica,  further 
characterized  by  increased  tension,  arteriosclerosis  and  nephritis.  In  this 
variety  according  to  Anders  the  spleen  is  not  enlarged. 

Diagnosis. — This  is  easy  when  the  three  cardinal  symptoms  are  present 
without  emphysema  or  congenital  heart  disease;  and  the  cyanosis  is  not 
traceable  to  coal  tar  products. 

Prognosis.- — This  is  bad  for  cure  but  cases  last  some  time  with  fair  health 
They  die  of  cardiac  failure,  hemorrhage  and  recurring  ascites. 

Treatment. — The  symptoms  may  be  relieved  by  purging,  bleeding  and 
low  diet  and  by  inhalation  of  oxygen.  Splenectomy  is  not  advised.  The 
X-ray  proved  useless  in  Osier's  cases,  but  favorable  cases  have  been  reported. 

HEMOGLOEANEMIC  CYANOSIS 

Definition. — A  change  in  the  composition  of  the  hemoglobin  of  the 
blood,  causing  a  permanent  cyanosis. 

Etiology. — By  far  the  commonest  cause  of  hemoglobanemic  cyanosis  is 
the  use  of  headache  powders  sold  freely  by  the  druggist  to  the  laity.  The 
powders  contain  acetanilid  or  phenacetin  or  (acetphenetidin) ;  almost  any 
of  the  coal  tar  products  including  sulphonol,  trional  and  other  chemicals, 
such  as  potassium  chlorate,  carbon  monoxide  and  sulphuretted  hydrogen, 
will  cause  this  hemoglobanemic  disturbance. 

Stok\ns  pointed  out  that  some  of  the  cases  of  chronic  cyanosis  with 
hemoglobanemia  are  associated  with  intestinal  disturbances,  to  which  dis- 
turbance he  attributes  the  hemoglobanemia.  He  named  these  cases 
"Enterogenous  Cyanoses."  The  Spectroscope  will  discover  whether  the 
blood  change  is  due  to  methenglobin  or  sulphemiglobin. 

Diagnosis. — This  condition  of  chronic  cyanosis  may  be  easily  mistaken 
for  cyano  is  due  to  interference  with  circulation,  either  from  heart  or  lung 
disease.  But  in  the  heart  or  lung  cases,  the  sjTnptoms  and  physical  examin- 
ation will  show  the  presence  of  disease  of  these  organs. 

The  cases  which  are  due  to  disturbances  of  the  intestinal  tract  have 
symptoms  pointing  to  the  intestines. 

The  drug  cases  usually  come  complaining  only  of  the  color  of  their 
skin,  the  lips,  the  finger  tips;  the  whole  surface  of  the  skin  is  of  a  leaden  hue, 
looking  not  unlike  the  poisoning  in  chronic  Argyria.  Sometimes  there  is 
rapid  feeble  heart  action. 


PURPURA— SCURVY  659 

Examination  of  the  blood  shows  a  dark  chocolate  color  which  makes  it 
impossible  to  estimate  hemoglobin  by  any  ordinary  means. 

Treatment.- — Perhaps  the  most  important  point  to  remember  is  that 
the  cases  which  are  due  to  acetanilid  soon  acquire  the  habit  of  taking  the 
drug  and  almost  without  exception  attempt  to  deceive  the  physician.  The 
drug  causing  the  disease  must  be  searched  for  carefully  and  removed. 
Many  cases  are  much  weakened  by  the  continual  use  of  the  drug  and  need 
rest,  tonics  (such  as  strychniii)  and  good  food. 

In  cases  which  are  due  to  intestinal  intoxications  search  for  and  removal 
of  all  parasites  and  food  causing  fermentation  should  be  debarred  and  intes- 
tinal antiseptics  such  as  salol  and  bismuth  should  be  tried. 

PURPURA. 

Synonyms. — Morbus  maculosus;  Peliosis. 

Definition. — A  name  given  to  several  dyscrasic  states,  all  attended  by 
subcutaneous  or  submucous  extravasations  of  blood.  Such  extravasations 
do  not  disappear  on  pressure,  and  vary  in  size  from  that  of  a  pin-point  to 
areas  a  centimeter  or  more  in  extent.  When  minute  or  punctiform,  they  are 
called  petechias;  when  larger  than  this,  ecchymoses.  An  indisposition  on 
the  part  of  the  blood  to  coagulate  is  commensurate  mth  the  tendency  to 
extravasation.  Purpura  is  alwa^'s  a  symptom  rather  than  a  disease,  but 
in  certain  conditions  it  forms  the  most  conspicuous  symptom  of  a  group 
which  scarcely  admits  of  any  other  classification.  In  this  event  an  adjective 
term  derived  from  some  more  conspicuous  one  of  these  symptoms,  or  from 
the  name  of  some  investigator  who  has  described  the  condition,  is  added 
to  give  precision.  In  other  instances  it  is  so  piu"eh^  a  symptom  and  plays 
so  minor  a  role  in  the  disease  that  it  is  called  symptomatic.  Under  any 
circumstances  it  is  not  always  easy  to  keep  the  varieties  distinct. 

Sy-mptomatic  Purpura. 

This  includes  the  forms  of  purpura  in  which  the  petechise  and  ecchy- 
moses are  usually  of  minor  importance.  In  a  few  instances  in  which  the 
dyscrasia  is  very  great  they  become  by  their  number  and  extent  indices 
of  the  degree  of  such  dyscrasia.  Such  are:  Old  age. — Infectious  diseases, 
toxic  condition  such  as  snake  bite,  cachexias,  tuberculosis,  leukemia,  and  so 
forth. 


SCURVY. 

Synonym. — Scorbutic  Purpura,  Scorbutus. 

Definition. — A  disease  characterized  by  a  dyscrasic  state  of  the  blood, 
associated  with  subcutaneous  or  submucous  hemorrhages,  by  a  peculiar 
spongy  state  of  the  gums,  and  extreme  general  weakness. 

Etiology. — Less  than  half  a  centurj^  ago  the  idea  of  scurvy  was  always 
associated  with  the  seafaring  life,  since  sailors  were  its  chief  victims,  though 


660  DISEASES  OF  THE  BLOOD 

almshouses  and  prisons  also  held  their  complement.  In  the  food  of  these 
persons  fresh  vegetables  and  vegetable  juices  and  organic  salts  were  want- 
ing. So  it  came  to  be  acknowledged  that  such  privation  was  responsible 
for  scurvy,  and  proof  of  this  belief  was  thought  to  exist  in  the  fact  that  with 
the  quicker  voyages  of  ships  and  a  supply  of  suitable  food,  scurvy  had 
almost  vanished  from  the  nosolog}\  According  to  Hutchinson^  there  are 
three  theories  as  to  the  causation  of  the  disease:  First,  that  the  disease  is 
essentially  an  acid  intoxication  due  to  diminution  of  alkalinity  of  the  blood, 
second,  that  it  is  caused  by  poisoning  with  ptomaines;  third,  that  it  is  the 
result  of  a  specific  poison,  the  latter  being  based  upon  experience  in  the 
Boer  War.  All  the  theories  however  acknowledge  that,  privation,  insani- 
tary surroundings,  exposure  and  overwork  or  deficiency  of  fresh  vegetables 
form  the  predisposing  causes  which  lead  to  the  disease. 

At  the  present  day  sciuvy  has  become  a  rare  disease,  but  is  still  met  in 
camps,  prisons,  almshouses,  and  situations  where  the  food  causes  named 
exist  along  with  dampness,  foul  air,  and  depressing  influences  generally, 
among  which  nostalgia  is  supposed  to  be  especially  potent. 

The  disease  attacks  the  old  and  j'oimg  of  either  sex,  though  the  old  are 
more  susceptible,  and  it  happens,  probably  from  accidental  circumstances, 
that  more  males  are  affected  than  females. 

Morbid  Anatomy. — This  consists  in  (i)  alterations  of  the  blood;  (2) 
the  extravasations  of  blood,  which  may  be  anywhere — subcutaneous,  sub- 
mucous, sub-serous,  intermuscular,  and  interstitial.  The  blood  changes  are 
not  distinctive.  The  blood  is  dark  and  thin,  the  blood-corpuscles  and 
hemoglobin  are  conciurently  reduced  in  number,  and  there  is  no  leukocy- 
tosis. Rarely  there  is  even  sloughing  of  the  skin  and  mucous  membranes, 
leaving  ulcerated  patches  in  the  skin  and  bowels-  The  spleen  is  soft  and 
enlarged,  and  there  may  be  degenerative  changes  as  well  as  hemorrhages 
in  the  bladder,  kidneys,  liver,  and  muscles. 

Symptoms. — The  more  evident  symptoms  are  the  changes  in  the  gums, 
and  the  deep-seated  and  superficial  hemorrhages. 

The  gums  are  swollen,  soft,  and  spongy,  with  disposition  to  bleed  easily. 
In  the  more  severe  cases  there  is  ulceration,  mth  loosening  and  falling  out 
of  the  teeth,  the  tongue  is  swollen,  and  the  breath  excessively  foul.  The 
gums  of  young  children  and  of  the  aged  are  more  often  uninvaded.  In  rare 
cases  only  is  there  necrosis  of  the  jaw. 

The  hemorrhages,  always  petechial,  appear  usually  first  in  the  lower 
extremities,  then  on  the  arms  and  truiik,  but  they  occur  anywhere  as 
roundish,  dark-red  spots  which  may  assume  larger  size.  They  are  rare  in 
the  face  and  scalp,  and  are  less  common  under  the  mucous  membranes  and 
in  deep-seated  tissues.  Subperiosteal  hemorrhages  maj^  occur.  Necrosis 
of  bone  may  occur.  Nasal  hemorrhages  may  be  frequent,  melena  and  hem- 
aturia are  rare,  hematemesis  and  hemoptysis  still  rarer.  The  extravasations 
are  slow  to  disappear,  even  when  recovery  takes  place.  The  occasional 
sloughing  has  been  referred  to.  A  residual,  slowl}^  heaUng  and  sometimes 
foul  ulcer  restilts. 

"Scur^^y   sclerosis"  is  a  condition  most  frequent  in  the  legs  in  which 

'  '■  The  Relation  of  Scurvy  to  Recent  Methods  of  Artificial  Feeding."  "N.  Y.  .Med.  Jour.."  Feb.  23.  I90I. 
"Scurvj-,  Not  Rheumatism."  "Phila.  Med.  Jour.."  Feb.  2.  1901;  "American  Pediatric  Society's  Collective 
Investigation  on  Infantile  Scurvy."  "Arch  of  Fed."  July.  1898. 


INFANTILE  SCURVY  661 

infiltration  takes  place  of  the  subcutaneous  tissue  and  muscles  producing 
a  brawny  discoloration,  the  skin  covering  which  may  be  blood  stained. 

Other  symptoms  are  debility,  extreme  in  severe  cases,  and  anemia. 
The  pulse  is  small,  feeble,  and  frequent,  and  corresponds  to  the  heart's 
action,  which  is  sometimes  irregular;  more  rarely  is  it  slower  than  in  health. 
The  temperature  is  normal,  rarely  somewhat  elevated.  Sore  throat  is 
mentioned  as  a  premonitory  symptom.  In  bad  cases  nephritis  and  endo- 
carditis occur.  Articular  swelling  is  an  occasional  symptom;  it  is  one  of 
the  results  of  the  dyscrasia;  so  are  wheals  and  vesicles.  In  some  cases  these 
conspicuous  symptoms  are  much  less  pronounced  and  even  absent. 

Diagnosis. — This  depends,  as  stated,  on  the  etiology,  the  gingival 
changes,  and  the  hemorrhages.  It  is  these  which  chiefl}^  distinguish  it 
from  the  other  forms  of  pixrpura. 

Prognosis. — Sporadic  cases  always  get  well,  and  epidemic  cases  usually, 
unless  too  far  advanced  before  coming  under  treatment. 

Treatment. — This  is  usually'  most  satisfactory  when  the  necessary  con- 
ditions are  fulfilled — a  restored  wholesome  hygiene  and  suitable  food. 
Good  ventilation  and  outdoor  life  in  healthy  localities,  and  plenty  of  fresh 
vegetables,  fruits,  and  fresh  meats,  ordinarily  suQice  to  accomplish  a  prompt 
cure.  It  is  usual  to  give  lemon  and  orange-juice  as  the  types  of  the  fruit- 
juices.  Tonics  and  roborants,  of  which  iron,  quinin,  and  str^'chiiin  are  the 
type,  are  the  medicines  needed.  Calcium  chlorid  or  calcium  lactate  may 
be  used  in  doses  of  from  5  to  15  grains  (0.3  to  i  gm.).  Antiseptic  and 
astringent  mouth-washes  should  be  used,  and  tdcers  should  be  stimulated 
by  local  applications,  of  which  nitrate  of  silver  in  solution  is  the  best. 

Infantile  Scurvy. 

Synonyms. — Barlow's  Disease;  Periosteal  Cachexia. 

Definition. — A  cachectic  condition  of  infants,  associated  with  sub- 
periosteal hemorrhagic  extravasations.     Due  to  improper  food. 

Etiology. — This  might  be  said  to  be  the  dependence  of  physicians  upon 
manufacttues  of  patent  foods.  The  papers  read  before  the  American 
Pediatric  Society  prove  that  the  most  common  cause  is  the  use  of  arti- 
ficial foods,  of  these  the  proprietary  foods  take  the  lead.  It,  however, 
has  been  observed  in  children  fed  in  apparently  proper  manner. 

Symptoms. — Barlow's  account  is  graphic.  The  condition  exists 
essentially  in  a  hemorrhagic  subperiosteal  extravasation,  causing  thicken- 
ing and  tenderness  in  the  shafts  of  the  bones  beginning  in  the  lower  ex- 
tremities, but  invading  also  the  forearm  and  arm  to  a  less  degree,  more 
rarely  the  scapula,  vault  of  the  craniiun,  and  face.  Rarely  there  is  inter- 
muscular extravasation,  later  may  appear  bruise-like  ecchymoses  and 
rarely  small  ptupuric  spots.  The  resulting  tenderness  and  pain  on  motion 
cause  the  child  to  keep  quiet,  with  the  legs  drawn  up;  immovable  (pseudo- 
paralytic) as  long  as  undisturbed,  and  to  cry  out  when  handled.  It  is 
soon  evident  the  pain  is  in  the  lower  extremities.  Then  there  follows 
obscure  and  ill-defined  swelling  around  the  shafts  of  the  bones  in  rapid 
succession  above  the  epiphyseal    junction.     The  position  of    the    limbs 


662  DISEASKS  Of  THE  BLOOD 

is  now  somewhat  different,  the  leg  being  everted  and  immobile  for  the 
cause  above  mentioned.  The  inability  to  move  the  limb  depends  on  the 
pain.  The  lesions  are  symmetrical  but  not  absolutely  so.  The  joints 
remain  free.  The  sternum  and  adjacent  cartilages  and  a  small  portion 
of  the  contiguous  ribs  may  be  sunk  bodily  back  as  though  subjected  to 
violence.  There  may  be  a  sudden  prolapse  of  an  eyeball.  Along  with  these 
symptoms  are  profound  anemia  and  erratic  temperature,  which  may  be 
subnormal,  normal,  or  as  high  as  102°  P.  (38.9°  C). 

The  disease  occurs  at  any  period  after  four  months,  but  it  is  most  com- 
mon from  the  ninth  to  the  iSth  month,  and  develops  rapidly. 

Diagnosis. — The  disease  wdth  which  infantile  scun^y  is  most  commonly 
confused  is  rheumatism.  But  in  scurvy  there  is  the  history-  of  impro]3cr  food. 
There  is  swelling  and  tenderness  along  the  shafts  of  the  bones.  In  rheuma- 
tism there  is  swelling  of  the  joints.  The  X-ray  will  show  a  swollen  tibia  or 
humerus.  It  may  be  confounded  with  Parrot's  disease  or  syphilitic  pseudo- 
paralysis or  osteo-chondritis.  Young  children  exhibiting  symptoms  of 
paralysis  should  be  carefully  examined  for-  it.  The  lesion  of  scurvy  does 
not  involve  the  epiphyses  and  diaj^hyses  except  in  rare  cases  while  in  sypilitic 
osteo-chondroses  this  is  the  characteristic  lesion.  In  both  there  is  pseudo- 
paratysis. 

Treatment.  The  substitutions  of  the  proprietan,-  food  or  sterilized  milk 
by  modified  cows  milk,  and  the  administration  of  whole-grain  cereals. 
Orange-juice  or  lemon-juice  will  bring  about  a  recovery  which  is  marvelous 
in  its  rapidity  and  completeness.  The  child  who  gives  all  the  above 
symptoms,  in  from  24  go  48  hours  will  be  apparently  in  perfect  health, 
when  so  treated. 


Arthritic  Purpura. 

Synonyim. — Rheumatic  Purpura. 

Definition. — The  characteristic  featvire  of  arthritic  piupura  is  a  joint 
involvement.     Hence  it  is  also  called  rheumatic  purpura. 
Symptoms. — Three  varieties  are  distinguished: 

1.  Purpura  Simplex,  Simple  Arithritic  Purpura. — This  is  a  mild  form, 
most  frequent  in  children.  The  articular  pain  is  vers'  mild  and  attended 
wnth  but  slight  fever.  The  spots  are  found  for  the  most  part  on  the  legs, 
more  rarely  on  the  trunlv  and  arms.  There  may  be  digestive  derangement, 
manifested  by  loss  of  appetite  and  diarrhea.  The  condition  terminates 
favorably  in  a  week  or  ten  days.  It  may  be  associated  v.nth  a  mild  degree 
of  anemia. 

2.  Peliosis  Rheumatica. — Schonlein's  disease.  This  is  a  much  more 
serious  aflEection  from  ever}-  standpoint,  occiuring  usually  in  young  persons 
from  14  to  30.  The  joint  symptoms  are  pronounced  and  multiple,  and 
there  are  decided  swelling,  pain,  and  fever,  with  a  temperature  of  101° 
to  103°  F.  (38.3°  to  39-4°  C).  The  eruption  first  appears  on  the  legs  near 
the  affected  joint,  but  it  has  been  present  extensively  on  the  arm,  distant 
from  the  joint,  followed  by  sloughing;  in  the  same  case  were  retinal  hemor- 
rhages.    Sloughing  and  necrosis  of  the  skin  even  have  occurred.     It  may  be 


PURPURA  HEMORRHAGICA  663 

simply  purpmic,  or  may  be  associated  with  urticarial  wheals — exudative — 
or  vesicles  (pemphigoid  purpura) .  When  severe,  it  is  often  associated  with 
hematuria  and  hemorrhagic  nephritis  with  edema.  Endocarditis  is  also  a 
complication. 

3.  Henoch's  Purpura. — This  is  a  variety  occurring  most  often  in  chil- 
dren, but  also  in  adults,  characterized  by  severe  gastrointestinal  disturbance 
with  colic  in  addition  to  the  previously  named  symptoms.  There  are  pain, 
vomiting,  and  diarrhea,  rarely  intestinal  ulceration  and  perforation  with 
fatal  peritonitis.     Acute  enlargement  of  the  spleen  has  been  observed. 

Here,  also,  recovery  is  the  rule. 

Diagnosis  of  Arthritic  Purpura. — The  diagnosis  is  easy  by  reason  of 
the  associated  joint  symptoms,  but  the  same  doubt  exists  as  to  a  true 
rheumatic  nature  in  all  forms. 

Prognosis. — This  is  regarded  as  favorable,  but  fatal  terminations  do 
occur,  especially  in  peliosis  rheumatica  in  which  there  is  nephritis.  Relapses 
in  this  form  may  occour  at  the  samme  time  of  year  for  several  years  in 
succession. 

Purpura  Hemorrhagica. 

Synonym. — Morbus  maculosus  Werlhofi. 

Symptoms. — This  is  a  severe  form  of  purpura  characterized  by  hemor- 
rhage from  the  mucous  membranes,  including  nose,  mouth,  palate,  stomach, 
and  intestinal  canal,  in  addition  to  extensive  subcutaneous  ecchymosis.  It 
attacks  all  ages  but  particularly  young  and  delicate  girls.  The 
brain  and  kidneys  and  serous  membranes  may  also  be  seats  of  hemor- 
rhage— apoplectic  symptoms  indicating  the  first.  A  '  prodrome  of  languor 
and  weakness  may  precede  for  a  couple  of  days,  to  be  succeeded  by  a  rapid 
succession  of  ecchymoses  and  hemorrhages.  More  decided  constitutional 
disturbances  follow,  including  typhoid  symptoms  and  fever,  though  the 
latter  is  mild  and  may  be  altogether  absent,  even  in  severe  cases.  Death 
may  take  place  from  loss  of  blood  or  hemorrhage  into  the  brain,  or  recovery 
in  from  ten  days  to  two  weeks. 

In  the  purpura  fulminans  the  hemorrhages  are  mainly  confined  to  the 
skin,  producing  confluent  ecchymoses  and  dense  infiltrations  covering  large 
areas,  with  sanguineous  blisters.  The  internal  organs,  on  the  other  hand, 
remain  free,  while  the  urine  and  the  bowel  evacuations  are  natural.  At 
times  there  is  fever;  at  others,  not.  Hemorrhagic  purpura  has  occurred 
after  pneumonia  and  scarlet  fever,  and  again  in  children  apparently 
healthy.  In  these  fulminating  cases  death  may  occtu-  before  piu-pura 
manifests  itself. 

Diagnosis. — As  to  diagnosis,  scurvy  is  almost  the  only  condition  liable 
to  be  mistaken  for  purpura  hemorrhagica.  In  the  latter  the  gums  are 
intact,  and  there  is  an  absence  of  the  conditions  favoring  scurvy. 

Prognosis. — The  termination  is  usually  favorable  in  from  ten  days  to 
two  weeks,  although  there  may  be  fulminating  cases,  usually  in  children, 
terminating  fatally  in  24  hours.     Severe  cases  recover  more  slowly. 

Treatment  of  Arthritic  Purpura  and  Purpura  Hemorrhagica. — Treat- 
ment is  best  directed  to  improving  the  quality  of  the  blood  and  to^build- 


664  DISEASES  OF  THE  BLOOD 

ing  up  the  general  tone  rather  than  to  the  control  of  the  hemorrhage, 
though  the  latter  must  not  be  entirely  ignored.  Almost  all  that  has  been 
said  of  the  tretment  of  scurvy  is  applicable  to  these  forms  ofpiupura. 
Iron  and  arsenic  are  the  typical  blood-builders,  to  which  nutritious  food, 
including  vegetable-juices,  is  to  be  added.  Arsenic  shoidd  be  given  in 
full  doses,  beginning  wath  small  ones  and  ascending  rapidly. 

In  the  articular  forms  the  salicylates  and  salicin  should  be  used  in  such 
doses  as  the  stomach  wall  tolerate. 

Lactate  or  chlorid  of  calcium  in  doses  of  15  grains,  (onegram,)  is  a  valu- 
able remedy.  The  injection  of  a  normal  blood  scrum  will  give  often  im- 
mediate improvement. 

Hemorrhagic    Disease    of    the    New-born. 

Hemorrhagic  Syphilis  of  the  New-horn. — Usually  about  from  the  third 
to  the  fifth  day  after  birth  hemorrhage  is  observed  at  the  nave)  of  the  child, 
or  it  may  occur  earlier.  Blood  also  flows  from  the  mucous  membranes  of 
the  mouth,  the  bowels,  and  the  kidneys.  The  skn  becomes  jaimdiced. 
The  stomach  rejects  food,  and  though  it  may  appear  well  nourished  at  birth, 
the  child  rapidly  wastes,  and  dies  at  the  end  of  a  week  or  ten  days.  The 
autopsy  discloses  syphilitic  lesions  in  the  liver,  lungs,  nasal  passages,  and 
elsewhere. 

Epidemic  Hemoglobinuria  of  Infants,  or  Winckel's  Disease. — As  de- 
scribed by  Winckel  in  1879,  in  an  epidemic  at  the  Foundlings'  Hospital,  at 
Dresden,  the  first  symptoms,  noticed  usually  on  the  fourth  day  after  birth, 
are  a  bluish  tinge  on  the  skin  of  the  face,  trunlc,  and  limbs,  with  a  more  or 
less  icteroid  hue.  There  are  fever,  rapid  breathing,  and  sometimes  cyanosis. 
Occasionally  there  are  vomiting  and  diarrhea.  The  urine  is  light  brown, 
albuminous,  contains  methemoglobin,  and  deposits  a  sediment  consisting 
of  epithelium  and  tube-casts.  The  blood  contains  an  excess  of  leukocytes 
and  numerous  granular  bodies.  The  child  lives,  on  an  average,  two  days, 
though  in  one  case  death  supervened  in  nine  hours.  The  autopsy  in  this 
case  disclosed  yellow  staining  of  the  skin  and  internal  organs;  the  spleen 
was  large,  hard,  and  darkened;  the  kidneys  were  dark  brown  in  color, 
their  tubvdes  being  filled  with  granular  pigment;  the  liver  and  heart  were 
fatty.  There  may  be  ptmctiform  hemorrhages  on  the  surface  of  the  internal 
organs.  There  is  no  septic  condition  of  the  umbilical  vessels.  An  in- 
fectious origin  is  not  imlikely. 

Actite  Degeneration  of  the  Internal  Organs  of  the  New-born,  or  Buhl's 
Disease. — How  far  this  disease,  described  by  Buhl  in  1861,  diiTers  from 
Winckel's  disease,  or  the  latter  from  the  former,  remain  to  be  settled,  for, 
in  the  first  place,  fatty  degeneration  of  the  heart  and  liver  is  found  in  many 
cases  of  Winckel's  disease,  while  in  others  there  is  found  the  general  fatty 
degeneration  of  kidneys,  liver,  heart,  etc.,  described  by  Buhl.  In  the  second 
place,  infants  surviving  the  first  few  hours  after  birth  in  Bulh's  disease 
have  the  same  symptoms  as  those  described  under  Winckel's  disease,  while 
the  other  symptoms,  such  as  minute  hemorrhages  and  bile  staining  of 
various  internal  organs,  are  not  essentially  different. 

Morbus  Macullosus  Neonatorum. — Still   another  form   of   hemorrhage 


HEMOPHILIA  665 

from  one  or  more  of  the  surfaces,  and  especially  of  the  alimentary  canal,  in 
the  new-born  is  described  under  this  title.  The  bleeding  generally  begins 
within  the  first  week,  but  may  be  as  late  as  the  second  or  third  week. 
Hemorrhage  from,  the  bowels  (meljena  neonatorum)  is  the  most  frequent 
form,  but  it  may  be  from  the  stomach,  mouth,  nose  and  navel,  or  from  the 
navel  alone.  It  m.ay  be  accompanied  by  hematogenous  jaundice — indeed, 
by  any  or  all  the  symptoms  described  under  Winckel's  disease — but  differs 
in  the  occasional  presence  of  fever  and  apparent  absence  of  postmortem 
lesions,  though  ulcers  of  the  esophagus,  stomach,  and  duodenum  have  been 
found.  It  is  generally  fatal  in  from  one  to  seven  days.  All  these  con- 
ditions can  be  appropriately  considered  as  forms  of  purpiu-a. 

Treatment. — The  treatment  of  hemorrhagic  affections  of  the  new-bom 
often  avails  little,  though  recoveries  take  place,  especially  in  the  last- 
described  form,  in  which  C.  W.  Townsend  reports  19  recoveries  otit  of  50 
cases  collected.  The  injection  subcutaneously  or  intravenously  of  fresh 
human  or  animal  serum,  however,  suggested  by  Weil  affords  relief.  Ten 
CO.  may  be  injected  subcutaneously  at  one  dose,  using  as  much  as 
100  or  even  200  c.c.  in  fotu  or  five  days.  Welch  of  N.  Y.  has  lately  brought 
this  treatment  before  the  profession,  he  claims  a  large  percentage  of 
recoveries. 

The  treatment  demands  absolute  rest  with  the  head  low.  Even  the 
exertion  necessary  in  nursing  at  the  breast  should  be  interdicted,  and  the 
infant  should  be  fed,  while  recumbent,  with  a  teaspoon,  using  also  the 
mother's  milk  if  this  be  not  condemned  as  worthless.  The  utmost  care 
in  providing  uniform  warmth  should  be  taken.  This  can  be  best  accom- 
plished by  means  of  an  incubator. 

HEMOPHILIA. 

Definition. — A  hereditary  disease,  manifested  by  a  tendency  to  uncon- 
trollable hemorrhage,  occurring  in  males  but  transmitted  by  females. 

Etiology. — Instances  of  fatal  hemorrhage  from  this  disease  were  observed 
centiuies  ago,  the  first  mention  of  it  seems  to  have  been  by  an  Arabian 
physician  who  died  in  1107.  "Families  of  bleeders"  were  first  described  in 
this  country  by  Dr.  John  C.  Ottis  of  Philadelphia  in  1803,  who  also  first 
used  the  word  bleeder  (Osier).  Of  great  importance  because  of  its  bear- 
ing on  the  marriage  of  these  hemophilic  subjects  is  the  fact  that  the  tend- 
ency is  transmitted  through  the  female  line  rather  than  through  the  male. 
Thus,  if  a  man  belonging  to  a  bleeding  family  who  is  himself  not  a  bleeder 
marries  a  woman  who  is  healthy  and  not  a  bleeder,  his  offspring  are  exempt 
from  the  affliction.  On  the  other  hand  if  a  woman  a  member  of  a  bleeding 
family  marry,  she  may  have  offspring  who  are  bleeders.  These  facts  were 
pointed  out  by  Grandidier.  The  females  of  such  families  are  never  bleeders, 
and  only  some  of  the  males.  The  families  of  bleeders  are  apt  to  be  large,  and 
their  appearance  is  that  of  health,  as  a  rule.  It  is  said  that  blondes  pre- 
dominate, with  delicate,  soft  skin  and  distinct,  distended  veins. 

More  cases  are  reported  from  Germany,  Switzerland  and  the  United 
States  than  any  other  countries  while  some  hold  that  it  is  more  common 
among  Jews.     In  1893  Sir  Almroth  Wright  showed  that  the  coagulations 


666  DISEASES  OF  THE  BLOOD 

of  the  blood  in  bleeders  ranged  between  ten  and  sixty  minutes  instead  of 
the  normal  five  to  six  minutes.  He  also  showed  that  bleeders  and  female 
descendents  of  bleeders  had  a  leukopenia  partieularly  of  the  polymorpho- 
nuclear leukoeytes.  Upon  these  faets  it  is  supposed  that  the  cause  of  the 
bleeding  in  hemophilia  is  some  disturbance  with  the  phenomenon  of  clotting. 
Howell  diagrammatically  states  that  in  normal  individuals  the  cellular 
elements  of  the  blood  and  the  woitnded  tissue  provide  thrombokinase,  that 
thrombokinase+calcium+thrombogen  form  thrombin,  that  the  union  of 
thrombin  and  fibrinogen  form  fibrin.  In  which  of  these  factors  necessary  to 
complete  clotting  the  fault  lies  is  not  decided  because  of  the  still  unsettled 
state  of  the  whole  question  of  clotting  of  blood. 

Symptoms. — Attention  is  commonly  called  to'  a  bleeder  by  the  occur- 
rence of  a  hemorrhage  difficult  to  control,  though  induced  by  some  trifling 
cause.  Epistaxis  leads  in  frequency  in  169  out  of  334  cases  collected  bj' 
Grandidier.  The  extraction  of  a  tooth  is  one  of  the  most  frequent  of  these 
events.  It  may  be  the  prick  of  a  pin,  or  a  scratch,  or  a  slight  cut,  as  in 
vaccination,  or  no  cause  may  be  discoverable.  The  tendency  may  mani- 
fest itself  at  the  cutting  of  the  umbilical  cord  at  birth,  or  in  Jewish  children 
at  the  circumcision.  On  the  other  hand,  the  same  accidents  which  are 
without  result  early  in  life  may  induce  the  hemorrhage  later.  It  may  be 
induced  by  simply  blowing  the  nose.  Other  situations  were  the  mouth  and 
stomach.  Hemorrhages  also  occur  in  the  interstices  of  organs,  and  though 
interstitial  hemorrhages  do  occur,  they  are  usually  the  result  of  trifling 
blows,  when  the  well-known  "  black-and-blue "  appearance  is  produced. 
One  of  us  has  reported  two  brothers  who  had  huge  hematomata  apparently 
without  cause.  Hemorrhages  into  the  joints  and  periarticular  tissues 
occur  in  and  about  the  knee. 

The  external  hemorrhages,  including  those  of  the  mouth  and  nose, 
may  be  profuse  and  even  fatal.  They  often  last  24  hoiu-s  or  longer.  When 
checked,  reaction  from  them  is  rapid,  and  the  victims  quickly  resume  their 
nattiral  appearance,  though  repeated  hemorrhages  may  engender  a  per- 
manent anemia. 

Joint  affections  may  be  associated  with  this  as  with  the  acquired  hem- 
orrhagic tendency.  They  involve  usually  the  larger  joints,  and  may  include 
swelling  and  pain,  wth  fever,  producing  a  close  resemblance  to  rheumatism, 
or  there  may  only  be  pain. 

Diagnosis. — This  is  apparent  if  the  family  tendency  is  known,  but 
repeated  hemorrhages  from  both  or  infancy  are  necessar}^  to  the  diagnosis. 
Alarming  hemorrhage  ^vithout  sufficient  cause  should  excite  inquin^,  but 
no  single  hemorrhage  however  large  or  inexplicable  should  be  regarded  as 
hemophilia  \\athout  one  can  trace  back  a  history  to  a  family  of  bleeders. 

Prognosis. — The  younger  the  subject,  the  more  serious  the  outlook,  but  even 
in  young  cliildren  the  outlook  is  not  so  ver\'  serious.  Measures  are  now  at 
hand  which  fairly  well  control  the  condition. 

Treatment. — This  may  be  prophylactic.  Wright  administered  thymus 
tablets  and  certain  forms  of  j'east  to  bleeders  with  the  effect  of  dimin- 
ishing the  tendency  to  bleed.  The  administration  of  the  calcium  salts 
also  lowers  the  coagulation  time  of  the  blood  in  certain  instances.  The 
actual  hemorrhage  may  be  controlled  here  as  in  scur\'y  and  piupura  by  the 


HEMOPHILIA  667 

subcutaneous  injection  of  blood  serum.  Human  blood  serum  is  better 
than  foreign  serum  because  it  will  not  cause  anaphylaxis,  but  the  latter  may 
be  used.  As  much  as  200  to  300  c.c.  may  be  used  in  24  hours.  The  children 
of  bleeding  families  should  be  carefully  guarded  against  traumatic  causes, 
however  slight,  while  they  should  be  carefully  looked  after  from  the  hygienic 
and  nutritive  standpoints.  Fresh  air,  daily  bathing,  outdoor  exercise,  and 
judicious  measxu-es  intended  to  harden  the  threatened  subject  should  be 
practised.  Plain,  wholesome,  and  nourishing  food  should  be  given,  and 
due  attention  should  be  paid  to  digestion.  As  a  part  of  the  prophylactic 
treatment,  too,  is  discouragement  from  marriage  especially  in  the  case  of 
women. 

During  an  attack  absolute  quiet  must  be  enjoined.  Styptics  are  to  be 
employed  locally.  Of  styptics,  the  solution  of  the  perchlorid  or  persul- 
phate of  iron  is  the  best,  beginning  at  first  with  dilute  solutions  and  increas- 
ing to  the  full  strength  of  the  official  solution  if  necessary.  Tannic  acid 
is  another  good  styptic,  and  if  at  hand,  may  be  dusted  well  upon  the  part 
or  applied  on  cotton  to  cavities.  In  epistaxis  the  nose  must  be  plugged  if 
the  ordinary  methods  of  applying  these  agents  fail.  Wright  suggests  a 
"physiological  styptic"  made  from  the  thymus  gland  of  calf  or  lamb  by 
extracting  it  with  a  normal  salt  solution,  10  parts  of  the  solution  to  i  part 
of  chopped  gland. 


SECTION  VI. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 
DISEASE  OF  THE  THYROID  GLAND. 

GOITER. 
Simple  Goiter  or  Struma. 

Synonyms. — Bronchocele;    Thyrocele;    Thick    Neck;    Derbyshire    Neck. 

Definition. — The  name  is  derived  from  Latin,  guttiir,  throat.  Under 
this  name  are  included  all  enlargements  of  the  thyroid  gland  ■  other  than 
those  due  to  inflammation,  malignant  disease,  exophthalmic  goiter,  or 
parasites. 

Distribution. — Simple  goiter  may  occur  endemically  or  sporadically,  but 
in  this  country  it  is  only  sporadic.  It  is,  however,  quite  prevalent  about 
the  eastern  end  of  Lake  Ontario  and  in  the  State  of  Michigan.  It  is  still 
endemic  in  certain  parts  of  Finland  and  of  Switzerland  (cantons  of  Freiburg 
and  Berne),  in  Italy  (in  the  Southern  Alps  and  in  Savoy),  in  England,  the 
Himalayas,  in  South  America  and  in  Asia,  in  Siberia.  In  the  cantons  named 
as  many  as  80  and  90  per  cent,  of  recruits  are  found  goitrous.  It  has  even 
occurred  in  epidemic  form  in  Finland. 

Etiology. — The  exciting  cause  of  goiter  still  remains  unknown,  although 
a  belief  has  long  prevailed  as  to  the  endemic  form  that  some  constituent  of 
drinking-water  is  responsible  for  it.  That  locality  is  in  some  way  responsi- 
ble is  shown  by  the  fact  that  removal  from  a  territory  subject  to  it  arrests 
its  development,  while,  if  a  healthy  family  moves  into  a  goitrous  district, 
the  disease  develops  in  some  one  or  more  members.  A  change  in  the 
water-supply  of  a  district  where  goiter  has  been  prevalent  has  led  to  its 
disappearance,  while  the  water  in  certain  wells  on  the  continent  of  Europe 
is  known  to  produce  it.  In  fact,  certain  water  is  said  to  be  drunk  by  men 
who  desire  to  develop  in  themselves  a  goiter  in  order  that  they  may  be 
exempt  from  military  service.  What  the  responsible  constituent  of  the 
water  is,  is,  however,  unknown,  but  it  is  supposed  to  be  an  organic  impurity. 

It  is  much  more  common  in  women  than  in  men,  according  to  dif- 
ferent authorities  seven  to  41  times  as  frequent.  It  has  been  suggested 
that  this  is  because  women  drink  more  water.  The  disease  generally 
develops  after  puberty,  sometimes  after  50-  Congenital  cases  are  known. 
It  is  sometimes  hereditary,  but  heredity  must  be  separated  from  the 
operation  of  one  cause  on  different  members  of  the  same  family. 

Morbid  Anatomy. — AH  simple  goiters  start  in  a  true  hypertrophy  of 
the  gland  follicles,  and  the  entire  gland  then  resembles  a  "normal  but 
enlarged  thyroid,"  but  ultimately  assume  special  peculiarities,  on  which 
are  based  anatomical  varieties.  According  to  anatomical  peculiarities 
assumed  after  the  goiter  sets  in,  there  occiur:  (i)  Vascular  thyroid,  in  which 

668 


GOITRE  669 

the  vessels  are  enlarged  and  dilated;  (2)  Fibroid  thyroid,  in  which  there 
is  an  excessive  development  of  fibroid  tissue;  (3)  Colloid  thyroid,  in  which 
the  follicles  are  enlarged  and  filled  with  colloid  matter;  sometimes  the 
contents  of  the  follicles  become  calcified  or  undergo  amyloid  change. 

Symptoms. — It  may  be  said  of  the  majority  of  goiters  that  thej'  cause 
no  inconvenience,  and  are  mainly  objectionable  through  the  resulting 
deformity.  The  size  attained  varies:  the  enlargement  may  but  slightly 
exceed  that  of  the  normal  gland,  or  the  organ  may  be  very  large  and  pen- 
dulous. It  may  be  one-sided,  or  bilateral,  or  only  affect  the  isthmus.  It 
is  characteristic  of  all  goiters  and  enlargements  of  the  thyroid  of  any 
kind  that  they  rise  up  when  the  patient  swallows,  and  tumors  of  doubtful 
locality  may  thus  be  located.  The  goiter  is  sometimes  low  down,  behind 
the  sternum,  and  can  only  be  felt  during  deglutition.  Occasionally  goiters 
have  a  wholly  aberrant  position  and  give  rise  to  symptoms  dependent  upon 
disturbance  of  the  parts  in  which  they  are  situated. 

A  goiter  may  press  on  the  trachea,  causing  dyspnea,  or  upon  the  esoph- 
agus, causing  difficulty  in  swallowing.  When  behind  the  sternum,  it 
may  press  upon  the  veins  in  the  neck,  causing  swelling  of  the  face  and 
head,  and  sometimes  headache  and  drowsiness.  There  may  be  pressure 
on  nerves,  especially  the  pneumogastric,  causing  spasm  of  the  glottis, 
paralysis  of  the  abductor,  and  even  complete  paralysis  of  one  or  both 
vocal  cords. 

Treatment. — When  goiter  is  endemic,  it  is  important  to  have  the  water 
supply  carefully  examined  for  defects.  When  possible  individuals  with 
beginning  goiter  should  remove  from  the  goitrous  locality.  Water  of  the 
district  should  he  boiled.  The  drug  treatment  of  goiter  consists  principally 
in  the  use  of  iodin.  It  is  undoubtedly  efficient  at  times.  The  simple  iodin 
ointment  or  ointment  of  the  red  iodid  of  mercur}^  may  be  daily  rubbed  into 
the  goiter.  It  is  recommended  that  after  applications  of  the  latter  the  neck 
should  be  exposed  to  the  rays  of  the  sun.  This  treatment  has  been  especially 
efficient  in  India.  Injections  of  iodin  into  the  cyst  are  also  used — 20  to  30 
minims  (1.3  to  2  c.c.)  of  a  solution  of  one  part  in  twelve  parts  of  alcohol  twice  a 
week,  a  new  point  being  selected  each  time,  care  being  taken  not  to  wound 
any  vessels  or  nerves.  This  is  a  dangerous  procedure  and  should  never 
be  used  until  other  methods  of  applying  iodin  are  tried. 

Internal  treatment  is  frequently  efficient.  Naturall}^  the  iodid  of 
potassium  is  conspicuous  among  remedies,  in  the  usual  doses — s  to  20 
grains  (0.3  to  1.3  gm.)  three  times  a  day.  Lugol's  solution  of  iodin  can 
be  used.  Thyroid  extract  is  also  being  used  with  disputed  success.  Bruns 
treated  12  cases  with  raw  thyroid  glands  in  doses  of  75  to  150  grains  (5  to 
10)  gm.  twice  a  week  at  first  and  once  a  week  afterward.  Nine  were  bene- 
fited. Kocher,  however,  thinks  that  the  results  with  thyroid  extract  are 
no  better  than  with  iodin,  and  this  view  is  now  generally  held. 

If  the  goiter  is  produced  by  local  causes,  a  change  of  residence  is,  of 
course,  desirable.     X-ray  application  is  often  of  benefit. 

Surgical  Treatment. — In  view  of  the  extremely  successful  surgical 
treatment  of  goiter  in  the  hands  of  competent  surgeons,  proper  advice  to 
patients  is  that  with  a  very  small  operative  risk — about  i  per  cent,  by  the 
Mayo's  last  1200  cases — a  goiter  may  safely  be  removed  never  to  return. 


670  DISEASES  OF  THE  DUCTLESS  GLANDS 

This  will  save  time  and  the  possible  appearance  of  severe  or  fatal  hyper- 
thyroidism in  the  course  of  a  simple  goiter. 


Hyperthyroidism. 

Synonyms. — Exophthalmic   gaiter;   Struma  exophthalmica;  Graves'  Disease; 

Basedow's  Disease;  Parry's  Disease;  Cardiothyroid  Exophthalmos; 

Tachycardia  strumosa. 

Definition. — A  disease  characterized  especially  by  enlargement  of  the 
thyroid  gland,  protruding  eyeballs,  and  palpitation  of  the  heart  and  fine 
muscular  tremors,  due  to  hyperactivity  of  function  of  the  thvToid  gland. 

Etiology. — Exophthalmic  goiter  is  much  more  common  in  women  than  in 
men.  It  is  also  more  common  in  the  young  adult  and  in  the  middle-aged. 
The  average  age  maybe  put  down  at  from  30  to  31  years;  Brs-om  Bramwell 
says  1 5  to  30  for  women  and  30  to  45  for  men.  It  has  been  observed  as  early 
as  two  and  a  half  years,  and  as  late  as  68.  Heredity  is  a  rare  factor,  but  its 
influence  cannot  be  denied.  It  sometimes  happens  that  several  members 
of  a  family  are  affected.  Sometimes  myxedema  affects  one  member  of  a 
family,  and  exophthalmic  goiter  another.  It  occurs  with  especial  frequency 
in  neurotic  families.  Sudden  mental  shock,  worrj^  and  grief,  and  physical 
fatigue  are  assigned  as  exciting  causes.  So  are  many  acute  diseases,  of  which 
rheumatism  is  especially  cited,  also  typhoid  fever.  Some  of  these  are 
more  likely  to  be  coincidences.  Its  association  with  diabetes  mellitus, 
though  infrequent,  is  a  recognized  one.  Some  perversion  of  function  of  the 
thyroid  gland  lies  at  the  foundation  of  exophthalmic  goiter. 

Morbid  Anatomy.- — The  anatomical  changes  are  as  a  rule  hyperplastic  as 
to  gland  tissues  and  colloid  content,  though  terminating  also  in  atrophy. 
The  iodin  content  increases  directly  as  the  colloid  matter. 

Pathology. — Louis  B.  Wilson  comes  to  the  following  conclusions  from 
the  examination  of  294  thyroid  glands  of  Grave's  disease  for  the  Mayo 
clinic.     The  development  of  the  disease  occurs  as  follows. 

1.  Following  a  metabolic  chemical,  or  extra-organismal  irritant,  thyroid 
parenchyma  proliferates,  over-functionates  and  degenerates. 

2.  This  process  primarily  resembles  simple  adenomatous  proliferation, 
or  reminds  one  of  adenopapilloma. 

3.  Either  process  may  start  in  a  gland  not  previously  enlarged  by  re- 
tained secretion  or  in  one  which  is  already  distended  with  non-absorbed 
secretion. 

4.  The  severity  of  the  symptoms  depends  upon  (a)  the  amount  of 
absorbable  secretion;  and  (6)  the  patient's  ability  to  neutralize  the  secretion. 

From  a  clinical  standpoint  he  comes  to  the  following  conclusions : 

1 .  VeVy  early  acute  cases  show  pathologically  hyperemia  and  cellular 
hyperplasia. 

2.  Later  acute,  moderate,  se^•ere  and  ven,'  severe  cases  show  greater 
parenchyma  increase  and  in  many  instances  evidence  of  increased  absorbable 
secretion. 

3 .  Cases  which  clinically  are  showing  any  remission  of  toxic  symptoms 
show  somewhere  within  the  gland  more  or  less  evidence  of  decreased  function 


HYPERTHYROIDISM  671 

in  the  exfoliation  or  marked  flattening  of  parenchyma  cells,  or  of  probably 
decreased  absorption,  by  the  presence  of  thick,  gelatinous  stainable  secretion, 
the  so-called  "colloid." 

4.  Patients  who  have  recovered  from  their  toxic  symptoms  and  are  now 
suffering  principally  from  long  previously  acquired  heart  or  nerve  lesions 
or  from  myxedema,  show  exfoliated  or  much  flattened  (probably  non- 
secreting)  epithelium  and  large  quantities  of  well  stained,  thick,  gelatinous, 
probably  non-absorbable,  colloid. 

5.  The  recently  developed,  very  mild,  or  probably  mild  cases  of  long 
standing  show  pathologically  almost  always  some  total  parenchyma 
increase  by  the  mtdtiplication  of  alveoli,  but  apparently  not  greatly  increased 
functionating  power  of  the  individual  parenchyma  cells  of  the  adenoid 
type. 

6.  Simple  goiters  should  be  regarded  as  multiple  retention  cysts  filled 
with  non-absorbable  secretion,  cell  detritus,  etc. 

Symptoms. — Of  the  cardinal  symptoms  mentioned  in  the  definition, 
the  cardiac  and  vascular  usually  appear  first.  The  palpitation  is  extreme, 
delirious,  as  it  were,  the  pulse-rate  being  commonly  in  the  neighborhood 
of  i2oto  140,  and  sometimes  reaches  200.  The  slightest  excitement  augments 
the  pulse-rate  instantly.  The  cardiac  impulse  is  strong,  but  the  voliune  of 
the  pulse  small.  The.heart-sounds  are  loud,  audible  to  the  patient  and  even 
at  a  distance  from  the  body,  in  one  case  described  by  Graves  himself  as  far 
as  four  feet.  A  systolic  murmur  is  often  heard  at  the  base,  usually  soft, 
but  sometimes  loud ;  more  rarely  at  the  apex,  when  it  may  be  due  to  relative 
insufficiency  of  the  mitral  or  tricuspid  valve.  The  blood  pressure  may  be 
high  in  the  toxic  cases,  or  low  or  normal  in  other  phases. 

Exophthalmos  is  commonly  described  as  the  second  of  the  cardinal 
symptoms  to  make  its  appearance,  but  it  is  nearly  as  frequent  as  palpitation. 
The  degree  of  this  protrusion  varies  very  decidedly.  It  may  be  so  slight 
as  to  be  scarcely  noticeable,  while  again  the  peculiar  staring  effect  arising 
from  it  is  conspicuous,  and  attracts  attention  instantl3^  Exophthalmos 
may  be  present  on  one  side  only,  although  some  do  not  admit  such  cases  in 
the  category  of  true  exophthalmic  goiter.^  The  eyes  show  a  large  amount 
of  white,  and  the  eye-lids  when  closed  often  cannot  cover  the  eyes.  It  is 
in  these  extreme  cases  that  von  Graefe's  symptom  presents  itself — a  condi- 
tion in  which,  when  the  eye  is  cast  down,  the  lid  fails  to  follow  it  as 
it  does  in  health.  Stellwag's  sign,  is  met.  In  it,  the  palpebral  fissure  is 
increased  in  width,  owing  to  the  persistent  retraction  of  the  upper  lid.  It 
may  occur  with  or  without  von  Graefe's  sign.  Retraction  of  the  lower  lid 
is  occasionally  seen.  Moebius  considers  Graefe's  symptoms  the  result  of 
Stellwag's.  The  patient  winks  less  frequently  than  in  health.  Pulsation 
of  the  retinal  arteries  can  be  seen  with  the  ophthalmoscope,  but  other  changes 
in  the  retinae  are  rare.  There  is  Httle  change  in  the  pupils.  A  lack  in  ability 
to  converge  the  two  eyes  was  pointed  out  by  Moebius.  Exophthalmos  is 
absent  in  20  per  cent,  of  cases.  Riesman  has  described  a  loud  to-and-fro 
murmur  occasionally  heard  over  the  eyeball. 

The  thyroid  enlargement  commonly  presents  itself  at  about  the  same 

iSee  paper  on  "Unilateral  Exophthalmos  in  Exophthalmic  Goiter  "  by  Posey  and  Swindells,  "  Oph- 
thalmic Record,"  May,  1904. 


672  DISEASES  OF  THE  DUCTLESS  GLANDS 

time  as  exophthalmos.  The  goiter  is  usually  of  moderate  size,  almost  never 
reaching  the  dimensions  sometimes  attained  by  a  simple  goiter.  The  tumor 
is  largely  contributed  to  by  its  vascularity,  though  there  is  also  an  over- 
growth of  the  proper  glandular  tissue  of  the  thyroid.  Pulse  and  thrill  are 
both  palpable,  while  a  loud  systolic  murmur  may  be  heard  on  auscultation. 
The  enlargement  may  be  on  one  side  only.  In  other  cases  there  may  be  no 
enlargement.  This  may  also  be  apparent  only,  but  we  are  informed  by  the 
Mayo  brothers  that  they  have  operated  on  exophthalmic  goiters  hardly 
palpable  which  proved  greatly  enlarged  on  exposure.  When  such  a  con- 
dition is  associated  with  absent  exophthalmos,  the  disease  may  be  completely 
masked. 

Another  set  of  symptoms  already  alluded  to  as  nervousness  is  restless- 
ness, a  disposition  to  start  at  the  slightest  soiuid,  and  wakefiilness  at  night. 
A  part  of  this,  or  due  to  the  same  cause,  at  least,  is  "tremor,"  a  highly  im- 
portant sj'mptom,  of  such  frequency  as  to  be  included  by  George  R.  Murray 
in  his  definition.'  It  may  be  best  studied  by  holding  out  the  hand  with  the 
palm  downward;  even  better  by  laying  the  examiner's  palm  lightly  upon  the 
patient's  fingers  when  the  hand  of  the  latter  is  held  out.  Occasionally  the 
whole  body  is  affected.  It  occurs  eight  or  nine  times  in  a  second.  Its  extent 
is  small,  but  not  always  the  same.  It  may  be  seen,  too,  in  the  foot,  and  in 
some  instances  the  whole  bodj^  appears  to  tremble.  It  is  generally  equal  on 
the  two  sides  of  the  body,. but  has  been  unilateral  when  goiter  and  exoph- 
thalmos have  been  on  one  side.  It  resembles  the  tremor  of  fatigue  or  that 
seen  in  recoverj^  from  long  illness.  Another  symptom  included  in  the  same 
category  is  a  sudden  giving  away  of  the  legs,  so  that  the  patient  falls  to  the 
ground  without  previous  feeling  of  faintness  or  giddiness.  Painfid  cramps 
sometimes  occur.    Localized  muscular  atrophy  is  occasionally^  met. 

Excessive  sweating  is  a  frequent  symptom.  It  may  be  intermittent 
or  irregular,  or  there  may  be  a  simple  feeling  of  flushing  without  sweating. 
Diminished  electrical  resistance  was  pointed  out  by  Vigouroux.  This  is  a 
natural  result  of  the  constant  moisture  of  the  skin.  Polyuria  often  occurs, 
caused,  perhaps,  as  is  the  sweating,  through  nervous  excitation.  A  dark 
coloration  of  the  skin  sometimes  takes  place,  more  decided  in  those  situations 
in  which  the  pigment  is  naturally  more  abundant,  such  as  the  face  and  arms. 
Yet  the  flexures  of  the  joints,  the  axillae,  the  genitals,  and  the  inside  of  the 
thighs  are  also  affected.  The  skin  may  be  uniformly  bronzed,  or  it  may  be 
darker  in  patches.  Parts  of  the  body  which  are  subject  to  constant  pressure 
are  also  disposed  to  take  on  pigmentation  more  deeply.  Erythema  is 
frequent.  Edematous  swellings  of  the  skin  in  various  parts  of  the  body  may 
occur,  and  are  to  be  carefully  separated  from  edema,  the  result  of  associated 
conditions,  such  as  anemia,  organic  heart  disease,  etc.  It  manifests  itself 
as  swelling  in  the  feet  and  anldes,  and  has  been  ascribed  to  vasomotor  paral- 
ysis. The  nails  sometimes  become  thin,  and  occasionally  have  a  corrugated 
appearance. 

Gastro-intestinal  symptoms  are  frequent,  manifesting  themselves  by 
attacks  of  diarrhea,  apparently  of  ner%''ous  origin,  coming  on  suddenly 
without  pain,  with  copious  loose  motions,  of  which  there  are  two  or  three 
or  more  in  a  day.     Uncontrollable  vomiting  may  be  associated  with  this. 

1  "Twentieth  Century  Practice  of  Medicine,"  vol.  iv..  1895. 


HYPERTHYROIDISM  673 

Acute  forms  are  sometimes  thus  ushered  in.  The  tongue,  however,  remains 
clean,  and  there  is,  as  a  rule,  no  rise  oj  temperature.  Sometimes  there  may 
be  very  sHght  fever.  The  skin  discoloration  and  gastro-intestinal  symp- 
toms, suggest  those  of  Addison's  disease,  and  it  is  not  impossible  it  may 
have  been  associated.  Rapid  breathing  is  a  frequent  accompaniment, 
equaling  30  to  40  respirations  a  minute.  It  may  be  associated  with  cyanosis 
of  the  face  and  swelling  of  the  vessels  of  the  neck.  Intermittent  albuminuria 
is  frequent,  as  pointed  out  by  Begbie.  Derangements  of  menstruation  are 
less  frequent  than  might  be  expected,  this  function  being  normally  main- 
tained in  the  majority  of  instances. 

The  mental  condition  has  been  alluded  to.  It  may  be  added  that  fits 
of  depression  alternate  with  buoyancy,  whUe  the  moral  nature  may  also  be 
changed  to  a  degree  amounting  to  melancholia  and  mania.  Active  cerebral 
symptoms  are  sometimes  present.  This  mania  is  of  bad  augury.  Dullness 
or  stupor  occasionally  occurs  and  has  been  observed  by  us. 

Among  complications,  hysteria  and  chorea,  and  even  epilepsy  are  included. 

Diagnosis. — When  the  case  is  carefully  examined,  the  above  symptoms 
can  be  found  in  sufficient  degree  to  make  a  diagnosis,  and  a  lack  of  diagnosis 
is  usually  due  to  faiilty  observation.  Rapid  heart,  with  either  an  en- 
larged thyroid  which  pulsates  and  over  which  a  murmur  can  be  heard  or 
with  muscular  tremor,  or  with  exophthalmos,  is  quite  sufficient  evidence 
upon  which  to  base  a  diagnosis.  It  is  true  that  no  one  of  these  symptoms 
is  pathognomonic  of  Gravess  disease,  but  a  combination  of  two  or  more 
means  practically  a  positive  diagnosis. 

Prognosis. — Exophthalmic  goiter  is  frequently  fatal,  the  patient  dying 
of  acute  toxic  symptoms.  At  times  the  condition  remains  permanent, 
with  gradual  change  in  the  heart  muscle,  and  in  the  gland  itself,  but  in  the 
course  of  time  some  cases  improve  greatly,  and  some  get  well.  However, 
many  cases  as  the  result  of  overstrain,  mental  or  physical,  develop  an  acute 
thyroid  intoxication  and  die  of  exhaustion.  Unquestionably  certain  mild 
cases  recover  without  any  treatment. 

In  some  rare  instances  a  rapidly  fatal  course,  ensues,  death  taking 
place  in  a  few  days  after  the  onset.  The  majority  of  cases  run  a  chronic 
course,  the  symptoms  persisting  more  or  less  for  years.  When  death  occurs, 
it  is  from  failure  of  the  heart  or  of  thymic  intoxication.  It  is  generally 
preceded  by  an  aggravation  of  all  the  symptoms.  It  may  be  sudden,  as  by 
syncope.  Acute  cases  are  reported,  following  one  of  the  cited  causes,  in 
which  the  symptoms  lasted  a  few  days,  and  then  disappeared  completely. 

Treatment.  Medical  Treatment. — Rest  and  protection  from  excitement 
are  essential  conditions  to  successful  treatment.  In  cases  of  any  severity 
rest,  physical  and  mental,  shotdd  be  absolute.  The  patient  should  be  in 
bed  and  protected  from  any  disturbing  friends.  Milder  cases  may  be  about 
but  under  strict  orders  as  to  amount  of  work,  rest  and  kind  of  food.  The 
modern  method  of  having  an  abundance  of  fresh  air  and  sunlight  in  the  room 
should  be  carefully  attended  to.  The  diet  shovild  be  varied  but  easily 
assimilable — much  such  a  diet  as  advised  in  typhoid  fever.  Ice  bags  to  the 
heart  and  region  of  the  thyroid  are  valuable.  After  this,  the  treatment 
has  been  mainly  directed  to  the  sj^mptoms.  The  remedies  heretofore  used 
were  mainly  the  bromids  and  digitalis:  the  bromids  as  nervous  sedatives. 


674  DISEASES  OF  THE  DUCTLESS  GLANDS 

Drugs. — Among  numerous  remedies  is  one  of  the  bromids  for  its  sedative 
effect,  ergot  for  its  power  of  contracting  the  caliber  of  blood-vessels.  By 
German  writers,  galvanism  of  the  sympathetic  is  claimed  to  be  of  service. 
Theoretically,  it  should  be.  A  constant  current  of  from  five  to  eight  cells 
is  used;  the  negative  pole  is  placed  on  the  fifth  cervical  vertebra,  the  positive 
pole  along  the  sternum.  Thyroid  extract  is  contraindicated;  it  adds  more 
of  the  active  principle  of  the  gland  to  a  body  already  suffering  from  over- 
activity of  the  gland. 

Belladonna  is  sometimes  useful.  In  our  hands  digitalis  has  not  been  of 
value  except  when  there  is  actual  cardiac  dilatation. 

Opium  in  small  doses  has  been  recommended.  This  drug  does  quiet 
the  individual,  but  its  use  should  be  restricted  to  cases  which  are  in  a  severe 
condition.  In  such  a  condition  as  this  where  the  case  is  likely  to  be  chronic 
there  is  too  great  danger  of  the  opium  habit  to  allow  the  use  of  the  drug. 
X-ray  is  recommended  by  the  Mayos. 

Surgical  Treatment. — The  results  of  operative  treatment  have  been  most 
satisfactory,  especially  at  the  hands  of  such  surgeons  as  the  Kochers,  of 
Zitrich,  and  the  Mayos,  of  Rochester,  Minn.,  U.  S.  A. 

Charles  Mayo  advises  a  graduated  operation  in  certain  cases,  and  states 
that  this  method  of  selecting  the  time,  the  preparation,  etc.,  has  reduced  the 
mortality  to  less  than  2  per  cent.  In  certain  cases  the  toxic  condition  is  so 
great  that  no  operation  can  be  undertaken  until  the  patient  is  restored  to 
a  more  normal  condition. 

As  to  the  question  of  treatment  of  any  given  case.  The  proper  steps 
seem  to  be  the  f ollo-wdng : 

Given  a  case  of  hyper thjrroidism.  If  it  is  recent  and  of  moderate  sev^cr- 
ity,  it  should  be  subjected  to  medical  treatment,  of  which  rest  is  the  essential 
element.  If  the  case  responds,  no  further  steps  need  be  taken  unless  it 
relapses.     If  it  relapses,  a  surgeon  should  at  once  be  consulted. 

If  the  case  is  severe,  it  also  must  be  put  at  once  upon  rest  treatment,  and 
everything  done  to  reduce  the  toxic  sj'mptoms.  After  it  is  recovered,  an 
operation  should  be  imdertaken  by  a  competent  surgeon.  The  mortality 
of  surgical  treatment  in  skilled  hands  is  amazingly  low.  In  1913  the  Mayos 
report  275  cases  of  removal  of  the  gland  with  i  death;  4  double  ligations 
with  no  deaths;  363  single  ligations  wath  5  deaths.  These  figiu^es  are  prob- 
ably lower  than  those  of  the  country  at  large. 

No  condition  needs  better  judgment  as  to  the  time  of  operation;  opera- 
tion in  the  midst  of  severe  symptoms  is  followed  by  a  high  mortality.  It 
should  be  done  only  by  those  skilled  in  this  line  of  work. 

The  serum  treatment  for  exophthalmic  goiter  proposed  by  Rogers  and 
Beebe,'  though  it  has  passed  the  experimental  stage,  must  be  regarded  as 
still  on  trial.  For  this  they  offer  a  specific  antiserum  which  is  made  by 
injecting  rabbits  or  sheep  with  the  nucleo-proteid  and  thyro-globulin 
obtained  from  the  himian  thyroid  gland.  The  statistics  are  not  as  good  as 
those  of  the  operative  treatment. 

A  second  form  of  serum  treatment  is  feeding  with  the  milk  of  dethy- 
roidized  goats  introduced  by  Lanz.  It  is  obtainable  in  the  shape  of  a  sub- 
stance called  rodogen. 

>  Mutter  lecture  for  1907  before  the  College  of  Physicians,  Philadelphia. 


MYXEDEMA  675 

The  X-ray  has  proven  useful  in  a  few  cases.  Faradism  has  failed  of  its 
purpose. 

MYXEDEMA. 

Synonyms. — Cachexie  pachydermique  (Charcot);  Cachexia  thyroidea  vel 
strumipriva  vel  thyreoprtva  (Kocher);  Athyrea;  A  Cretinoid  State  Super- 
vening in  Adult  Life  in  Women  (Gull) ;  Cretinism. 

Definition. — A  myxomatous  infiltration  of  the  subcutaneous  connec- 
tive tissue  of  the  body,  characterized  also  by  dryness  of  the  skin,  subnormal 
temperature,  mental  failure  or  lack  of  development  and  atrophy  of  the 
thyroid  gland. 

Etiology. — All  forms  of  myxedema  are  the  result  of  loss  of  function  of 
the  thyroid  gland  due  to  disease  or  removal  of  the  gland. 

Morbid  Anatomy. — The  morbid  changes  in  the  myxedema  after  death 
are  those  described  as  characteristic  in  life,  but  autopsy  has  disclosed 
the  thyroid  absent  in  nine  out  of  ten  cases  of  cretinism  examined,  confirm- 
ing the  theory  of  its  origin.  Enlargement  of  the  hypophysis  cerebri  was 
found  in  six  cases  of  cretinism  by  different  observers,  and  Horsley  says 
that  the  convolutions  of  the  brain  are  ill-defined,  and  the  blood-vessels 
small,  even  in  proportion  to  the  rudimentary  condition  of  the  nervous 
system. 

Symptoms. — Three  groups  of  cases  are  recognizable: 

1.  Pure  myxedema. 

2 .  Myxedema  associated  with  endemic  or  sporadic  cretinism. 

3.  Operative  myxedema  or  cachexia  strumipriva. 

I.  Pure  Myxedema. — This  is  much  more  frequent  in  women  than  in 
men — at  least  as  six  to  one — and  occurs  usually  between  the  ages  of  30 
and  so.  but  is  not  confined  to  these  ages,  being  found  in  those  who  are 
younger  and  older.  Heredity  is  a  recognized  factor,  acting  usually  through 
the  mother.  Several  members  of  a  family  may  be  affected.  The  poor 
suffer  most.  It  is  said  to  have  no  relation  to  the  catamenia,  but  has 
followed  frequent  pregnancies,  injuries,  severe  hemorrhage,  and  mental 
disturbance.  Most  essential  is  some  change  in  the  thyroid  gland.  For- 
merly thought  to  be  rare  in  this  country,  cases  have  mtdtiplied  since  atten- 
tion has  been  called  to  it. 

The  face  is  the  chief  seat  of  the  myxedematous  change,  but  the  ex- 
tremities, the  trunk,  the  tongue,  and  even  the  internal  organs  may  be  in- 
volved. The  face  is  uniformly  svuollen,  broadened,  and  flattened,  the  nose 
is  broad,  the  mouth  large,  all  lines  are  obliterated,  and  expression  is  gone. 
The  skin  of  the  neck  above  and  below  the  clavicle  is  thrown  into  folds  of 
fatty  and  myxomatous  tissue.  It  is  yellow,  translucent  or  waxy,  dry  and 
scaly.  The  cheeks  and  sometimes  the  nose  are  flushed.  True  edema  may 
be  associated,  and  there  are  rarely  albuminuria  and  glycosuria.     The  hands 

1  The  student  is  referred  to  five  noteworthy  papers  on  the  subject  of  "Myxedema  and  Cretinism"  in 
vol.  viii.,  1893.  "Transactions  of  the  Association  of  American  Physicians,"  by  Francis  P.  Kinnicutt,  James 
J.  Putman,  M.  Allen  Starr,  W.  Oilman  Thompson,  and  William  Osier;  to  the  "Atlas  of  Clinical  Medicine," 
by.Byrom  Bramwell.  for  admirable  illustrations;  and  to  the  exhaustive  article  on  "Myxedema"  by  George 
R.  Murray,  of  Newcastle.  England,  in  the  "Twentieth  Century  Practice  of  Medicine,"  vol.  iv.,  1895.  Also 
to  an  address  by  Victor  Horsley  on  the  "Physiology  and  Pathology  of  the  Thyroid  Gland,  published  in 
the  "British  Medical  Journal,"  December  5,  1896. 

1  Von  Eiselberg's  experiments  were  made  chiefly  on  cats. 


676  DISEASES  OF  THE  DUCTLESS  GLANDS 

lose  their  natural  shape,  and  were  described  by  Gull  as  "spade-like";  the 
feet  are  also  misshapen;  the  gait  is  slow  and  labored.  The  tnind  is  feeble, 
slow  in  its  action,  memory  is  poor,  while  irritability  and  suspicion  are  added 
qualities,  and  sometimes  there  are  delusions  and  hallucinations,  ultimately 
often  dementia.  The  organic  functions  are  fairly  well  performed.  Atrophy 
of  the  optic  nerve  is  a  rare  but  possible  symptom,  also  synovitis  from  trifling 
causes.  Subnormal  temperature  is  characteristic,  though  in  early  stages 
the  temperature  may  be  normal  or  slightly  above.  In  winter  the  patient 
always  feels  cold  and  hugs  the  stove.  The  course  of  the  disease  is  slow, 
and  the  patient  tisually  dies  of  some  intercurrent  affection  unless  proper 
treatment  is  instituted.  Mild  cases  are  not  rare  and  are  frequently  over- 
looked.    A  paper  by  Pittfield  of  Philadelphia  well  describes  the  condition. 

2.  Myxedema  Associated  with  Cretinism,  Congenital  or  Acquired. — 
(Cretinoid  idiocy:  Idiotic  avec  cachexie  pachydermique.)  Cretinism 
is  a  form  of  idiocy  associated  with  absence  of  the  thyroid  or  with  a  func- 
tionless  thyroid.  It  is  myxedema  in  childhood.  There  is  almost  complete 
arrest  of  mental  and  bodily  development.  The  cretin  is  a  dwarf.  In  the 
congenital  form,  there  is  congenital  absence  of  the  thjToid,  and  the  child 
is  further  characterized  by  its  thick  neck,  short  arms  and  legs,  and  prominent 
belly.  The  face  is  large,  the  lips  are  thick,  and  the  tongue  is  large  and 
often  protruding,  the  hair  is  thin  and  stiff.  All  the  bones  of  the  skeleton 
are  short  and  broad,  the  epiphyses  swollen,  but  not  ossified.  The  skull  is 
short  and  broad,  and  the  basosphenoid  junction  early  ossified.  The  cretin 
resembles  the  rickety  child,  and  may  be  confounded  with  it,  but  the  bone 
changes  are  entirely  different. 

Acquired  cretinism  may  start  before  birth  and  be  barely  appreciable 
at  birth.  More  frequently  the  infant  appears  normal  at  birth,  and  the 
changes  make  their  appearance  between  the  second  and  fifth  years.  The 
arrest  of  development  continues,  or,  rather,  there  is  very  slow  development, 
so  that  at  adult  age  the  man  or  woman  does  not  exceed  in  stature  a  child 
of  from  five  to  seven  years.  The  myxedemic  symptoms  are  similar  to 
those  described  in  pure  myxedema. 

From  the  fact,  however,  that  the  disease  may  start  to  develop  later 
than  infancy,  there  results  a  series  of  types  intermediate  between  those 
represented  by  congenital  and  adult  cretinism.  This  arrest  of  mental  and 
physical  development  is,  of  course,  greater  the  earlier  the  disease  begins 
to  develop;  whence  two  cretins  of  the  same  age  will  differ  materially  if 
one  has  commenced  to  develop  at  or  before  birth,  and  the  other  not  until 
seven  or  eight  years  of  age. 

True  congenital  cretinism — that  is,  cretinism  which  is  evident  at  birth — 
is  very  rare.  Some  cases  of  anchodroplasia  may  have  been  diagnosed 
cretinism.  In  most  cases,  the  child  does  not  long  survive  its  birth.  In 
another  form  described  by  Horsley  the  disease  s  supposed  to  begin  shortly 
before  birth,  but  develops  slowly,  so  that  at  birth  it  had  not  attained  the 
degree  incompatible  with  life,  and  the  child  can  live.  In  this  there  is  usually 
a  goiter  at  birth. 

Cretinism  may  be  endemic,  as  in  some  parts  of  the  continent  of  Europe; 
or  sporadic,  as  m.  England,  and  America  as  well.  The  sporadic  cases  are, 
as  a  rule,  without  goiter,  the  thyroid  glands  being  either  imdeveloped  or 


MYXEDEMA  677 

atrophied,  while  one-third  also  of  the  endemic  cretins' are  without  goiter. 
In  either  event,  the  gland  is  functionally  dead,  even  though  it  may  appear 
natural  in  size,  the  original  true  gland  tissue  having  been  replaced  by  an 
indifferent  element.  Endemic  cretinism  occurs  in  localities  where  goiter 
is  also  endemic — in  the  shut-up  valleys  of  mountainous  districts  of  Europe 
and  Asia,  to  which  it  is  confined.  At  one  time — in  1847 — a  number  of 
cases — some  24  out  of  a  population  of  350 — prevailed  in  Cheselborough, 
Somerset,  England,  but  the  disease  has  died  out.  The  endemic  form  is 
commonly  ascribed  to  the  use  of  certain  drinking  water,  but  no  responsible 
constituents  have  been  isolated.  The  child,  being  normal  at  birth,  remains 
so  until  the  change  begins  in  the  thyroid,  when  it  becomes  less  lively,  de- 
velopment is  arrested,  and  the  conditions  described  on  page  676  slowly 
develop.  The  cretin  may  reach  the  age  of  30  or  40  years,  but  ceases  to 
change  after  the  20th  year,  whether  the  case  be  sporadic  or  endemic. 

3.  Operative  Myxedema  or  Cachexia  Strumipriva. — By  this  is  meant 
a  condition  of  myxedema  the  result  of  removal  of  the  thyroid.  It  is  more 
likely  to  follow  total  than  partial  removal  of  the  thyroid,  but  does  not 
follow  every  case,  having  been  observed  in  69  out  of  468  cases.  Cases  of 
operative  myxedema  are  very  rare  in  this  country. 

Diagnosis. — This  is  easy.  The  edema  of  Bright's  disease  or  heart 
disease  may  be  confounded,  especially  as  albuminuria  and  casts  are  some- 
times present  in  myxedema;  but  the  peculiar  fiat  face,  the  absence  of 
pitting  on  pressure,  and  of  the  signs  of  heart  disease  are  distinctive  features 
of  myxedema,  and  will  not  be  overlooked  by  those  familiar  with  the 
condition.  Certain  forms  of  idiocy,  however,  may  easily  be  mistaken,  as 
may  achondroplasia.  Achondroplasia  is,  however,  characterized  by  a 
bright  intellect. 

Prognosis. — This  was  rega'rded  as  unfavorable  until  the  use  of  thyroid 
extract  was  suggested  by  George  R.  Murray,  of  Newcastle,  England,  in 
187 1,  based  upon  the  satisfactory  effect  obtained  by  Bettencourt  and 
Verrano,  in  1890,  in  ingrafting  sheep's  thyroid  in  human  subjects  having 
myxedema,  the  idea  being  in'  this  manner  to  substitute  the  juice  or  secretion 
of  the  gland.  Every  expectation  was  realized.  In  1892,  Howitz,  of  Copen- 
hagen, and  soon  after,  E.  L.  Fox  and  H.  Mackenzie,  in  England,  substi- 
tuted for  the  hypodermic  use  the  administration  of  the  gland  itself  or  some 
preparation  of  it  by  the  mouth.  At  the  present  day,  the  effects  of  the  admin- 
istration of  thyroid  preparations  in  myxedema  are  among  the  marvelous 
results  of  medicine. 

Treatment. — The  treatment  at  the  present  day  is,  therefore,  solely  by 
preparations  of  the  thyroid  gland.  The  gland  is  best  administered  in  the 
shape  of  tablets  of  the  dessicated  gland.  A  small  dose  must  be  first  given, 
one  grain,  three  times  a  day  and  its  effect  carefully  watched.  If  no  effect 
follows,  the  dose  should  be  doubled,  and  further  increased  if  necessary. 
As  improvement  takes  place,  smaller  doses  shotdd  be  given  at  longer 
intervals,  until  finally  one  grain  of  the  gland  is  gi'ven  once  a  day.  During 
the  first  week  the  patient  should  be  watche.d  with  a  view  to  guarding  against 
overaction  of  the  remedy — great  emaciation,  diarrhea,  vomiting  arid  tremor, 
in  a  word  hyperthyroidism  may  occur  from  overdoses. 

The  myxedema  being  removed,  it  is  necessary,  of  course,  to  continue 


678  DISEASES  OF  THE  DUCTLESS  GLANDS 

the  treatment  in  this  second  stage  by  such  doses  as  will  maintain  the  cure, 
for  it  is  to  be  understood  that,  as  the  thyroid  is  still  functionless,  the 
omission  of  the  treatment  is  followed,  sooner  or  later,  by  its  return.  The 
quantity  required  varies  in  different  cases,  but  it  is  found  to  range,  the  more 
precise  dose  being  determined  by  trial.  A  single  daily  dose  is  preferred  by 
Murray  to  a  smaller  dose  more  frequently  repeated.  A  fall  of  temperature 
below  normal,  a  slight  return  of  swelling  or  of  other  symptoms,  indicate 
that  too  small  a  dose  is  being  given,  while  acceleration  of  the  pulse  indicates 
that  the  dose  should  be  reduced.  In  a  climate  not  subject  to  great  varia- 
tions the  same  dose  may  be  given  the  year  round.  In  hot  weather  a  smaller 
dose  suffices  than  in  cold,  and  a  dose  that  has  been  found  sufficient  during 
the  summer  may  not  be  enough  in  the  winter. 

The  results  of  treatment  in  cretinism  are  as  marvelous  as  in  myxedema. 
They  include  not  only  the  removal  of  the  hideous  deformity  and  the  restora- 
tion of  intellect,  but  also  an  increase  in  height.  A  case  under  observation 
was  corrected  from  a  drivelling  idiot  at  3  years  to  a  bright  boy  at  10  years  of 
age.  The  earlier  treatment  is  commenced,  the  more  prompt  and  marked 
is  its  eflect.  It  is  useless  if  the  child  is  many  years  old  before  the  treatment 
is  begun.      The  treatment  must  be  continued  through  life. 

DISEASES  OF  THE  PARATHYROID  GLANDS. 

The  discovery  of  the  parathyroid  glands  has  opened  a  new  field  of  phys- 
iological and  pathological  study  which  has  not  yet  been  completely 
explored.  There  are  two  pairs  of  these  little  glands  on  each  side  of  the 
lateral  lobes  of  the  thyroid,  ovoid  in  shape  and  6  to  8  mm.  in  length.  They 
secrete  an  important  internal  secretion  supplementing  that  of  the  thyroid 
gland  and  controlling  calcium  metabolism.  The  latter  is  established  by 
their  extirpation,  which  is  followed  by  severe  muscular  spasm,  paralysis, 
dyspnea  and  death,  counteracted  sometimes  by  intravenous  injection  of 
parathyroid  extract  or  by  the  transplantation  of  parathyroid  structures 
or  even  their  ingestion  by  mouth.  Their  secretions  maj'  be  harmonic 
to  secretions  of  other  duetless  glands.  Although  various  spasmodic 
derangements  are  ascribed  to  deranged  functions  of  these  glands,  tetany 
is  the  only  one  whose  symptoms  are  sufficiently  traceable  to  justify  its 
classification  under  the  heading  of  disorders  of  the  parathyroids. 


TETANY. 

Synonyms. — Tetanilla;    Intermittent    Tetanus;    Hypoparathyreosis;    Status 
Parathyreoprivus;  Contracture  des  nourrices. 

Definition. — A  condition  of  deranged  metabolism  exhibiting  continu- 
ous or  intermittent  tonic  spasm  of  the  extremities,  usually  symmetrical, 
but  occasionally  confined  to  one  limb,  rarely  even  becoming  general. 
It  is  due  to  disease  of  the  parathyroid  gland  or  insufficiency. 

Etiology. — Tetany  must  now  be  ascribed  to  deranged  function  of  the 
parathyroid  glands.     It  occurs  in  children  and  in  adults. 

Tetany  in  Adults. — Among  possible  predisposing  causes  may  be  men- 


TETANY  679 

tioned  digestive  derangement,  dilatation  of  the  stomach,  hyperchlorhydria, 
and  diarrhea;  rheumatism,  whence  this  form  is  sometimes  called  rheumatic 
tetany;  open  wounds;  laceration.  Pregnancy,  acute  fevers,  and  diphtheria 
are  also  alleged  causes.  What  relations  these  conditions  just  metioned  have 
with  parathyroid  disease  is  unknown.  It  has  been  suggested  that  gastric 
tetany  and  that  of  the  infectious  fevers  is  connected  with  disturbance  of 
calcium  metabolism.  Its  presence  in  nursing  women,  as  pointed  out  by 
Trousseau,  may  have  to  do  with  the  drain  of  calcium  in  the  formation  of 
milk  which  is  rich  in  calcium,  and  in  pregnancy  with  the  formation  of  the 
bones  of  the  child.  The  analyses  of  MacCallum  tend  to  confirm  this 
explanation. 

Postoperative  Tetany. — The  effect  of  removal  of  the  parathyroid  glandules 
in  producing  tetany  is  well  known.  A  few  days  after  the  parathyroids  have 
been  removed  the  patient  is  seized  with  severe  convulsions  of  spasmodic 
type — coma  and  death. 

Infantile  tetany  occurs  in  rickets,  in  digestive  diseases,  and  is  character- 
ized by  the  usual  spasms — by  laryngismus  stridiilus. 

Symptoms. — The  characteristic  spasm  is  usually  limited  to  the  hands 
and  feet,  arms  and  legs.  In  the  hands  the  thumbs  are  flexed  into  the 
palms,  the  fingers  firmly  bent  at  the  metacarpophalangeal  articulation, 
but  straight  elsewhere.  The  fingers  are  adducted,  the  ring  and  middle 
fingers  sometimes  overlapping.  The  wrists  are  flexed,  the  elbows  bent, 
and  the  arms  folded  over  the  chest.  The  hand  is  described  as  the  ob- 
stetrical hand,  from  the  position  caused  by  the  cramp.  In  the  lower 
limbs  the  knees  and  hips  are  stiff  and  extended,  the  feet  extended,  and  the 
toes  adducted.  Sometimes  there  is  dorsal  flexion  of  the  foot  and  flexion  at 
the  knee.  Contractions  may  last  from  a  few  hours  to  several  days.  The 
term  continuous  may  be  applied  to  those  cases  in  which  the  contractions 
have  lasted  uninterruptedly  for  over  two  days,  and  intermittent  when  they 
do  not  last  longer  than  two  days  without  permanent  or  temporary  disap- 
pearance. Following  this  standard,  Griffith  found  38  cases  intermittent 
and  25  continuous.  The  spasm  is  always  associated  with  tenderness  or 
pain,  the  latter  being  often  extreme.  At  other  times  these  symptoms  are 
present  only  in  the  beginning  of  the  attack  or  when  the  members  are  handled. 
Rarely  the  muscles  of  the  back,  neck,  and  face  are  involved;  and  there  may 
be  trismus,  the  angles  of  the  mouth  being  drawn  out. 

Associated  symptoms  are  stridulous  respiration,  laryngismus  stridulus, 
regarded  by  some  as  an  essential  part  of  the  disease. 

Further  interesting  phenomena,  especially  studied  and  called  cardinal 
symptoms,  are  contraction  caused  by  tapping  over  nerve  trunk,  as,  for  example, 
the  facial  nerve,  known  as  Chvostek's  symptom.  Another  is  Trousseau's 
symptom — the  production  of  spasm  by  pressure  upon  a  large  artery  or  nerve, 
especially  in  the  arm;  and  still  another  is  Erb's  symptom — increased  elec- 
trical excitability.  Inability  to  urinate  may  be  present,  and  anesthesia  has 
been  recorded  among  symptoms.  There  may  be  slight  elevation  of  tem- 
perature and  frequent  pulse. 

Diagnosis. — The  rarity  of  this  disease  sometimes  causes  it  to  be  over- 
looked, while  differences  of  view  as  to  what  constitute  its  essential  symp- 
toms  also   cause   a   different   diagnosis.     Thus,    some  would   exclude  the 


680  DISEASES  OF  THE  DUCTLESS  GLANDS 

carpopedal  spasm  of  children;  while  Gowers,  Dana,  and  Griflith  include 
these  cases  under  tetany.  Many  cases  of  mild  spasm  succeeding  gastro- 
intestinal irritation  and  the  like  would  be  regarded  by  some  as  tetany  and 
by  others  not.  It  possesses  nothing  in  common  with  tetanus,  whose  name  it 
so  closely  resembles,  but  whose  symptoms  are  totally  different. 

Prognosis. — This  varies  with  the  cause.  Operative  cases  are  mostly  fatal 
if  not  treated  by  parathyroids.  Cases  due  to  gastric  dilatation  are  fatal  un- 
less the  gastric  condition  be  operated  upon.  The  fatal  cases  are  those 
associated  with  dilated  stomach,  gastric  carcinoma,  and  thyroidectomy. 
The  disease  has  a  marked  tendency  to  return,  and  is  most  common  in  late 
winter  and  early  spring. 

Treatment. — In  postoperative  tetany  the  immediate  grafting  of  para- 
thyroids and  the  feeding  of  parathyroid  tissue  shoxdd  be  begun  at  once. 
The  cause  of  the  condition  shovdd  be  sought  and,  if  possible,  eliminated. 
After  this,  remedies  calculated  to  diminish  nervous  excitability  should  be  ad- 
ministered; also  wholesome  hygienic  measures  availed  of,  including  massage, 
passive  motion,  and  electricity.  Warm  baths  are  especially  recommended. 
The  cases  attended  with  severe  pain  may  reqture  the  hypodermic  use  of 
morphin,  and  delayed  response  to  the  latter  ma}'  even  demand  chloroform 
inhalation. 

The  rational  treatment  of  tetany  includes  any  measure  which  will  restore 
the  function  of  the  parathyroids.  Parathyroid  may  be  administered  by 
the  mouth,  but  the  effect  is  found  to  continue  only  so  long  as  the  adminstra- 
tion  is  continued.  The  hypodermic  injection  of  a  serum  from  the  same 
source  promises  more  permanent  results,  but  most  promising  of  all  is  the 
transplantation  of  the  parathj^roid  itself,  as  suggested  by  Pays  and  re- 
peated by  Halsted.  Conforming  to  what  has  been  said  at  the  outset  of  the 
consideration  of  this  subject,  calcium  should  be  effective.  Calcium  lactate 
is  given  in  doses  of  1 5  grains  (one  gram)  every  three  or  four  hours.  Lavage 
with  saline  solutions.  The  bromids  may  be  serviceable  and  in  extreme 
cases  chloroform  anesthesia  may  be  necessary'-.  When  the  condition  is  due 
to  gastric  dilatation  the  cases  should  at  once  be  operated  upon  by  gastro- 
jcjimostomy. 

NEOPLASMS  OF  THE  THYROID. 

The  thyroid  is  subject  to  a  variety  of  morbid  groi,\i;hs,  among  which 
may  be  mentioned : 

1.  Adenoma,  which  occurs  as  an  encapsiolated  growth,  varying  con- 
siderably in  size.  There  may  be  nodules  in  both  lobes.  Metastases  of 
growi;hs  resembling  thyroid  tissue  are  reported  to  have  been  found  in  the 
lungs  and  bones  of  the  body. 

2.  Primary  medullary  cancer,  as  a  rare  growth  with  a  tendency  to  invade 
the  trachea  and  esophagus,  developed  from  the  epithelial  cells  of  the  follicles. 
Secondary  cancer  has  also  been  reported. 

3.  Tuberculosis,  always  supposed  to  be  a  possible  but  rare  disease,  has 
been  found  by  Chiari  in  seven  out  of  100  postmortems  on  persons  who  had 
had  tuberculosis.     Bruns  refers  to  sLx  cases  of  tuberculous  goiter. 

4.  Syphilis,  including  gummas.     5.  Hydatid  disease.     6.  Actinomycosis. 


ADDISON'S  DISEASE  681 

5.  Abscess  of  the  thyroid  is  an  occasional  event. 

The  treatment  of  these  abnormalities  is  surgical,  except  in  the  case  of 
tuberculosis  and  syphilis,  which  demand  the  usual  antitubcrculous  and 
antisyphilitic  remedies. 


DISEASES  OF  THE  SUPRARENAL  CAPSULES. 

ADDISON'S  DISEASE. 

Definition. — A  term  applied  to  any  degenerative  disease  of  the  suprarenal 
capsules,  especially  tuberculosis,  atrophy  and  carcinoma  attended  with  pig- 
mentation of  the  skin.  It  is  associated  also  with  asthenia  of  the  muscular 
and  vascular  system. 

Etiology. — Its  etiology  is  obscure,  being  that  of  the  morbid  states  consti- 
tuting its  morbid  anatomy.  Blows  on  the  abdomen  or  back  have  preceded 
it,  so  has  Pott's  disease,  and  numerous  other  events  which  may  or  may  not 
have  been  causal.     It  occurs  1 19  times  in  men  to  64  times  in  women. 

Morbid  Anatomy. — This  includes  (i)  tuberculosis  with  fibrocaseous  and 
calcareous  degeneration — the  most  frequent  lesion;  (2)  cystic  degeneration; 
(3)  fatty  degeneration;  (4)  simple  atrophy;  (5)  chronic  interstitial  inflamma- 
tion which  may  lead  to  atrophy;  (6)  malignant  disease,  including  carcinoma 
and  sarcoma;  (7)  hemorrhagic  extravasations;  (8)  embolism. 

Pathology. — Its  pathology  is  as  obscure  as  its  etiology.  Experiment 
helps  us  only  to  this  extent,  that  removal  of  the  suprarenals  in  animals 
causes  death  by  progressive  weakness  and  toxemia.  The  cortex  of  the  supra- 
renal capside  is  composed  of  epithelial  elements,  the  medvdla  of  a  mesh  work 
containing  nerve  cells,  nonmedullated  nerve  fibers  and  certain  polymorphous 
cells  known  as  "chromaffin"  cells — cells  which  take  a  brownish  pigmenta- 
tion in  solution  of  chromic  acid.  These  cells  are  also  found  outside  of  the 
adrenals  in  the  ganglia  of  the  abdominal  sympathetic,  in  the  carotid  glands, 
in  the  coccygeal  gland,  the  parovarium,  the  epididymus,  and  along  the 
course  of  the  aorta.  Collectively  these  elements  are  known  as  the 
"chromaffin  system." 

The  special  function  of  the  medvdla  in  which  the  "chromaffin"'  system 
shares  is  to  distill  an  internal  secretion,  epinephrin,  whose  purpose  is  to 
stimulate  the  nervous  mechanism  regulating  blood  pressure  and  pigmenta- 
tion— to  play,  in  a  word,  the  role  of  hormone.  And  thus  is  explained  the 
muscular  and  vascular  asthenia,  and  excessive  pigmentation  incident  to 
disease  of  the  suprarenals,  and  the  arterial  scleroses  which  follows  upon 
the  intravenous  injection  of  epinephrin.  The  glycosuria  resulting  from 
such  injections  may  be  due  to  an  inhibiting  effect  on  the  pancreatic 
function  in  glucose  metabolism. 

Less  is  known  of  the  function  of  the  cortex.  Some  influence  on  the 
sexual  function  is  suggested  pro  and  con,  according  as  the  activity  of  the 
secretion  is  increased  or  diminished.  In  pregnant  rabbits  the  cortex  became 
twice  as  thick  as  in  the  nonpregnant  state.  It  has  been  suggested,  too,  that 
the  cortex  produces  a  product  which  influences  nitrogenous  metabolism 
favorably,  preventing  auto-intoxication  or  favoring  it  by  absence. 

Symptoms. — Some  of  these  morbid  states  appear  to  be  totally  without 


682  DISEASES  OF  THE  DUCTLESS  GLANDS 

symptoms,  the  conditions  having  first  come  to  light  at  autopsy.  Other 
symptoms  may  be  produced  by  any  of  them,  and  there  are  none  distinctive 
for  any  one  state.     They  include: 

Pigmentation  or  bronzing  of  the  skin.  This  was  first  noted  by  Addison 
as  accompanying  lesions  of  the  suprarenal  capsules,  and  such  assocnation 
thus  constituted.  Addison's  disease  since  the  publication  of  his  paper 
in  1885.  It  is  a  disease  of  adults,  being  rare  under  35  years.  The  lesion 
of  the  suprarenal  most  frequently  thus  associated  is  the  fibrocaseous 
tuberculous  one.  But,  as  stated,  the  pigmentation  may  accompany  any 
one  of  the  above-named  lesions,  or  it  may  be  absent.  As  to  the  color 
itself,  usually  the  first  symptom  to  attract  attention,  it  ranges  from 
light  yellow  to  deep  brown,  and  even  almost  black.  It  is  deeper  on  the 
more  exposed  parts  of  the  body,  where  the  normal  pigmentation  is  greater, 
and  therefore  is  commonly  first  seen  on  the  face  and  hands.  In  rare  in- 
stances only  is  it  general.  It  is  associated  at  times  with  unpigmented 
patches — leukoderma.  It  is  noticeable  also  at  times  on  the  mucous  mem- 
brane of  the  mouth,  conjunctiva,  and  vagina,  and  very  rarely  even  upon 
serous  membranes  in  patches. 

As  stated,  there  are  no  other  symptoms  which  are  distinctive  of  any 
one  of  the  lesions  of  the  suprarenal  capsule  described,  but  among  those 
which  are  more  or  less  constantly  present  are  rapid  cardiac  action,  anemia 
extreme  debility  and  general  languor,  irritability  of  the  stomach,  and  quite  often 
diarrhea.  The  irritability  of  the  stomach  is  manifested  by  anorexia,  nausea, 
and  vomiting,  and  may  be  a  verj^  early  symptom.  The  heart's  action  is 
feeble,  the  pulse  correspondingly  small  and  rapid,  the  blood  pressure  is  low. 
A  case  in  a  man  the  pidse  was  130  and  feeble.  There  is  also  often  a  tendency 
to  fainting.  There  is  dyspnea.  It  will  be  remembered  that  this  symptom 
attends  the  asthenia  and  death  succeeding  removal  of  the  adrenals  in  ani- 
mals. At  other  times  there  is  headache.  Mental  hebetude  goes  pari  passu 
wth  bodily  weakness,  while  the  o.ther  symptoms  commonly  associated  with 
the  latter  condition  are  also  present — namely,  dizziness  and  ringing  in  the 
ears.  Ultimately,  the  asthenia  becomes  so  profound  that  the  patient  cannot 
rise,  but  keeps  his  bed,  growing  weaker  and  weaker,  until  he  dies  of  sheer 
exhaustion.     Sometimes  there  are  convulsions,  possibly  due  to  brain  anemia. 

The  urine  is  usually  normal,  although  occasionally  there  is  polyuria, 
and  sometimes  the  urinary  pigments  have  been  found  increased. 

Diagnosis. — Pigmentation  alone,  at  least  unless  it  be  very  decided  and 
general,  is  never  sufficient  to  justif}'  a  diagnosis  of  suprarenal  disease,  since 
other  abdominal  afi'ections  are  known  to  produce  a  similar  condition. 
Among  these  are  tuberculosis  of  the  peritoneum,  cancer  and  lymphoma; 
pregnancy,  uterine  and  even  hepatic  disease.  In  the  hardening  of  the  liver 
sometimes  associated  with  diabetes,  pigmentation  has  been  noticed.  All 
these  facts  go  to  show  that  the  nervous  system  must  have  some  powerful 
influence,  supporting  the  second  theory.  The  same  testimony  is  afforded 
by  the  pigmentation  which  attends  exophthalmic  goiter.  Protracted  filthiness 
and  vagabondism  also  produce  discoloration  of  the  body  which  is  not  dis- 
tinguishable per  se  from  that  of  Addison's  disease.  Deep  general  pigmenta- 
tion has  been  found  associated  with  melanotic  cancer.  Finally,  pigmenta- 
tion is  sometimes  the  result  of  the  prolonged  administration  of  arsenic.     It  is 


ADDISON'S  DISEASE  683 

well,  therefore,  to  seek  carefully  for  signs  and  symptoms  other  than  pigmen- 
tation before  a  diagnosis  is  made.  In  the  case  of  our  own  referred  to,  there 
were  pulmonary  tuberculosis  and  tuberculous  disease  of  the  spine,  with  pig- 
mentation and  asthenia,  on  which  was  based  the  diagnosis  of  Addison's 
disease,  confirmed  by  autopsy.  Certain  cases  of  hypopituitarism  reported 
by  Gushing,  closely  resemble  Addison's  disease. 

Prognosis. — In  a  well-determined  case  of  Addison's  disease,  as  might 
be  inferred  from  the  nature  of  the  causes,  recovery  is  impossible,  though 
the  course  of  the  disease  is  commonly  prolonged  and  improvement  may  take 
place.  In  a  few  cases  only  is  the  course  rapid.  From  i8  months  to  several 
years  usually  cover  the  duration. 

Treatment. — This  is  principally  symptomatic.  We  aim  to  restore 
the  condition  of  the  blood,  and,  of  course,  above  all,  iron  is  indicated. 
It  may  be  associated  with  that  other  tonic  so  constantly  used  with  iron 
especially — arsenic.  An  excellent  preparation  of  arsenic  is  the  solution  of 
the  chlorid,  which  is  as  good  as  Fowler's  solution  and  mixes  well  with  the 
chlorid  of  iron.  The  doses  are  the  same  as  those  of  Fowler's  solution — 
from  3  to  s  minims  (0.18  to  3  c.c);  or  the  iron  and  arsenic  may  be  given  in 
pill  form  as  the  carbonate  of  iron  and  arsenious  acid,  and  to  this  strychnin 
,  may  be  convenientl}^  added.  If  very  asthenic,  the  patient  should  be  kept  in 
bed  and  fed  with  nutritious,  easily  assimilable  food,  of  which  peptonized 
milk  and  broths,  beef-juice,  cod-liver  oil,  and  glycerin  are  the  type.  The 
diarrhea  should  be  treated  as  other  diarrheas,  with  bismuth  and  other 
remedies.  For  the  nausea  the  usual  gastric  sedatives,  including  ice,  car- 
bonic acid  water,  champagne,  milk  and  lime-water  in  small  doses,  koumiss, 
whey,  and  the  like  are  suitable,  massage  may  be  helpful. 

With  the  knowledge  which  has  grown  out  of  the  treatment  of  myx- 
edema with  thyroid  extract,  no  treatment  of  the  combination  of  symptoms 
known  as  Addison's  disease  would  be  complete  without  the  administration 
of  some  similar  preparation  of  the  adrenal  gland.  There  have  been  prepared 
an  extract  in  the  shape  of  the  tincture,  a  powder  and  a  glycerin  extract; 
and  the  glands  are  eaten  fresh  or  dried.  The  equivalent  of  two  a  day  is 
recommended.  Of  the  powder,  3  to  5  grains  (0.2  to  0.3  gm.)  are  given  three 
or  four  times  a  day.  At  the  present  day,  solution  of  adrenalin  i-iooo  would 
be  employed  in  doses  of  from  5  to  15  minims  or  more.  In  an  analysis  by 
E.  W.  Adams  of  97  cases,  treated  by  suprarenal  extract,  there  was  seeming 
permanent  relief  in  16.  In  two  cases  treated  at  the  Johns  Hopkins  Hospital, 
one  died  of  an  acute  infection  after  all  severe  symptoms  had  disappeared, 
and  at  the  autopsy  the  suprarenal  bodies  were  found  sclerotic.  The  remed}^ 
is  still  sub  judice,  and  as  the  disease  is  rare  some  time  must  elapse  before  its 
value  can  be  determined. 

OTHER  AFFECTIONS  OF  THE  SUPRARENAL  GLANDS. 

The  suprarenals  are  subject  to  hyperplasia  and  hypoplasia.  The  former 
occurs  in  association  with  chronic  nephritis  and  in  arterio-sclerosis. 
No  explanation  is  offered  of  the  former,  but  the  arteritis  may  be  due  to  an 
excess  of  the  internal  secretions  poured  into  the  blood  from  excess  of  func- 
tion.    Precocious  development  of    sexual    organs   has   been   found   with 


684  DISEASES  OF  THE  DUCTLESS  GLANDS 

hypertrophy  and  tumor.  A  case  has  just  been  reported  by  Henry  JumiJ 
of  Philadelphia.  Hypernephromata  are  frequent  tumor  formations. 
Hypoplasia,  absence  of  the  adrenals  or  their  medulla  is  found  associated 
with  anomalies  of  the  brain  and  low  blood  pressure.  The  latter  would  be 
a  natural  consequence  of  deficient  internal  secretion. 


DISEASES  OF  THE  SPLEEN. 

Most  of  the  morbid  states  of  the  spleen  which  possess  clinical  interest 
are  considered  in  connection  with  diseases  of  the  blood  and  with  malaria. 

Splenitis. — Splenitis  occurs  rarely  as  the  result  of  extension  of  inflam- 
mation from  a  neighboring  organ,  such  as  the  stomach,  perinephric  tissue, 
the  diaphragm  and  lungs,  or  as  the  consequence  of  injury. 

The  symptoms  are  tenderness  and  enlargement  in  connection  with  the 
inflammatory  conditions  of  adjacent  organs  referred  to,  and  it  is  upon  the 
association  of  such  symptoms  with  those  in  the  spleen  itself  that  the  diag- 
nosis depends. 

Perisplenitis. — This  may  occur  as  the  result  of  the  same  causes  as 
produce  splenitis,  and  may  be  recognized  by  the  presence  of  palpable  fric- 
tion fremitus.  It  may  be  suppurative  in  association  with  abscess  of  the 
spleen  giving  rise  to  one  form  cf  subphrenic  abscess. 

Abscess  of  the  Spleen. — Abscess  of  the  spleen  occurs  along  with 
pyemic  processes  elsewhere,  in  the  presence  of  the  usual  causes  of  pyemia. 
It  is  characterized  by  tenderness  and  enlargement.  A  remarkable  case 
associated  mth  suppurative  splenitis  occurred  in  the  wards  at  the  Pennsyl- 
vania Hospital,  after  metritis  following  criminal  abortion.  It  was  also 
associated  with  luxuriant  mitral  valvulitis.  Such  abscess  may  break  into 
the  stomach,  bowel,  or  lungs,  as  well  as  into  the  peritoneal  cavity. 

Rupture  of  the  Spleen. — This  arises  from  severe  injury,  also  from 
extreme  and  sudden  acute  hyperemia,  due  to  malignant  malaria,  and  from 
rapidly  growing  splenic  tumors.  The  symptoms  are  sudden  pain  in  the 
region  of  the  spleen,  collapse,  pallor,  and  death,  associated  with  the  causes 
named.    Conner  has  reported  a  case  in  typhoid  fever. 

The  Amyloid  Spleen. — This  appears  as  a  hard,  smooth,  and  enlarged 
organ,  associated  with  amyloid  disease  of  other  organs,  such  as  the  liver 
and  kidneys,  especially  when  there  has  been  long-continued  suppuration, 
as  in  hip  disease,  osteomyelitis,  tuberculous  consumption,  or  syphilis. 

Atrophy  of  the  Spleen. — On  the  other  hand,  the  spleen  may  be 
reduced  in  size  by  fibroid  overgrowth  and  contraction  due  to  syphilis. 

Hemorrhagic  Infarct  of  the  Spleen. — Infectious  hemorrhagic 
infarct  results  in  abscess  of  the  spleen.  The  noninfectious  is  the  result  of 
embolism  by  a  noninfectious  embolus  such  as  arises  from  the  cardiac  valves 
in  acute  or  chronic  endocarditis,  from  clots  in  the  cavities  of  the  left  ven- 


DISEASES  OF  THE  SPLEEN  685 

tricle,  or  from  clots  in  aneurj'sm  in  the  large  arteries.     After  the  kidney, 
the  spleen  is  the  most  frequent  seat  of  such  lodgment. 

Symptoms. — The  infarction  is  sometimes  ushered  in  b}'  chills,  vomiting, 
and  painful  enlargements,  the  true  nature  of  which  can  only  be  inferred 
when  the  causes  named  are  present  or  the  symptoms  of  embolism  elsewhere 
occur  simultaneously. 

Neoplysms  of  the  Spleen. — These  are  represented  most  frequently 
by  gummata,  which  are  almost  never  recognized  before  death.  Carcinoma, 
sarcoma,  and  tuberculosis  occur,  but 'are  not  recognizable  by  special  char- 
acters. A  nodular  and  uneven  spleen  may  be  regarded  as  due  to  cancer 
when  associated  with  cancer  elsewhere,  sarcomatous  when  there  is  general 
sarcoma,  tuberculous  if  there  is  tuberculosis  elsewhere,  and  syphilitic  if 
associated  with  the  hostory  of  syphilis,  especially  the  congenital  form. 

EcHiNOCOccus  OF  THE  Spleen. — The  spleen  may  present  a  fluctuating 
tumor  the  nature  of  which  can  only  be  determined  by  the  certain  knowledge 
that  a  tumor  of  the  same  kind  exists  elsewhere,  or  by  the  recognition  of 
hooklets  in  the  aspirated  fluid.  Shoiild  the  fluctuating  tumor  be  associated 
with  chills  and  fever,  it  is  more  likely  to  be  abscess,  which,  it  is  to  be  re- 
membered, may  also  begin  as  echinococcus  disease  which  later  takes  on 
suppiu-ation. 

Wandering  Spleen. — This  is  a  term  applied  to  a  condition  of  the  spleen 
analogous  to  the  movable  kidney  and  liver.  It  is  the  direct  result  of  an  elong- 
ation of  the  gastrosplenic  ligament  and  splenic  artery  and  vein.  Under 
these  circumstances  the  usual  splenic  dullness  in  the  midaxillary  line,  be- 
tween the  ninth  and  eleventh  ribs  has  disappeared,  and  the  spleen  can 
usually  be  felt  elsewhere  in  the  abdominal  cavity,  usually,  however,  on  the 
side  below  its  normal  site,  whence  it  ma}''  be  pushed  into  the  natural  situation 
to  leave  it  immediately  as  the  upright  position  is  assumed.  Rarely,  it  is 
found  in  more  distant  situations,  even  in  the  pelvis.  At  times  it  may  form 
attachments  by  inflammatory  adhesion  in  the  new  situations,  making  its 
restoration  difficult  or  impossible. 

Symptoms. — The  symptoms  are  not  unchanging.  The  most  constant 
is  a  dragging  sensation,  while  there  may  also  be  the  effects,  of  pressure,  which 
vary  with  the  situation.  There  may  be  pressure  on  the  ureter  or  bladder, 
causing  difficiilty  in  micturition;  upon  the  bowel,  causing  partial  obstruction 
or  pain  from  compression  of  sensitive  parts.  The  same  train  of  nervous 
symptoms  which  attends  floating  kidney  may  also  be  present. 

Diagnosis. — Some  difflcultj^  of  diagnosis  may  result  in  consequence  of 
such  vagueness  of  symptoms.  There  may  be  a  question  between  the  exist- 
ence of  wandering  spleen  and  fecal  tumor.  With  the  former,  the  normal 
splenic  dullness  is  wanting,  though  the  well-known  fact  that  the  dullness  is 
sometimes  very  small  in  health  may  give  rise  to  error.  A  freely  movable 
cancer  of  the  pylorus,  a  tumor  so  movable  that  it  may  be  felt  in  the  left 
hypochondrium,  may  occasion  similar  difficulty,  which  must  be  settled  in 
the  same  way.  And  so  with  other  abdominal  tumors  of  movable  nature — 
the  normal  splenic  dullness  remains.  The  question  as  to  whether  a  movable 
organ  is  the  spleen  or  kidney  is  not  likely  to  be  a  knotty  one,  even  if  the  mov- 


686  DISEASES  OF  THE  DUCTLESS  GLANDS 

able  kidney  be  the  left,  if  the  same  guide  be  availed  of.  The  difference  in 
outline  of  the  two  organs  may  be  recognized  in  persons  w4th  thin  abdominal 
walls,  and.  in  rare  instances,  by  the  splenic  notch.  The  possible  coexistence 
of  a  movable  spleen  and  a  movable  kidney  is  to  be  remembered. 

Treatment. — ^The  treatment  must  consist  of  mechanical  measures  to 
keep  the  spleen  in  place.  Surgery  must  frequently  be  employed.  They 
are  variously  successful. 

DISEASES  OF  THE  PITUITARY  BODY. 

The  pituitary  body  or  hypophosis  cerebri  is  a  ductless  gland  seated  in  the 
cella  turcica.  According  to  Gushing  "it  arises  from  an  epithelial  pouch 
which  buds  off  from  the  roof  of  the  bticcopharyngeal  cavity.  This  pouch 
meets  and  partly  envelops  a  corresponding  prolongation  (infundibular) 
from  the  adjoining  base  of  the  anterior  cerebral  vesicle,  the  tip  of  which 
becomes  thickened  into  the  infundibular  body  (neurohypophysis,  or  pars 
nervosa).  By  the  subsequent  formation  of  the  sphenoidal  bone  the  lumen 
of  practically  all  of  Rathke's  diverticulum  except  its  tip  becomes  obliterated. 
This  unobliterated  tip  of  the  pouch  comes  to  enfold  the  infundibular  body 
as  a  ball  is  held  in  a  catcher's  mitten,"  and  thus  the  pituitar>^  body  is 
formed.  It  is  composed  of  two  lobes,  a  larger  anterior  and  a  smaller  pos- 
terior, the  two  lobes  being  united  by  an  isthmus.  The  larger  anterior  lobe 
is  made  up  of  large,  granular,  epithelial  cells  arranged  in  columns  and  sur- 
rounded by  venous  spaces  into  which  the  secretion  is  discharged.  The 
smaller  posterior  lobe  is  mainly  nervous  in  composition  (pars  nervosa)  and 
invested  with  epithelial  cells.  The  secretion  of  this  lobe  is  thought  to  pass 
into  the  cerebrospinal  fiuid.  The  isthmus  also  contains  an  epithelium 
which  secretes  a  colloid  substance  like  that  of  the  th\Toid.  It  is  essential 
to  life  and  is  concerned  with  calcium  metabolism.  It  controls  the  growth 
of  the  skeletal  tissues,  bone  and  cartilage.  It  has  to  do  writh  the  develop- 
ment of  fat  and  holds  some  relationship  with,  other  ductless  glands,  especially 
the  thyroid,  adrenals  and  sexual  glands.  It  is  materially  influenced 
dviring  pregnancy  and  the  changes  induced  by  pregnancy  are  said  to  be 
permanent  so  that  from  them  it  can  be  averred  the  subject  has  been 
pregnant.  Like  the  adrenal  secretion  it  inhibits  the  pancreatic  secretion 
and  may,  therefore,  have  some  causal  relation  to  glycosuria.  It  increases 
blood  pressure  and  would  seem  to  cooperate  with  the  adrenals  but  antag- 
onize the  thjToid. 

Gushing  in  his  book,  "The  Pituitary  Body  and  Its  Disorders"  1913, 
re\aews  all  the  literature  and  has  the  most  recent  exposition  of  this  most 
interesting  condition.  He  classified  all  the  disorders  of  the  Pituitary  body 
under  the  name  Dyspituitarism.  This  author  divides  cases  based  upon 
experimental  e\ddence  and  the  obsen,'ation  of  fifty  odd  clinical  cases  as 
follows : 

Group  I. — Cases  of  dyspituitarism  in  which  not  only  the  signs  indicating 
distortion  of  neighboring  structures  but  also  the  symptoms  betraying  the 
effects  of  altered  glandular  activity  are  outspoken. 

Group  II. — Gases  in  which  the  neighborhood  manifestations  are  pro- 
nounced but  the  glandular  symptoms  are  absent  or  inconspicuous. 


DISEASES  Of  PirUITARY  GLAXD  687 

Group  III. — Cases  in  which  neighborhood  manifestations  are  absent  or 
inconspicuous  though  glandular  symptoms  are  pronounced  and  unmis- 
takable. 

Group  IV. — Cases  in  which  ob\'ious  distant  cerebral  lesions  are 
accompanied  by  symptomatic  indications  of  secondan,-  pituitary'  involve- 
ment. 

Group  V. — Cases  with  a  polyglandular  syndrome  in  which  the  functional 
disturbances  on  the  part  of  the  hypophysis  are  merely  one,  and  not  a  pre- 
dominant feature  of  a  general  involvement  of  the  ductless  glands. 

One  of  the  marked  results  of  Cushing's  studies  is  the  establishment  of 
the  fact  that  cases  which  are  affected  by  the  hyperacti\'it3-  of  the  glands  show 
first  the  result  of  this  overactivity  in  either  gigantism  or  acromegal3%  and 
then  later  develop  symptoms  indicative  of  hypoactivity  of  the  gland,  these 
becoming  mixed  cases. 

Inheritance  is  believed  to  have  a  certain  effect  which  makes  the  hyjjo- 
physis  susceptible  to  alterations  in  its  functional  activity. 

Traumatism  is  also  believed  to  have  a  marked  effect  upon  the  develop- 
ment of  certain  cases. 

Adolesence,  pregnancy ,  and  the  climacteric  are  also  believed  to  have  effect 
in  causing  changes  in  the  gland,  it  is  certain  that  in  pregnancy  there  is  a 
functional  hypertrophy  of  the  gland. 

He  divides  the  symptomatology  as  follows:  "(i)  Neighborhood  symp- 
toms, (2)  general  pressure  manifestations,  (3)  the  secreton,-  or  glandular 
symptoms  proper,  and  (4)  the  polyglandular  manifestations." 

Headaches  are  common,  severe  and  persistent. 

Deformity  of  the  sellatcursica  can  be  made  out  in  certain  cases  b}'  the 
X-ray.  Atrophy  of  the  optic  nerves  and  disturbance  of  the  fields  of  \'ision 
are  among  the  common  results  of  certain  tumors. 

Epistaxsis  and  marked  discharge  of  mucus  from  the  phars-n_x  often  sup- 
posed to  be  due  to  sinusitis. 

Acromelagy  and  gigantism  are  the  result  of  h^qDcrplasia  in  the  gland,  the 
former  after  adolesence  the  latter  when  young. 

Launois  and  Roy  say  "gigantism  is  acromegaly  in  indi^dduals  whose 
epiphyseal  cartilages  are  not  ossified,  whatever  maj'  be  their  age."  In  other 
words,  both  acromegaly  and  gigantism  are  the  same  condition  brought  about 
by  overactivity  of  the  gland  occurring  at  different  ages.  In  Cushing's 
words,  "The  disease,  in  short,  is  the  expression  of  a  fvmctional  instability  of 
the  pars  anterior,  doubtless  brought  about  by  some  underljdng  biochemical 
disturbance  which  leads  to  the  elaboration  of  a  perverted  or  exaggerated 
secretion  containing  a  hormone  that  accelerates  skeletal  gro'W'th  (the  long 
bones  if  epiphyseal  union  is  incomplete,  of  the  acral  parts  if  epiphyseal 
ossification  has  taken  place) .  Since  the  functional  disturbance  is  probably  a 
fluctuating  one,  with  periods  of  increase  and  remission,  epiphyseal  ossifica- 
tion may  occur  during  a  period  of  quiesence  in  the  disorder.  A  subsequent 
recrudesence  with  resumption  of  the  perverted  functional  acti^'it^'  mil  then 
serve  to  superimpose  acromegalic  manifestations  on  primary  gigantism. 
Acromegaly,  in  other  words,  cannot  precede  gigantism,  but  always  occturs,  as 
gigantism  which  has  become  acromegalized." 

Hypopituitarism  causes  skeletal  undergrowth  which  occurs  when  gland- 


688  DISEASES  OF  THE  DUCTLESS  GLANDS 

iilar  iiasufliciency  begins  before  the  fiill  stature  is  attained.  When  lack  of 
activity  begins  before  adolesence  the  skeleton  has  the  feminine  type. 

Adiposity  is  common  in  cases  where  there  is  a  lack  of  activity  of  the  gland- 
He  believes,  "We  have  attributed  this  particular  symptom-complex  of 
adiposity,  high  sugar  tolerance,  sub-normal  temperature,  slowed  pulse,  asthenia 
and  drowsiness  to  a  secretory  deficiency  of  the  posterior  lobe;  and  a  further 
argument  in  favor  of  this  view  is  the  reverse  condition — namely,  the  emacia- 
tion, spontaneous  glycosuria  with  hyperglycaemia,  and  the  slightly  elevated 
temperatiire — which  follows  posterior  lobe  administration." 

Polyuria  and  polydyspia  have  followed  sella  decompression.  Blood 
]jress\ire  is  low  in  cases  of  hypopituitarism. 

Drowsiness  and  mental  inactivity  are  also  symptoms  which  occur. 
Certain  symptoms  "pigmentation  of  the  skin,  asthenia,  low  blood  pressure, 
and  to  these  may  be  added  hypoglycaemia"  often  occur  in  hypopituitism 
which  greatly  resemble  Addison's  disease. 

Treatment. — Some  cases  require  medical  treatment,  others  operative. 

Surgical  methods  are  used  to  correct  pressure  distvu-bances,  to  combat 
functional  hyperplasia,  to  afford  relief  to  neighborhood  symptoms. 

"The  chief  service  of  surgical  therap}^  in  hypophyseal  maladies  is  to 
afford  relief  to  neighborhood  symptoms.  A  lesser  ser\4ce  has  been  shown 
to  be  the  palliation  of  the  manifestations  of  increased  intracranial  tension, 
just  as  in  the  case  of  tumors  originating  elsewhere.  Surgery  may  come  to 
render  a  third  service  in  the  partial  extirpation  of  the  gland  in  states  of 
hyperpituitarism  and  there  remains  a  possible  fourth  service  that  may  be 
rendered  in  states  of  hypopituitarism  through  glandular  implantations. 

Acromegaly  and  Gigantism. 

Historical. — It  was  first  described  by  Marie,  of  Paris,  in  "Revue  de 
Medecine,"  1886.  It  had,  however,  been  previously  described  imder  other 
names,  as  "hyperostosis  of  the  entire  skeleton"  by  Friedreich,  as  general 
hypertrophy,  or '  'makrosomie, ' '  by  Lombroso,  as '  'giant  growth, ' '  by  Fritsche 
and  Klebs.  Since  then  numerous  cases  have  been  reported,  and  the  disease 
was  exhaustiveljr  described  by  Arnold,  of  Heidelberg,  in  Ziegler's  "  Beitrage," 
in  1891. 

Definition. — A  disease  characterized  by  enlargement  of  the  bones,  espec- 
ially the  bones  of  the  hands,  feet  and  face. 

Etiology. — It  is  a  disease  of  early  adult  life,  usually  occurring  under  30 
and  is,  perhaps,  slightly  more  frequent  in  women.  Hereditj-,  syphilis,  and 
the  specific  fevers  have  preceded  the  disease,  but  no  necessary  relation  has 
been  shown.     Hyperactivtiy  of  the  pituitary  body  is  the  cause. 

Morbid  Anatomy  and  Pathology. — This  consists  in  a  true  hj-pertrophic 
enlargement  of  the  bones,  except  the  superior  maxillary,  which  contributes 
to  the  enlargement  of  the  face  by  a  dilatation  of  the  antrum,  while  the  lower 
jaw  is  simply  enlarged.  As  stated  the  enlargement  is  uniform  and  sym- 
metrical instead  of  involving  only  the  shaft  as  in  osteitis  deformans,  or  the 
ends  as  in  arthritis  deformans,  and  is  quite  independent  of  rheumatism. 
Hyperplasia  of  the  pituitary  body  has  been  a  striking  feature  in  most  cases 
which  have  come  to  necropsy,  in  every  one  of  thirty-four  collected  by  Furni- 


GIGANTISM— ACROMEGALY  689 

val.  Marie  eariy  sought  to  make  these  changes  responsible,  as  disease  of  the 
thyroid  is  for  myxedema.  Persistence  and  enlargement  of  the  thymus 
gland  have  been  found,  and  atrophy  as  well  as  enlargement  of  the  thyroid. 

A  further  study  of  acromegaly  in  connection  with  "giantism,"  "dwarf- 
ism and  "cretinism,"  go  to  show  that  it  is  at  least  probable  that  all  of 
these  are  the  result  of  some  deranged  function  of  the  pituitary  gland.  It  is 
well  known  that  giantism  may  degenerate  into  acromegalj',  while  a  compari- 
son between  the  skeletons  of  a  dwarf  and  a  macrocephalic  suggests  that  they 
are  opposite  extremes  of  one  and  the  same  process.  Of  further  interest  in 
this  connection  is  the  embryonic  relation  between  the  pharyngeal  tonsil — 
adenoids  in  the  vault  of  the  pharynx,  and  the  extraordinary^  influence  they 
have  on  nutrition — and  the  pituitary  body,  which  are  at  one  period  of  de- 
velopment in  connection  and  subsequently  separated  by  ossification  at  the 
base  of  the  skull ;  while  not  infrequently  in  early  life  they  remain  connected 
by  a  fibrous  cord  running  through  the  body  at  the  sphenoid. 

Symptoms. — The  most  strilving  features  are  the  enlarged  bones,  espe- 
cially those  of  the  hands  and  feet,  the  appearance  of  the  former  being  well 
characterized  as  spade-like,  while  the  fingers  and  nails  are  broad.  The  legs 
and  arms,  on  the  other  hand,  are  not  elongated  early,  but  late  in  the  disease : 
and  the  forearms  and  legs  may  increase  in  circumference;  while  the  ends 
of  long  bones,  like  the  femurs,  are  often  prominent.  The  scapulce,  clavicles, 
sternum  and  the  ends  of  the  ribs  are  also  sometimes  involved.  The  proper 
use  of  the  hands  is  not  interfered  with.  The  head  and  face  are  enlarged,  the 
spaces  between  the  teeth  are  increased,  while  the  neck  appears  short  and  the 
inferior  maxilla  may  project  beyond  the  upper,  and  the  lower  lip  protrude  in 
consequence.  The  ears  are  undiily  prominent,  while  the  cartilages  of  the 
nose,  eyelids,  and  larynx  are  enlarged  and  thickened,  as  is  also  sometimes 
the  tongue.  The  spinal  column  may  be  involved,  and  there  may  be  ky- 
phosis. The  muscles  on  the  other  hand  are  soraetimes  atrophied  and  the 
genitalia  are  unusually  developed.  The  skin,  though  coarse  and  exhibiting 
a  tendency  to  perspire,  is  not  thickened  as  in  myxedema. 

Among  other  symptoms  are  mental  dullness,  a  sense  of  fatigue,  and  quite 
severe  pain  in  the  head  and  extremities,  alteration  of  voice  due  to  changes  in 
the  tongue  and  larynx,  and  possibly  to  paresis  of  the  vocal  cords;  impairment 
of  special  senses  of  taste,  smell  and  hearing;  blindness  due  to  optic  atrophy; 
thirst,  shortness  of  breath,  asthmatic  attacks,  palpitation,  and  even  hyper- 
trophy of  the  heart.  In  a  number  of  cases  bitemporal  hemianopsia  has  been 
observed  and  was  due  to  pressure  on  the  chiasm  by  the  enlarged  pituitary 
body.  There  are  menstrual  derangement  and  early  cessation  of  the  menses 
in  women.  The  alterations  in  the  thyroid  have  been  alluded  to,  and  an  area 
of  dullness  over  the  manubrium  is  ascribed  by  Erb  to  persistence  of  the 
thymus. 

Diagnosis. — This  is  easy.  The  difference  between  acromegaly  and 
osteitis  deformans  has  been  mentioned.  In  osteitis  deformans,  too,  as 
pointed  out  by  Marie,  the  face  is  triangular,  with  the  base  upward,  while  in 
acromegaly  it  is  ovoid,  with  the  large  end  downward.  Acromegaly  has  been 
mistaken  for  congenital  progressive  hypertrophy  or  giant  growth,  but  in  the 
latter  only  one  limb  is  usually  involved  and  the  shaft  of  the  bone  is  affected. 

Prognosis. — The  duration  of  the  disease  is  long  and  usually  ultimately 


690  DISEASES  OF  THE  DUCTLESS  GLA.XDS 

fatal,  although  it  is  sometimes  arrested.     The  fatal  cases  are  probably  those 
with  tumor  of  the  pituitary  body. 

Treatment. — None  has  been  found  to  be  of  any  value.  Naturally  one 
thinks  of  the  possible  utility  of  extract  of  the  pituitary  gland,  though  if  the 
condition  be  the  result  of  excessive  pituitary  secretion,  but  little  can  be  ex- 
pected from  such  use.  In  fact  such  has  been  the  result  in  the  few  cases  in 
which  it  has  been  tried. 

Infantilism. 

Infantilism  or  dwarfism  and  pseudo-obesity  are  consequences  of  depressed 
pituitary  function,  but  not  every  case  of  dwarfism  is  thus  caused.  Thus 
cretanoid  infantilism  is  the  result  of  defective  thyroid  function  and  has  been 
described  on  page  676.  That  variety  of  dwarfism  known  as  idiopathic 
infantilism  (so-called  Lorain  type)  as  well  as  the  form  of  pseudo-obesity 
known  as  lipomatosis  universalis  asexualis  {dystrophia  adiposo-genitalis)  arc 
so  regarded  and  the  same  may  be  true  of  Dercum's  disease  (adiposis  dolo- 
rosa) and  achondroplasia,  but  it  cannot  be  confidently  asserted. 

Then  there  is  cachectic  infantilism  which  is  produced  by  any  prolonged 
diseased  state  as  hook  worm  disease,  syphilis,  chronic  malaria  and  congenital 
heart  disease.  There  is  also  said  to  be  a  toxic  infantilism  due  to  the  pro- 
longed effect  of  tobacco  and  alcohol.  Whenever  it  does  occur  sexual  de- 
velopment ceases  and  physical  development  remains  at  the  same  stage. 

I.  Varieties  of  Infantilism  {So-called  Lorain  Type). — In  this  variety,  as 
described  by  John  Thomson,  the  figure  resembles  that  of  a  child.  When 
the  patient  is  stripped,  however,  the  outlines  are  found  to  be  those  of  an 
adult,  simply  reduced.  The  head  is  proportionately  small,  the  trunk  well 
formed;  the  shoulders  proportioned  to  the  hips,  and  the  prominences  of  the 
bones  and  muscles  are  normally  maintained.  The  subject  is  a  miniature 
man  (or  woman) ,  not  one  who  has  retained  the  characteristics  of  childhood 
beyond  the  proper  time.  There  is  no  growth  of  facial,  pubic  or  axillan- 
hair,  yet  the  genital  organs  though  small  are  well  shaped  and  proportioned 
to  the  size  of  the  body.     The  intelligence  in  both  sexes  is  generally  normal. 

The  cause  of  this  form  is  not  positively  known,  but  there  is  reason  to 
believe  it  is  due  to  deranged  pituitary  secretion.  It  has  also  been  called 
" angioplastic  infantilism"  because  associated  with  defective  development 
of  the  vascular  system. 

II.  The  Harmonic  Type. — This  includes  several  varieties  directly  de- 
pendent upon  change  in  the  fimctions  of  the  ductless  glands.  The  most 
important  are: 

(a)   Thyroidal  or  Cretinoid  Infantilism. — Already  described  (p.  676). 

(6)  The  Frolich  type,  dystrophia  adiposo-genitalis,  associated  with  a  tumor. 
See  diseases  of  Pituary  gland. 

(c)  Pancreatico-Intestinal  Type. — Cases  of  infantilism  associated  with 
intestinal  changes  have  been  reported  by  Bramwell,  Herter,  Freedman  and 
others.  Bramwell  thought  the  pancreas  was  at  fault,  and  his  cases  improved 
under  treatment  with  pancreatic  extract.  In  Herter's  case  there  were 
looseness  of  the  bowels,  often  fatty  stools,  and  a  change  in  the  flora  of  the 
intestine  with  a  rise  in  ethereal  sulphates  in  the  urine. 


THYMUS  GLAND  691 

{d)  Ateliosis  {Continuous  Youth)  and  Progeria  {Premature  Old  Age). — 
Under  these  terms  Hastings  Gilford  describes  two  types  of  dwarfs.  Ateliosis 
also  includes  two  sub-varieties,  the  asexual  and  sexual.  The  asexual  is  an 
infantilism  unassociated  wdth  cretinism,  syphilis,  or  congenital  heart  disease, 
often  more  a  delay  than  an  arrest  of  development.  In  the  sexual  form  there 
is  a  like  delay  in  development  until  puberty  when  the  sexual  organs  mature 
and  the  body  becomes  set  as  a  miniature  man  or  woman.  This  is  termed 
the  "Tom  Thumb"  t3'pe  of  dwarf. 

DISEASES  OF  THE  THYMUS  GLAND. 

The  thymus,  a  ductless  gland  primarily  of  epithelial  structure,  has 
assumed  at  birth  a  lymphoid  type  so  pronounced  that  it  is  classed  among 
the  lymph  glands.  Supposed  to  produce  an  internal  secretion,  its  function 
is  unknown,  while  experiments  made  wdth  extracts  from  the  gland  have  as 
yet  taught  us  nothing.  Extirpation,  followed  at  times  by  change  of  func- 
tion in  other  organs  and  tissues,  is  at  other  times  without  effect.  Again, 
the  gland  has  been  held  to  have  some  connection  with  the  sexual  function 
and  the  development  of  the  bones  and  nen^es.  The  former  claim  is  at- 
tested by  castration  which  is  followed  by  permanence  and  enlargement  of  the 
gland.  From  birth  up  to  two  years  when  it  reaches  its  acme  of  develop- 
ment it  weighs  seven  to  ten  grams  (105  to  150  grains).  A  weight  of  20  to 
30  grams  (2/3  to  i  ounce)  means  abnormal  size.  The  thymus  occupies  the 
space  between  the  manubrium  sterni  and  the  spinal  column,  equal  to  2.2 
cm.  or  about  an  inch,  scant  space  for  enlargement  ■without  encroaching. 

I.  Simple  hypertrophic  enlargement  appears  to  be  the  most  frequent 
abnormality.  It  may  attain  a  weight  of  30  grams  (an  oimce)  or  more. 
Among  its  residts  either  directly  by  pressure  on  the  trachea  or  refiexly  are 

First,  Thymic  Stridor,  Inspiratory  and  Expiratory. — The  enlargement  may 
be  congenital  or  acquired  after  birth.  The  stridor  varies  in  intensity,  being 
especially  aggravated  by  crjdng  and  coughing.  It  has  been  mistaken  for 
diphtheria,  and  intubation  has  been  practiced  for  this  reason,  but  intubation 
furnishes  no  relief  unless  the  tube  be  carried  well  below  the  upper  thoracic 
strait.     Moreover  thymic  stridor  is  never  associated  with  hoarseness. 

Second,  Thymic  Asthma  or  Kopp's  Asthma. — A  persistent  and  more 
severe  form  of  asthma  characterized  by  a  progressive  tendency  to  increase 
in  severity.  Attacks  of  this  asthma  may  occur  in  a  child  without  a  previous 
symptom.  Kopp  ascribed  it  to  thymic  enlargement.  In  evidence  that  an 
enlarged  thjonus  is  the  cause,  its  removal  has  been  followed  by  complete 
recovery.  On  the  other  hand  recovery  has  been  spontaneous  after  the  lapse 
of  more  or  less  time  whence  one  maj^  infer  spasmodic  contraction.  Kopp's 
view,  though  widely  accepted,  was  much  disputed  notably  by  Friedleben  in 
1858,  but  reaffirmed  by  Grawitz  in  1888. 

Third,  finaU}^  thymic  death  (mors  thymica),  a  condition  in  which  death 
occurs  suddenly  with  or  without  a  history  of  previous  respiratory  difficulty. 
Between  thymic  asthma  and  thymic  death,  the  distinction  rests  purely  upon 
the  degree  of  severity  for  there  is  no  sharp  line  between  them.  The  same 
reasoning  as  to  etiology  applies  to  both  and  the  same  difference  of  opinion 
exists  as  to  it.     Causes   assigned  for  thymic  death  are  first,  enlargement 


692  DISEASES  OF  THE  DUCTLESS  GLANDS 

of  the  thymus  mechanically  encroaching  on  the  trachea ;  second,  a  nervous 
influence  which  may  be  associated  with  lymjjhatic  and  thymic  enlargement 
(status  lymphaticus,  with  symptoms  pointing  to  cardiac  failure  and  sud- 
den death.  No  one  doubts  that  a  certain  number  of  deaths  are  due  to 
thymic  enlargement,  these  being,  however,  generally  preceded  by  gradually 
increasing  dyspnea  so  that  death  is  never  quite  sudden.  The  precise  mode 
of  death  is  not  settled.  It  may  be  purely  mechanical  or  due  to  laryngeal 
spasm  succeeding  on  a  certain  degree  of  tracheal  stenosis.  The  truly  sudden 
deaths  are  cardiac  associated  or  not  with  status  Ij^mphaticus.  Another 
possible  cause  of  thymic  death  is  by  pressure  of  the  enlarged  thymus  on 
the  heart  and  great  vessels,  the  vagi  and  recurrent  laryngeal  nerves,  but 
this  has  not  ma^y  adherents. 

It  must  not  be  forgotten  that  there  are  other  causes  of  sudden  death  in 
infants  than  those  concerned  with  the  thymus.  Among  these  is  "over- 
lying." Careful  postmortem  examinations  should  be  made  in  all  cases  of 
sudden  death  in  infants. 

Treatment. — Modem  medicine  has  developed  a  treatment  for  enlarge- 
ment of  the  thymus  which  includes  measures  prophylactic  against  pressure 
and  excitement,  to  fortify  surgical  treatment  by  such  measures  as  might  be 
needed  in  emergency,  i.e.,  arrangements  for  intubation  and  tracheotomy. 
Curative  treatment  consists  in  intubation,  Roentgen  irradiation,  treatment 
for  rickets,  syphilis  and  operation. 

II.  Atrophyof  the  thymus  is  found  incidentally  and  appears  to  cause  no 
special  symptoms,  but  is  rather  the  result  at  times  of  marasmus  and  the 
wasting  diseases  of  children. 

III.  The  thymus  is  the  subject  of  other  abnormalities  often  not  recog- 
nized until  after  death.  Such  are  hemorrhage,  tuberculosis  and  syphilis, 
dermoid  and  other  cysts.  Mediastinal  growths  comparatively  frequently 
start  from  the  remnants  of  the  gland.  The  thymus  is  the  subject  of  post- 
mortem softening  at  one  time  supposed  to  be  a  morbid  state. 

IV.  A  persistence  of  the  gland  after  the  age  of  puberty  at  which  it  has 
usually  disappeared  is  not  unusual,  associated  with  conditions  which  are 
generally  accidentally  coincident,  including  exophthalmic  goiter  whose 
association  has  also  been  regarded  as  other  than  accidental. 


SECTION  VII 

DISEASES  OF  THE  URINARY  ORGANS. 

GENERAL  SYMPTOMATOLOGY. 

Four  important  symptoms  more  or  less  characteristic  of  diseases  of 
the  urinary  organs,  and  especially  of  disease  of  the  kidneys,  may,  for  the 
sake  of  brevity,  be  considered  at  the  outset  of  our  studies  of  these  affections. 
They  include  albuminuria,  renal  dropsy,  uremia  and  tube  casts. 

ALBUMINURIA. 

Definition. — By  albuminuria  is  meant  a  condition  of  the  urine  in  which 
it  contains  some  of  the  forms  of  albtunin  of  which  at  present  we  need  consider 
only  senmi  albumin  and  globulin.  The  sources  of  the  albumins  in  mine  are 
various,  and  may  be  conveniently  divided  into  extrarenal  and  renal. 

Extrarenal  Albuminuria. 

The  pelvis  of  the  kidney,  the  ureters,  the  bladder,  the  urethra,  and  in 
the  female  the  vagina  and  uterus  in  addition,  are  the  most  important 
sources  of  extrarenal  albuminuria.  In  all  of  them  it  is  almost  invariably 
the  serum  of  pus  formed  during  catarrhal  inflammation  which  furnishes  the 
albumin.  The  presence  of  pus-corpuscles,  therefore,  in  sufficient  number  in 
the  urine  com-monlj^  explains  the  source  of  such  albumin,  which  is,  moreover, 
usually  small  in  quantity — never  more  than  about  one-tenth  the  volume  of 
urine  tested,  even  with  the  most  copious  sediment  of  pus.  It  must  not 
be  overlooked,  however,  that  the  two  sources,  kidney  disease  itself  and  the 
mucous  surfaces  referred  to,  may  coexist,  in  which  event  careful  microscopic 
examination  will  sooner  or  later  discover  tube-casts,  while  the  quantitj^  of 
albumin  will  be  larger  than  can  be  accounted  for  by  the  presence  of  pus 
alone. 

Menstrual  or  lochial  blood  need  only  be  referred  to  as  sources  of  albumin 
in  the  mine  hardly  likely  to  be  overlooked  by  any  physician;  while  hemor- 
rhage from  any  one  of  the  mucous  surfaces  referred  to,  as  well  as  from  the 
kidney  itself,  would  be  a  source  of  albuminuria.  It  is  usually  comparativel}' 
easy  to  determine  whether  a  hemorrhage  has  its  source  in  the  kidney  or  in 
the  mucous  membranes  previously  mentioned.  In  the  former  coagula  are 
rarely  present,  for  the  blood,  entering  the  ureter  slowly,  becomes  intimately 
mixed  with  the  urine.  It  imparts  to  it,  too,  when  acid  in  reaction,  a  smoky 
hue  which  is  very  characteristic.  The  coloring-matter  of  the  corpuscles  is 
commonly  dissolved  out  by  the  urine  which  is  thus  tinged,  and  on  standing, 
the  stroma  of  the  corpuscles  sinks  to  the  bottom  as  a  brownish  sediment. 
The  microscope  reveals  these  corpuscles  shrunken,  almost  colorless,  and  often 
crenated.     We  have  said  that  the  smoky  hue  is  present  only  in  acid  urine. 

693 


694  DISEASES  OF  THE  URLXARV  ORGAXS 

When  the  latter  becomes  alkaline,  either  by  spontaneous  or  artificial  change 
in  reaction,  it  assumes  a  brighter  red  hue,  the  degree  of  which  depends  upon 
the  quantity  of  blood.  When  blood  comes  from  the  pelvis  of  the  kidney  or 
the  ureter  in  any  quantity,  coagula  which  are  molds  of  the  ureter  are  some- 
times found,  the  descent  of  which  is  often  attended  with  severe  pain.  Such 
coagula  are  frequently  the  result  of  bleeding  from  hypernephromata. 

Another  source  of  albuminous  urine,  though  not  likely  to  cause  error, 
should  be  mentioned — viz.,  the  so-called  chylous  urine,  or  chyluria,  in  which 
in  consequence  of  some  as  yet  imperfectly  understood  communication 
between  the  lymphatic  system  and  the  urinary  tracts,  chyle  enters  the  urine 
and  imparts  its  physical  and  chemical  characters  thereto.  These  are  the 
presence  of  albumin,  and  a  milk-white  appearance  due  to  the  presence  of  fat 
in  a  molecular  state. 

The  kidney  itself  may  be  the  seat  of  suppuration,  and  contribute  through 
the  pus  thus  added  to  an  albuminuria. 

Renal  Albuminuria. 

The  Immediate  Cause  of  Renal  Albuminuria. — Albumin  in  the  urine  is 

an  abnormal  condition,  and  while  renal  albuminuria  suggests  some  change 
in  the  epithelium  of  the  glomeruli,  its  presence  must  by  no  means  be  inter- 
preted as  a  serious  diseased  condition  of  the  kidneys.  As  above  stated  it 
may  be  extrarenal.  These  conditions  being  excluded  we  have  left  actual 
diseased  conditions  of  the  kidney  itself  or  abnormal  conditions  of  the  blood 
or  of  other  organs  which  so  effect  the  kidney  that  it  allows  albumin  to  pass 
over  into  the  urine.  Suppuration  of  the  kidne^',  actual  inflammation  or  in- 
testitial  change  in  the  kidney  and  congestion  or  hyperemia  of  the  organ  are 
the  conditions  in  which  changes  in  the  kidney  are  the  original  source  of  the 
albimiin. 

Renal  albuminuria  also  occurs  as  a  secondary  symptom  in  diseases  other 
than  renal.  First  may  be  mentioned  the  albuminuria  of  fever,  such  as  that 
of  typhoid  fever,  small-pox,  etc.  The  febrile  albuminuria  alluded  to  is  not 
usually  large,  and  disappears  with  the  decline  of  the  disease.  It  is  in  great 
measure  the  result  of  irritation  of  the  kidney  by  the  infectious  agent; 
possibly  also,  in  part,  the  result  of  diminution  of  the  cardiac  force  propelling 
the  blood  through  the  kidneys,  and  of  the  resulting  turgor.  Abnormal 
substances  in  the  blood  such  as  sugar,  lead  and  bile  pigment  may  produce 
renal  albuminuria,  especialh'  if  long  maintained,  probably  because  of  their 
effect  on  the  epithelium. 

Other  conditions  in  which  albuminuria  thus  occurs  are  anemia,  leu- 
kemia, diarrhea,  cholera,  lead  colic,  also  certain  conditions  of  the  brain 
and  spinal  cord,  including  hemorrhages  into  the  brain,  meningitis,  epilepsy, 
tetanus,  and  others. 

The  significance  of  renal  albuminuria  has  altered  greatly  as  our  knowledge 
of  this  subject  has  increased.  While  large  albuminurias  of  renal  origin  can 
scarcely  be  due  to  anything  else  but  renal  disease,  and  the  degree  of  al- 
buminuria is  within  limits  a  measure  of  the  seriousness  of  the  disease,  yet 
the  important  fact  remains  that  there  may  be  true  albuminuria,  usually 
moderate,  in  which  there  is  no  disease  of  the  kidney  whatever;  there  may  also 


ALBUMINURIA  695 

rarely  be  Bright's  disease  in  which  there  is  no  albuminuria.  The  signifi- 
cance of  albuminuria  is  always  increased  by  its  association  with  tube- 
casts,  yet  there  may  be  both  albumin  and  casts  in  urine  where  there  is  no 
Bright's  disease,  while  again,  there  may  be  Bright's  disease  without  al- 
bumin or  casts.  Such  cases  are  infrequent,  and  yet  this  possibility  must 
be  acknowledged. 

Physiological  or  Functional  Albuminuria. — The  possibility  of  a  physio- 
logical or  functional  albuminuria  at  the  present  day  is  generally  conceded. 
By  it  is  meant  an  albuminuria  unassociated  with  other  symptoms.  There 
are  no  tube-casts  or  feeling  of  ill-health.  Such  albuminurias  are  often 
discovered  accidentally,  especially  by  examiners  for  life-insurance.  Much 
care  should  be  exercised  in  concluding  upon  the  nature  of  an  albuminuria 
suspected  to  be  functional.  In  the  first  place,  it  should  be  small,  not 
exceeding  one-tenth  the  bulk  of  urine  tested,  and  though  it  is  not  neces- 
sary that  it  should  be  absent  on  rising,  yet  it  is  a  strong  point  in  favor  of 
the  functional  nature  if  it  is  absent  at  this  time  and  present  only  after  some 
exertion  has  been  made  or  on  taking  food.  No  tube-casts  should  be  in  the 
urine,  the  urea  should  be  in  sufficient  quantity,  there  should  be  no  retinal 
change,  no  hypertrophy  of  the  left  ventricle,  no  high  tension  to  the  pulse, 
nor  even  a  suggestion  of  dropsy.  Further,  this  condition  should  be  watched 
over  a  considerable  length  of  time  before  the  conclusion  is  arrived  at  that 
we  have  to  do  with  a  harmless  functional  albuminuria . 

It  may  be  that  these  albuminurias  are  due  to  some  changes  in  the 
epithelium  or  the  blood  pressure,  but  there  is  no  way  of.  proving  it  and 
presumably  it  passes  away  when  the  albumin  disappears.  The  term  cyclic 
albuminuria  is  given  to  such  albuminurias  as  appear  only  at  a  certain  time 
of  day,  and  albuminuria  of  adolescence  when  it  disappears  after  the  establish- 
ment of  maturity.  The  term  orthostatic  albuminuria  is  applied  to  these 
same  conditions. 

Other  proteid  matters  are  sometimes  found  in  the  urine,  such  as  globulin, 
mucin,  peptone,  albumose  and  hemialbumose,  but,  except  in  the  case  of 
globulin,  their  clinical  significance  is  not  sufficiently  determined  to  justify 
their  further  consideration  in  a  text-book.  A  certain  amount  of  globulin  is 
always  associated  with  albumin.  In  an  ordinary  serum  albuminvuria  the 
ratio  commonly  maintained  is  lo  to  i8  of  serum  albumin  to  one  of  globulin, 
the  ratio  in  the  blood  being  one  of  serum  albumin  to  i  1/2  to  3  of  globulin. 
A  like  ratio  holds  for  these  constituents  in  pus.  This  ratio  in  albuminuria 
is  at  times  exceeded,  especially  in  the  case  of  the  amyloid  kidney,  where  I 
regard  the  presence  of  globulin  in  large  amount  may  be  considered  of 
diagnostic  value. 

Albumosuria  is  of  greater  significance  when  associated  with  multiple 
myelomata  (Kohler's  disease)  and  its  long-continued  presence  suggests  these 
tumors  of  bone,  a  well-recognized  condition,  of  which  many  cases  have  been 
reported  chiefly  in  males  over  40,  and  terminating  fatally.  Albumose  is 
occasionally  found  in  association  with  other  tumors  of  bone. 

Tests  for  Globulin  and  Albumose. 

The  student  is  referred  to  works  on  Clinical  Diagnosis  for  tests  for  albu- 
min and  globulin. 


696  DISEASES  OF  THE  URINARY  ORGANS 

BACILLURIA  OR  BACTERIURIA. 

Bacteruria  is  a  condition  of  the  urine  charged  with  bacteria  commonly 
pathogenic.  The  bacilli  may  arise  from  a  focus  in  the  bladder  or  urinary 
tract  when  it  is  known  as  primary.  Or  they  may  come  directly  from  the 
blood  when  the  affection  is  secondary.  The  bacteria  commonly  foimd  are 
the  typhoid  bacillus,  the  colon  bacillus,  the  streptococcus  and  gonococcus. 
The  number  of  bacteria  may  be  so  great  as  to  make  the  urine  slightly  tur- 
bid, or  its  appearance  may  not  be  altered. 

Again  the  bacteria  may  be  associated  with  cystitis  or  pyelitis  and  their 
other  signs,  or  they  may  be  unattended  with  any  symptoms  of  inflam- 
mation. The  urine  is  acid  usually  with  the  bacUlus  coli,  and  alkaline  with 
the  staphylococcus.  It  may  be  associated  with  phosphaturia.  It  is  vari- 
ously amenable  to  treatment  and  commonly  easily  curable  by  hexamethyl- 
enamine. 

PHOSPHATURIA. 

The  term  phosphaturia  should  be  limited  to  a  condition  in  which  more 
than  the  normal  quantity  of  phosphoric  acid  in  combination  is  excreted  in 
the  24-hour  urine.  This  can  only  be  determined  by  careful  volumetrical 
analysis  of  the  24-hour  urine.  The  amount  of  P2O3  thus  excreted  accord- 
ing to  Hammarsten  is  from  i  to  5  grams  or  an  average  of  2.5  grains.  Such  a 
condition  was  described  by  Prof.  J.  Teissier  of  Lyons  in  1876  under  the  name 
of  essential  phosphaturia  or  phosphatic  diabetes.  To  the  true  phosphaturia 
are  added  some  of  the  most  distinctive  symptoms  of  diabetes  mellitus,  viz., 
polyuria,  thirst,  emaciation,  dry  skin  and  pruritus.  Charles  Henry  Rolfe, 
in  England,  has  described  thirteen  cases  with  like  symptoms.  It  is  well 
named,  therefore,  "phosphatic  diabetes."  As  much  as  7  to  9  grams  were 
found  by  Teissier  in  the  24-hour  urine.  To  those  who  would  make  a  differ- 
ence between  the  two  titles,  phosphaturia  would  be  a  condition  in  which 
there  is  simply  an  excessive  precipitation  of  phosphates  due  to  a  high 
alkalinitj''  or  deficient  acidity  of  the  urine,  such  phosphates,  chiefly  lime, 
being  further  precipitated  on  the  application  of  heat.  Such  precipitate  does 
not  employ  an  excess  of  secretion  of  phosphoric  acid  but  simply  a  deficient 
acidity. 

The  phosphoric  acid  in  the  urine  is  devised  chiefly  from  the  phosphates 
ingested  with  food.  A  portion  results  from  the  decomposition  of  nuclein, 
protagon  and  lecithin.  The  phosphoric  acid  thus  resulting  is  combined  with 
sodium,  and  potassium  (fixed  alkalies),  forming  the  alkaline  phosphates  and 
with  lime  and  magnesia  forming  earthj'  phosphates.  The  aUcaline  phos- 
phates predominate,  and  of  these  the  phosphate  of  sodium.  Of  the  earthy 
phosphates  the  phosphate  of  lime  preponderates.  After  the  ammoniacal 
fermentation  of  urine  within  or  without  the  bladder  there  is  fonned  the 
ammonio-magnesian  or  triple  phosphate  in  the  shape  of  triangular  prisms 
and  feathery  or  stellar  crystals  also  known  as  steUar  phosphates. 

It  has  long  been  an  impression  that  there  is  a  close  relation  between  the 
metabolism  of  tissues  and  especially  nen^ous  metabolism  and  the  excretions 
of  phosphoric  acid  in  the  shape  of  phosphates.     The  German  hold  to  this 


ox  ALU  RIA~IN  Die  ANURIA  697 

view  firmly  and  claim  that  on  the  part  of  the  English  Bence  Jones  erred  in 
claiming  that  no  increased  elimination  takes  place  in  nervous  diseases,  and 
that  an  absence  of  an  absolute  increase  in  the  excretions  of  P2O3  does  not 
disprove  an  increase  of  phosphoric  bodies  since  in  many  nervous  diseases 
phosphorus  appears  in  the  urine  not  fully  oxidized,  that  is  as  P2O3,  lecithin 
and  glycerophosphoric  acid. 

OXALURIA. 

Oxaluria  is  another  condition  which  in  the  past  has  been  assigned  an 
exaggerated  importance.  It  is  a  condition  of  luine  in  which  oxalate  of 
lime  in  the  characteristic  crystalline  shape  is  constantly  present.  Our  own 
belief  is  that  except  as  a  condition  favoring  the  formation  of  gravel  and  cal- 
culi it  is  of  no  importance.  Instead  of  being  a  cause  of  a  state  of  mental 
depression,  often  associated  with  it,  both  it  and  the  melancholy  and  the 
deranged  digestion  and  nervous  function  are  the  results  of  a  deranged 
metabolism. 

Most  of  the  oxalate  of  lime  in  the  urine  is  derived  from  vegetable  fcod 
in  which  rhubarb  is  conspicuous  while  the  intestinal  fermentation  of  ingested 
carbohydrates  with  associated  gastritis  and  the  absence  of  hydrochloric 
acid  is  another  source.  Finally  in  a  small  way  oxalate  of  lime  is  produced 
in  the  economy,  either  in  the  blood  or  at  the  moment  of  secretion  in  the  kid- 
ney, from  nuclein  which  is  one  of  the  antecedent  states  of  oxalic  acid  as  of 
uric  acid.  Connective  tissue  and  gelatin,  when  ingested  in  large  quantities, 
increase  the  output  of  oxalic  acid  probably  because  the}^  stimulate  the  forma- 
tion of  nucleus.  Abnormalities  in  the  conversion  may  be  responsible  for 
unusual  output. 

INDICANURIA. 

Indicanuria  so-called  requires  a  short  notice  only.  It  owes  its  name  to 
the  presence  of  indoxyl  sulphate  of  potassium  which  is  colorless,  and  is 
present  in  small  quantities  in  all  urines.  When  it  is  brought  in  contact  with 
strong  oxidizing  agents,  as  the  mineral  acids,  it  is  decomposed  and  indigo 
is  set  free.  It  is  derived  from  indol,  a  product  of  proteid  decomposition  in 
the  intestine.  Indol  is  absorbed  and  converted  into  indoxyl  which  later 
unites  with  potassium  sulphate.  It  is  increased  in  gastric  intestinal  auto- 
intoxications sometimes  abim.dantly,  but  later  studies  attach  less  impor- 
tance to  it.  It  may  be  a  constituent  of  renal  calculi.  Rarely  it  decomposes 
spontaneously. 

Cystinuria  is  a  rare  condition  of  the  urine  in  which  six-sided  plates  of 
cystin  are  found  in  it;  sometimes  aggregated  to  form  small  calculi.  The 
sediment  persists  through  life.     One  of  us  has  seen  one  such  case. 

Alkapton  is  a  substance  sometimes  found  in  urine  which  reduces 
Fehling's  solution  and  thus  misleads,  but  unlike  glucose  it  does  not  ferment 
and  is  not  removed  by  the  polarizing  saccharimeter. 

Melanuria  is  a  somewhat  vague  term  applied  to  dark  hued  urines  which 
are  rendered  thus  by  various  causes,  some  of  which  have  been  considered. 
They  include  hemoglobinuria  and  hematuria,  the  urine  of  certain  cases  of 


698.  DISEASES  OF  THE  URINARY  ORGANS 

melanotic  tumor,  urine  surcharged  with  indican,  certain  intensely  jaundiced 
urine,  the  urine  secreted  after  the  ingestion  of  certain  fruits  and  vegetables, 
certain  medicines  such  as  sulphanol  (hemato  or  phogrinuria),  carbolic  acid, 
resorcin  and  others. 

Lactosuria  is  the  presence  of  lactose  in  the  urine,  rather  common  in 
women  whose  milk  has  just  begun  to  be  excreted.  It  reduces  Fehling's 
solution,  but  cannot  be  fermented  bv  veast. 


RENAL  DROPSY. 

Renal  dropsy  does  not  differ  essentially  from  cardiac  dropsy,  though 
it  is  less  directly  traceable  to  venous  obstruction  and  consequent  transuda- 
tion. It  very  frequently  appears  first  in  the  face  and  upper  extremities, 
and  this  fact  alone  goes  to  show  that  something  else  than  obstruction  to 
the  circulation  enters  into  its  causation.  On  the  other  hand,  it  is  well 
known  that  there  may  be  advanced  renal  disease  without  drops}'  when  one 
would  naturally  expect  obstruction.  Venous  obstruction  must,  however, 
be  considered  as  one  of  the  contributing  factors,  especially  when  in  the  lower 
extremities.  Aside  from  this  we  must  have  recourse  to  theory  to  explain 
it.  A  hydremic  state  of  the  blood  has  much  to  do  with  the  transudation  in 
certain  cases.  At  first  thought  this  explanation  would  seem  scarcely 
sufficient  to  account  for  the  edema  which  appears  to  early  in  many  cases  of 
acute  Bright's  disease,  but  this  objection  is  more  apparent  than  real,  for 
one  need  pause  for  a  moment  only  to  realize  how  quickly  blood  may  be- 
come hydremic  when  there  is  almost  total  anuria,  while  the  habitual  quan- 
tity of  water  continues  to  be  ingested  daily.  Moreover,  diminished  urinary 
secretion  often  exists  for  some  time  before  attention  is  called  to  it.  We  be- 
lieve that  sufficient  stress  has  not  been  laid  on  this  factor.  Increased 
permeability  of  the  capillary  walls  produced  by  toxic  substances  in  the  blood 
also  forms  transudation. 

As  the  disease  advances,  the  conditions  favoring  the  hydremic  state 
continue  and  grow  so  that  in  advanced  stages  this  element  doubtless  con- 
tributes largely.  It  is  more  than  likely  also  that  in  this  stage  alterations 
of  some  kind  in  the  vascular  and  lymphatic  walls  contribute  to  facilitate 
the  transudation,  while  the  diminished  elasticity  of  surrounding  tissues  may 
also  constitute  a  factor.  Where  edema  does  not  occur,  its  absence  can 
only  be  explained  by  the  presence  of  continued  secretion  of  water  by  the 
kidneys  or  by  supplemental  secretion  by  some  other  organ,  as  the  skin,  the 
lungs  and  bowels. 

Chlorid  Retention. — Strauss,  in  Germany,  and  Widal  and  Javal,  in  France, 
in  1902  and  1903  called  attention  to  the  fact  that  there  is  an  abnormal 
quantity  of  sodium  chlorid  in  the  tissues  cf  persons  affected  with  renal 
dropsy,  reporting  cases  in  which  it  was  possible  to  cause  edema  to  appear 
and  disappear  almost  at  will  by  varying  the  amount  of  chlorid  in  the  diet. 
The  rationale  of  these  events  is  supposed  to  be  as  follows:  In  nephritis 
the  ability  of  the  kidney  to  excrete  chlorid  is  decreased,  whence  their  ac- 
cumtdation  in  the  tissues  and  the  consequent  accumulation  of  water  in 
the  same  tissues  in  order  to  keep  the  chlorids  in  solution.     Although  there 


PHTHALEIN  TEST  6d9 

appear  to  be  exceptions  and  the  parallelism  is  not  always  demonstrable, 
the  correctness  of  the  statement  is  generally  admitted.  An  opposite 
theory,  that  the  primary  trouble  in  nephritic  edema  is  the  retention  of 
water  to  which  the  retention  of  salt  is  secondary,  is  not  sustained  by  the 
weight  of  evidence.  Chlorid  retention  has  been  obsen^ed  in  some  cases 
of  cardiac  dropsy  and  with  some  cases  of  edema  occurring  in  patients  with 
inflammatory  disorders,  but  there  is  no  evidence  to  show  that  there  is  any 
causal  relation  between  the  two  conditions  or  that  the  chlorid  retention 
is  more  than  can  be  explained  by  the  retention  of  fluid  in  the  edematous 
parts.     The  effect  of  chlorid  retention  is  also  to  increase  albuminuria. 

On  the  other  hand  the  recent  experimental  studies  of  Richardell,^ 
P.  F.  Richter  and  Pearce  show  that  vascular  injury  and  renal  injury  the 
result  of  the  effect  of  toxic  elements  of  the  blood  as  well  as  plethoric 
hydremia  all  enter  into  the  cavxsation  of  edema. 

The  degree  of  dropsy  varies  greatly  in  different  cases  and  different 
forms  of  Bright's  disease,  being  in  some  cases  trifling  and  in  others  enor- 
mous, including,  ultimately,  invasion  of  serous  cavities  like  those  of  the 
pleura,  peritoneum,  and  even  pericardium. 

RENAL  SUFFICIENCY  AND  INSUFFICIENCY.^ 

The  Phthalein  Test. — In  19 lo  Geraghty  and  Rowntree,^  following  the 
work  of  Abel  and  Rowntree'*  published  their  method  of  estimating  renal 
function  by  means  of  phenolsulphonephthalein.  Prior  to  the  above  publi- 
cation numerous  other  methods  such  as  phloridzin  glycosuria,  cryoscopy, 
electrical  conductivity,  and  the  estimation  of  eliminated  urea,  methylene 
blue,  rosanilin,  or  indigo-carmine,  had  been  brought  forward  to  estimate 
this  most  important  function.  From  cumbersome  apparatus,  painful 
injection,  irregular  secretion,  or  quantitively  unknown  proportions  and  the 
impossibility  of  accurate  determinations,  these  procedures  ar  open  to  serious 
criticism  or  limited  in  their' interpretation,  and  are  being  superceded  by  this 
new  test  which  bears  the  mark  of  mathematical  accirracy.  The  drug 
phenolsulphonephthalein,  is  absolutely  non-irritating  and  non-toxic;  prac- 
tically it  is  excreted  entirely  by  the  kidneys  with  extraordinar}''  rapidity; 
it  is  secreted  chiefly  by  the  renal  tubule  cells,  which  appear  to  have  a  selec- 
tive power  for  it,  with  an  ability  to  excrete  it  in  high  degrees  of  concentra- 
tion. In  the  normal  individual,  when  given  intramuscularly,  it  makes  its 
appearance  in  the  urine  in  from  five  to  eleven  minutes;  38  to  60  per  cent, 
being  excreted  in  the  first  hour  after  its  appearance  in  the  urine,  and  60 
to  80  per  cent,  during,  the  first  two  hours.  Those  diuretics  that  stimulate 
the  renal  cells  to  increased  activity  cause  some  increased  secretion  of 
phenolsulphonephthalein,  whUe  those  that  act  mechanically  produce  no 
increased  secretion. 

The  technic  is  as  follows:  A  catheter  is  introduced  and  the  bladder 
completely  emptied.     Exactly  i  c.c.  of  the  prepared  solution  of  phenol- 


1  The  production  of   edema  on  experimental   study,  etc.     Report  from  the  "Archives  of   Internal 
Medicine,"  June,  1909. 

2  We  owe  much  of  this  section  to  Dr.  Alexander  Randall. 

3  Geraghty  and  Rowntree,  Jour.  Pharm.  and  Exper.  Therap.,  July.  1910,  i,  579.     Bibliography  to  date: 
"Jour.  Amer.  Med.  Assoc,"  1912,  vol.  lix.,  p.  1813. 

*  Abel  and  Rowntree,  "Jour.  Pharm.  and  Exper.  Therap.,"  Aug.,  1909,  vol.  i.,  231. 


700  DISEASES  OF  THE  URINARY  ORGANS 

sulphonephthalein,  which  contains  6  milligrams  of  the  drug,  is  injected  deep 
into  the  lumbar  muscle,  the  exact  time  of  the  injection  being  noted.  As  this 
is  quantitative  work  an  accurately  graduated  syringe  (Record)  is  necessary-. 
The  urine  is  allowed  to  drop  from  the  catheter  into  a  test-tube  in  which  has 
been  placed  a  few  drops  of  a  25  per  cent,  solution  of  sodium  hj'droxide.  The 
phthalein,  straw-colored  in  the  acid  urine,  immediatel)'  indicates  its  pres- 
ence in  the  alkaline  test-tube  contents,  by  a  rose-pink  coloration.  In  patients 
without  urinary  obstruction,  or  residual  urine,  the  catheter  may  be  wathdrawn 
tit  the  time  of  the  appearance  cf  the  drug  in  the  urine,  and  the  patient  re- 
quested to  empty  the  bladder  into  a  receptacle  at  the  end  of  the  first  hour, 
from  the  time  of  its  first  appearance,  and -into  a  second  receptable  at  the 
end  of  the  second  hour  period.  If  there  is  any  contraindication  to  the  pas- 
sage of  the  catheter,  a  rough  estimate  of  the  time  of  appearance  may  be 
obtained  by  having  the  patient  void  at  frequent  intervals,  or  one  may  allow 
ten  minutes  (as  the  outside  limit  of  normal)  and  have  him  void  at  the  end  of 
the  first  hour  and  ten  minutes,  and  again  at  the  close  of  two  hours  and  ten 
minutes.  Such  methods,  however,  are  not  advised,  as  they  are  prejudicial 
to  accurate  quantitative  work  and  may  allow  faulty  deductions.  In  case 
there  is  residual  urine,  due  to  urinary  obstruction,  the  catheter  should  be  fast- 
ened in  place  and  corked  at  the  time  of  the  first  appearance  of  the  drug,  the 
bladder  being  completely  emptied  by  this  means  at  the  end  of  the  allotted 
periods  without  any  loss  of  the  total  amount  of  the  drug  eliminated.  The 
first  and  second  hoiu-  specimens  as  collected  are  measured  and  each  alkalized 
by  the  addition  of  25  per  cent,  sodium  hydroxide  solution  tmtil  the  brilliant 
purple-red  color  is  obtained.  Each  one  is  then  placed  in  a  liter  graduated 
flask  and  sufficient  clear  tap-water  is  added  to  make  i  liter.  The  solutions 
are  stirred  thoroughly  and  a  small  filtered  specimen  of  each  is  taken  for 
colorimetric  determination.  The  quantity  of  the  drug  in  each  specimen 
can  be  estimated  by  comparing  it  with  a  standard  solution  in  either  the 
Duboscq  or  the  modified  Autenrieth-Konigsberger  colorimeter,  or  by  com- 
parison with  a  set  of  tubes  of  known  percentage  content.  If  the  Duboscq 
instrument  is  used,  a  standard  solution  of  3  milligrams  of  phenolsulpho- 
nephthalein  to  the  liter  is  advised,  setting  the  Vernier  scale  at  10  in  the 
standard  solution  cup  for  fine  colorimetric  reading.  With  the  modified 
Autenreith-Konigsberger  apparatus  a  standard  solution  of  6  milligrams  of 
phthalein  to  the  liter  is  used.  In  cases  the  output  of  the  drvig  is  low,  the  urine 
specimen  may  be  diluted  to  only  500  c.c,  or  to  250  c.c.  and  a  mathematical 
correction  made  after  colorimetric  estimation. 

This  test  is  of  distinct  advantage  in  determining  functional  derangement; 

a.  In  acute  nephritis; 

b.  In  chronic  interstitial  nephritis; 

c.  In  chronic  parenchj^matous  iiephritis  (to  a  less  degree) ; 

d.  In  surgical  disease  of  one  or  both  kidneys  (aided  by  the  ureteral 
catheter) ; 

e.  In  the  differential  diagnosis  of  uremia  from  conditions  simulating  it ; 

f.  In   indicating   impending   uremia   before   the   existence   of   clinical 
evidence ; 

g.  In  determining  to  what  degree  renal  insufficiency  is  responsible  for 
the  clinical  picture  in  cardio-renal  disease; 


UREMIA  701 

h.  And,  when  ureteral  catheterization  is  performed,  in  showing  the  abso- 
lute amount  of  work  performed  by  each  kidney  as  well  as  its  reser\'e  force  in 
health  or  disease. 

It  is  to  be  borne  in  mind  that  such  a  test  estimates  renal  function  only, 
and  that  often  a  markedly  altered  kidney  may  have  a  remarkably  good 
function;  moreover,  that  renal  function  is  a  variable  quantity  allowing  of 
a  wide  range  of  change,  often  in  a  comparatively  short  space  of  time.  The 
curve  of  excretion,  with  an  abrupt  rise  and  a  gradual  fall,  as  the  concen- 
tration of  the  drug  in  the  body  decreases,  with  a  normal  maximum  in  the 
first  hour  and  a  marked  decrease  during  the  succeeding  periods  shoidd  be 
taken  as  an  indication  that  normal  function  is  being  performed,  while  it  is 
to  be  remembered  that  diseased  kidneys  tend  to  work  constantly  at  their 
maximum  and  each  hour's  elimination  may  be  equalled,  or  excelled,  by  the 
succeeding  ones  and  the  total  of  a  longer  period  of  time,  than  one  hotir,  may 
equal  that  of  a  normal  pair  of  kidneys  for  the  same  space  of  time. 

In  cases  of  nephritis  when  the  drug  is  excreted  only  in  traces,  or  not  at  all, 
a  grave  prognosis  should  be  given  even  though  no  signs  of  irremia  exist. 

A  case  just  observed  with  double  renal  ttunors.  At  the  first  observation 
was  passing  urine  of  normal  specific  gravity  in  about  normal  amounts 
with  neither  tube  casts  nor  albimiin.  No  phthalein  was  excreted  in  two 
hours.  The  patient  three  days  after  was  given  another  test  and  passed  no 
phthalein.  In  less  than  two  weeks  she  became  uremic  and  died  comatose. 
The  blood  contained  a  high  percentage  of  tu-ea. 

Other  tests  are  used  enabling  the  laboratory  worker  to  tell  with  consider- 
able accuracy  whether  the  kidney  is  functioning  or  not.  But  they  are  not 
practicable  for  the  clinic. 

For  further  consideration  and  the  details  of  the  technic  of  these  tests  the 
reader  is  referred  to  works  on  Clinical  Chemistry  and  especially  to  a  paper 
by  Rowntree  and  Fritz,  "Studies  of  Renal  Functions,"  "Archives  of 
Internal  Med.,"  Mar.,  1913. 


UREMIA.    ■ 

Uremia  is  a  symptom  peculiar  to  renal  disease.  It  majr  be  defined  in 
general  terms  as  a  condition  due  to  retention  within  the  blood  of  excremen- 
titious  substances  which  it  is  the  function  of  the  kidney  to  excrete.  When 
we  come  to  separate  these  substances,  we  are,  however,  completely  at  a  loss, 
for  no  clinical  or  experimental  studies  have  as  yet  given  us  the  required 
information.  Ligation  of  the  renal  veins  has  been  equally  futile  in  produc- 
ing them.  C.  A.  Herter  has  shown  that  the  toxicity  of  the  blood-serum  is 
increased  in  uremic  states,  while  extirpation  of  the  kidney  or  a  part  of  it 
increases  the  accumulation  in  the  blood  of  urea  and  nitrogenous  substances 
of  the  creatin  class.  It  is  probable  also  that  the  alloxuric  bases,  xanthin, 
hypoxanthin,  which  are  virulently  toxic,  contribute  to  the  s\mx  of  toxins 
responsible  for  uremia.  Retained  ammonia  was  held  responsible  by  Frerichs 
and  others. 

A  second  view  ascribes  uremia  to  deranged  kidney  metabolism  which 
Brown-Sequard  long  ago  suggested  might  depend  on  an  internal  secretion. 


702  DISEASES  OF  THE  URINARY  ORGANS 

Such  disturbance,  especiall}'  that  of  the  muscles  results  in  a  large  increase 
of  urea  and  nitrogenous  bodies  of  the  creatin  class,  as  is  shown  by  extirpa- 
tion of  a  part  of  the  kidney.  Rose  Bradford,  Hughes  and  Cortes  conclude 
that  the  poison  is  albuminous  and  different  from  any  of  the  normal  ingre- 
dients of  the  urea. 

A  third  theory  ascribes  urea  to  nephrctysms  residing  in  the  renal 
substance  which  is  specifically  destructive  of  renal  cells  when  injected  into 
an  animal.  This  is  apparently  confirmed  by  the  obscurations  of  Filluller 
who  ascertained  that  uremia  occurs  in  those  cases  where  there  is  most 
destruction  of  renal  substance. 

Finally  some  clinicians — and  preeminently  Rees  and  Traube — sought 
to  explain  certain  of  the  more  active  nervous  symptoms,  such  as  the  coma 
and  convulsions,  by  supposing  a  localized  edema  of  the  brain  or  its  mem- 
branes. 

Symptoms. — It  is  not  unlikely  that  gastrointestinal  symptoms  includ- 
ing the  loss  of  appetite,  nausea,  vomiting,  and  headache  which  sometimes 
usher  in  an  attack  of  nephritis  may  be  due  to  retained  excrementitious 
matter.  At  all  events,  these  same  symptoms  may  be  the  initial  ones  of 
a  uremia,  coming  on  suddenly  when  the  cause  is  unsuspected.  Vomit- 
ing thus  caused  may  persist,  and  the  patient  perish  in  consequence.  Head- 
ache is  often  occipital,  extending  down  the  neck.  To  it  is  superadded 
dizziness. 

An  early  symptom  is  drowsiness,  which  may  be  sudden  or  gradual  in 
its  onset  and  may  be  slight  or  decided.  From  the  latter  degree  the  tran- 
sition is  easy  to  the  next  symptom,  coma,  from  which  the  patient  may  or 
may  not  be  temporarily  aroused.  Alternating  with  the  latter  may  be 
epileptoid  convulsions,  which  are  the  most  alarming  and  dangerous  symp- 
tom of  Blight's  disease.  This  is  not  alwaj-s  the  order  of  succession  of  these 
symptoms.  Convulsions  may  succeed  drowsiness,  but  as  often  precede, 
and  they  may  occur  without  warning.  Indeed,  there  may  be  no  suspicion 
of  Bright's  disease  whatever  until  a  convulsion  suddenly  occurs.  Drowsi- 
ness, in  like  manner,  maj'  be  the  first  symptom  of  the  renal  disease  to  attract 
attention,  others  being  overlooked  or  possibly  even  absent.  The  convulsion 
exhibits  every  grade  of  movement,  from  the  slightest  twitching  to  the  most 
violent  epileptiform  spasm. 

Suppression  of  urine,  an  almost  constant  symptom,  is  frequently  the 
initial  one  and  should  at  once  excite  suspicion.  Accompanying  it  is  often 
a  breath  of  urinous  odor,  and  when  vomiting  accompanies  scanty  or  sup- 
pressed urine,  the  vomited  matters  sometimes  have  the  same  odor,  the 
constituents  of  urine  being  thus  supplementarily  eliminated.  Renal 
insufficiency  as  determined  by  the  phthalein  test  (p.  699)  is  an  important 
evidence  of  uremia. 

Defective  vision  or  actual  blindness — amaurosis — suddenly  occurring  is 
another  symptom  of  acute  uremia  which  sometimes  supen-enes  upon 
others,  or  it  may  itself  usher  in  the  complication.  This  blindness,  it 
must  be  remembered,  is  altogether  different  from  that  which  is  the  result 
of  organic  retinal  changes,  which  are  rare  in  acute  nephritis,  but  common 
in  some  of  the  chronic  forms.  It  may  be  due  to  retinal  hemorrhage  but 
is  often  unassociated  -Rith  demonstrable  retinal  change.     Uremic  amaurosis 


UREMIA  703 

often  disappears  as  suddenly  as  it  sets  in.  Uremic  deafness  is  also  possible, 
but  is  a  rare  event. 

Itching  of  the  skin  is  another  symptom  sometimes  present  in  uremia.  It 
is  probably  due  to  the  irritant  action  of  urea  upon  the  nen^es  of  the  skin  as 
it  is  being  supplementarily  eliminated  by  that  organ.  That  such  increased 
elimination  takes  place  is  attested  by  that  rare  but  still  unquestioned 
occurrence,  in  which  the  entire  integument  is  covered  with  a  frost-like 
coating,  which  has  been  found  upon  analysis  to  be  made  of  crytals  of 
pure  urea.  Cramps  especially  in  the  muscles  of  the  calf  is  included  by  some 
among  the  symptoms  of  uremia. 

Another  symptom  of  uremia  which  belongs  rather  to  the  uremia  of 
chronic  renal  disease  is  shortness  of  breath — uremic  asthma.  This  is  an 
asthma  which  differs  from  bronchial  asthma  in  the  absence  of  spasmodic 
contraction  of  the  bronchi  but  that  it  is  uremic  in  origin,  we  think,  is  very 
doubtful.  We  believe  it  is  more  frequently  a  cardiac  asthma,  due  to  dilatation 
of  the  heart  succeeding  the  hypertrophy  so  often  present  in  chronic  Bright's 
disease.  It  may  be  that  true  spasmodic  asthma  is  produced  by  uremia,  but  it 
must  be  exceedingly  rare.  The  attacks  are  likely  to  occur  suddenly  at  night. 
To  it  alone  shotdd  the  name  uremic  asthma  be  given.  Paroxj^sms  of 
dyspena  are  also  caused  by  edema  of  the  lung,  which  is  not  infrequent  in 
acute  ne'phritis.  It  is  recognized  by  the  presence  of  fine,  moist  rales.  Of 
course,  it  is  not  impossible  for  nephritis  to  occur  in  an  asthmatic,  whose 
attacks  would  then  occur  as  before,  or  they  might  be  more  frequent  or 
rendered  more  unmanageable  by  the  uremia. 

Cheyne-Stokes  breathing  is  also  a  symptom  of  uremia  and  may  last  for 
a  long  time.  It  may  occur  quite  independently  of  coma.  It  is  more  than 
likely  that  other  disturbances  of  breathing,  even  some  which  closely  resemble 
Cheyne-Stokes  variety,  may  be  due  to  disturbances  of  the  respiratory 
center. 

The  question  of  temperature  in  uremia  has  not  been  satisfactorily  settled. 
Usually  there  is  an  absence  of  any  elevation,  with  at  times  a  tendency  to 
subnormal  temperature.  Sometimes  there  is  an  abnormally  high  tempera- 
ture. But  in  true  uncomplicated  uremia  in  the  majority  of  cases  the 
temperature  will  not  much  exceed  the  normal.  It  is  true,  too,  that  toward 
the  very  end  there  is  commonly  a  rise,  but  this  attends  dissolution  in  so 
many  diseases  that  it  cannot  be  considered  characteristic. 

The  pulse  is  often  slow  in  uremia  before  the  appearance  of  severe  symp- 
toms: sometimes  as  infrequent  as  from  forty  to  fifty,  but  with  severe 
symptoms  it  becomes  more  frequent. 

Acute  mania  and  delusional  insanity  {Folic  Brightique)  may  also  be 
symptoms.  Such  acute  delirium  is  not  very  frequent  and  other  conditions 
are  sometimes  mistaken  for  it,  as  for  example  the  delirium  of  mania  a  potu. 
Rarely  melancholia  and  paralysis  including  hemiplegia  and  even  mono- 
plegia are  symptoms.'  These  may  occur  independently  of  a  convulsion 
or  succeed  it,  in  which  event  there  may  be  may  not  be  any  coarse  lesion 
found  at  necropsy.     True  uremic  plasies  are  of  undoubted  occurrence. 

The  following  table,  although  not  distinctive  gives  a  general  idea  of  the 
differences  between  the  efEects  of  cerebral  hemorrhage,  alcoholic  narcosis 
and  uremia. 


704 


DISEASES  OF  THE  URINARY  ORGANS 


Cerebral  Hemorrhage 

Alcoholic  Narcosis 

Uremia 

Pupils  unequal  or  dilated. 

Pupils  contracted  or  dilated; 

Pupils  generally  dilated;  al- 

eyes injected. 

buminuric  retinitis. 

Stertorous    puffy    breathing 

May  be  stertorous  breath- 

Sterterous breathing. 

and  flapping  cheek. 

ing. 

No  odor. 

Odor  of  alcohol. 

No  odor,  unless  urinous. 

Paralysis;  hemiplegia. 

No  paralysis  usually. 

Paralysis  often  present,  but 
may  be  atypical. 

Pulse  slow  and  strong  or  irreg. ; 

Pulse  frequent  and    feeble. 

Pulse  at  first  strong,  later 

arteries  often  sclerotic. 

weak  and  rapid ;  high  blood 
pressure;  arterio-sclerosis. 

Coma  sudden  and  deep. 

Coma  gradual. 

Coma  gradual  or  sudden. 

Convulsions  late;  may  be  un- 

No  convulsions. 

Preceded  by  general  convul- 

ilatural. 

sions,  headache,  etc. 

Urine  generally  negative. 

Urine  generally  negative  al- 

Urine albuminous  and  con- 

though patient  may  have 

tains  tube  casts. 

Bright's  disease. 

Apoplectic  habit;  heart  may 

Red  face  and  nose,  heart 

Edema    and    paUor;    heart 

show  hypertrophy. 

often   weak   and   dilated; 
myocarditis. 

hypertrophied. 

Moderate  increase  of  blood 

No  rise  in  blood  pressure. 

Blood  pressure  very  high. 

pressure;  Hypertension  how- 

200 mm.  or  more. 

ever  .caused  by  large  intra- 

cranial hemorrhage. 

Renal  insufficiency  as  evidence  by  testing  is  conspicious  in  uremia. 
especially  previous  section  on  Renal  Sufficiency. 


See 


TUBE-CASTS. 

Tube-casts  or  "cylinders,"  as  they  are  sometimes  called,  are  molds 
of  the  uriniferous  tubules.  Their  origin  is  not  always  the  same.  They 
may  be  produced  by  the  coagulation  of  a  fibrinous  constituent  of  the  blood 
which  having  exuded  into  the  tubule  entangles  whatever  it  may  have  sur- 
rounded in  its  liquid  state;  subsequently  it  may  contract  and  slip  out  of  the 
tubule  into  the  pelvis  of  the  kidney,  whence  it  is  carried  to  the  bladder  and 
voided  with  the  urine.     Casts  rarely  exceed  1/25  inch  (i  mm.)  in  length. 

Two  other  possible  modes  of  formation  of  casts  must  be  mentioned, 
according  to  one  of  which  the  cast  represents  disintegrated  and  fused  cells 
which  may  be  the  epithelial  lining  of  the  tubules,  red  corpuscles,  or  leuko- 
cytes; and  according  to  another,  of  a  secretion  from  these  same  cells  as  origin- 
ally suggested  by  Rovido.  That  casts  are  sometimes  formed  accord- 
ing to  the  first,  at  least,  of  these  two  methods  is  not  unlikely,  although  it 
is  more  likely  that  even  in  these  cases  the  basement  substance  which  cements 
the  cells  and  this  debris  is  the  same  exuded  substance  above  referred  to; 
while  there  is  reason  also  to  believe  that  the  so-called  "  cylindroids  "  or  mu- 
cus-casts originate  in  the  second  way. 

That  casts  are  sometimes  f otmd  in  urine  free  from  albumin  in  undoubtedly 
true.     Persons  in  whom  such  casts  occur  are  frequently  healthy. 

The  mechanism  of  the  formation  of  the  different  varieties  of  casts, 
on  the  supposition  of  an  albimninoid  basis  substance  exuded  from  the  blood, 
is  very  simple.  Thus,  suppose  a  tubule  to  be  filled  with  detached  and 
loosely  attached  epithelium  at  the  time  the  coagulable  material  is  poured 
into  it.     These  elements  are  entangled,  and,  as  the  casts  contract,  are  car- 


TUBE  CASTS 


705 


ried  out  in  the  shape  of  an  "epithelial"  cast  (Fig.  121).  If  the  tubule  should 
happen  to  have  contained  blood,  the  cast  entangling  it  is  called  a  "blood- 
cast"  (Fig.  123);  if  white  corpuscles  or  leukocytes,  a  "pus-cast"  (Fig.  122). 
Casts  containing  even  a  few  blood-corpuscles  are  also  called  blood-casts. 


S 


Fig.  121.— Epithelial      Fig.  122.— Pus  Cast. 
Casts     and     Granular 
Fatty  Renal  CeUs. 


123. — Blood  Casts — {after 
Whiltaker). 


The  basic  substance  of  blood-casts  is  most  probably  the  fibrin  of  the  blood. 
If  the  epithelium  be  firmly  attached  to  the  basement  membrane  of  the 
tube  and  remain  behind  when  the  cast  passes  out,  or  if  the  tube  be  entirely 
bereft  of  epithelium,  then  is  the  cast  a  "hyaline"  (Fig.  124)  or  structureless 


Fig.  i24.-Hyaline  Casts.     X  210.  Fig.  I2s.-Hyaline  and  Granular 

Casts.     Illustrating  the  Formation 
of  the  Former  at  a.~(Rindfleisck). 

cast.  In  the  former  instance  the  cast  is  of  smaller  diameter,  and  in  the 
latter  of  larger,  the  diameter  in  the  latter  being  that  of  the  former  plus  twice 
the  thickness  of  an  epithelial  cell.  Figure  125,0,  from  Rindfleisch,  explains 
this  sufficiently.  From  causes  like  these,  as  well  as  a  subsequent  con- 
traction of  the  cast  itself,  the  diameter  of  casts  may  vary  considerably 


706 


DISEASES  OF  THE  URINARY  ORGANS 


ranging  commonly  from  1/2500  to  1/500  inch  (o.oi  to  0.05  mm.).  A  cast 
is  seldom  completely  hyaline,  generally  containing  a  few  granules  and  some- 
times one  or  two  glistening  oil  drops,  but  it  is  still  called  hyaline.  Com- 
pletely hyaline  casts  are,  however,  not  infrequent.  Less  intense  irrita- 
tion seems  to  form  hyaline  casts  while  more  intense  irritants  produce 
granular  casts  which  in  the  course  of  time  may  become  hyaline.  A  vari- 
ety of  hyaline  cast,  more  solid  in  appearance  and  resembling  molten 
wax,  is  a  "waxy  cast"  (Fig.  127).  Some  hyaline  casts  are  so  delicate  as  to  be 
overlooked  unless  the  light  from  the  mirror  illuminating  the  field  of  view  be 
modified  by  shading  with  the  hand  or  by  manipulation  of  the  mirror  itself.  If 
a  cast  contains  granular  matter,  which  is  generally  the  granular  debris  of 
the  degenerated  epithelial  lining  of  the  tubule  or  blood-corpuscle,  it  is 
called  a  "granular"  cast,  and  highly  granular  (Fig.  126,  a),  moderately  or 


Fig.  126. — a.  a.  Dark  Granular  Casts. 
b.  b.  Casts  Partially  Hyaline,  Containing 
Oil-Drops  and  Granular  Matter.     X225. 


Fig.  127. — Wa.xy  Casts.     Xiso. 


pale  granular  (Fig.  125,  c),  slightly  or  delicately  granular  (Fig.  126,  /'),  ac- 
cording to  the  amoimt  of  grantilar  matter  present.  When  the  material 
of  grantilar  casts  is  derived  from  broken-down  blood-corpuscles,  the  casts 
appear  yellow  or  yellowish-red.  Finally,  if  a  cast  is  loaded  with  oil  drops, 
either  free  or  contained  in  epithelial  cells,  it  is  called  an  ' '  oil  cast  or  fatty 
cast"  (Fig.  128). 

Casts  of  smaller  diameter  are  sometimes  found  within  those  of  larger, 
the  material  of  the  latter  having  been  poured  out  around  that  of  the 
former  after  it  has  undergone  some  contraction.  This  occurs  usually  with 
waxy  or  hyaline  casts.  In  consequence  of  the  mode  of  formation  previously 
referred  to,  hyaline  and  waxy  casts  vary  considerably  in  diameter,  some 
being  as  narrow  as  i/iooo  inch  (0.025  mm.)  and  even  narrower,  while 
others  are  as  much  as  1/500  inch  (0.05  mm.)  wide.  There  is  no  doubt 
that  some  of  these  are  formed  in  the  straight  or  collecting  tubes  near  their 
openings  on  the  papillas.  To  these  a  limited  number  of  epithelial  cells  is 
sometimes  attached. 


ACTIVE  CONGESTION  OF  KIDNEY 


707 


Studies  of  the  origin  of  casts  experimentally  ]jroduced.  Ijy  Wollenstein, 
Ribbert,  Schleaht  and  R.  M.  Smith  do  not  lead  to  results  widely  different 
from  the  above.  For  a  fuller  discussion  of  this  subject,  however,  the  reader 
is  referred  to  a  paper  by  Henry  A.  Christian,  "Jour.  Amer.  Med.  Assoc, 
vol.  liii.,  1909,  "Clinical  Value  of  Recent  Studies  in  Experimental  Nephritis." 

Mucus-casts,  Cylindroids. — Casts  are  occasionally  found  which  are 
apparently  pure  mucus-molds  of  the  uriniferous  troubles  (Fig.  129).  Un- 
less covered  by  accidental  elements,  as  granular  urates  or  phosphates  of 
lime,  they  are  smooth,  hyaline,  or  gently  fibrillated  molds,  especially  charac- 
terized by  their  great  length,  in  the  course  of  which  they  may  divide  and 
subdivide,  diminishing  in  diameter  as  the  division  proceeds,  showing  posi- 
tively that  they  come  from  the  kidney.     Yet  there  is  no  albumin,  or  merely 


Fig.  128. — Oil-casts  and  Fatty 
Epithelium.     X  200. 


Fig.  129. — Cylindroid  or  Mucus- 
casts.     X  200. 


as  much  as  could  be  accounted  for  by  the  presence  of  pus  which  some- 
times attends  them.  For  they  are  particularly  apt  to  occur  where  there 
is  irritation  of  the  bladder,  which  is  apparently  extended  through  the 
ureters  to  the  kidney.  Under  these  circumstances  they  are  frequently  met. 
They  are  not  infrequently  voided  in  cases  where  the  urine  has  a  very  high 
specific  gravity,  1030  or  higher,  containing  an  excess  of  urea  and  urates. 

These  casts  are  not  identical  with  the  bands  of  mucin  which  are  found 
in  urine  of  highly  acid  reaction.  The  mucin  bands  are  probably  precipi- 
tated by  the  acids,  are  often  beset  with  granular  urates,  and  might  on  this 
account  be  mistaken  for  casts.  At  the  same  time  the  mucus-cast  is  probably 
nothing  but  pure  mucus  or  mucin. 

DISEASE  OF  THE  KIDNEY. 

DERANGMENTS  OF  CIRCULATION. 


Active  Congestion. 

Etiology. — Active  congestion  occurs  as  the  result  of  poisoning  by  can- 
tharides  or  arsenic,  overdose  of  turpentine,  copaiba,  cubebs,  and  carbolic 
acid  and  in  acute  fevers.  It  is  identical  with  the  first  stage  of  acute  nephritis, 
however  caused.  The  kidney  in  acute  fever  has  usually  been  considered  as 


708  DISEASES  OF  THE  URINARY  ORGANS 

actively  congested,  but  recent  experiments  by  Walter  Mendelsohn  go  to 
show  that  it  is  really  anemic  during  fever,  i.  e.,  small,  pale  and  bloodless, 
so  that  the  organ  is  really  comparable  to  the  anemic  kidney  of  cholera, 
in  which,  too,  there  are  albuminuria  and  nutritional  changes  of  a  degen- 
erative kind  analogous  to  the  cloudy  swelling  affecting  the  renal  cells  in 
acute  fever,  but  more  advanced  in  degree.  Postmortem  this  state  of  the 
kidney  is  not  found  in  fever,  it  is  large,  red  and  swollen  as  all  can  attest 
who  have  to  do  with  either. 

Morbid  Anatomy. — The  kidney  of  active  congestion  is  slightlj'  en- 
larged, swollen,  and,  after  removal  of  the  capsule,  brown  or  mottled.  On 
section,  the  cortex  is  wider  and  darker  than  in  health,  the  blood-vessels 
are  overfull,  the  Malpighian  capsules  are  distended,  and  the  cells  are  the 
seat  of  cloudy  swelling.  The  medulla  is  less  markedly  red  and  is  sharply 
defined  from  the  cortex. 

Symptoms. — There  are  none  except  a  scanty  urine  of  high  specific 
gravity  and  high  color,  sometimes  small  albuminuria,  with  a  few  hyaline 
and  pale  granular  casts. 

Passive  Congestion  or  Cyanotic  Induration. 

Etiology  and  Pathogeny. — While  any  agency  which  obstructs  the 
movement  of  the  blood  through  the  kidney  may  cause  passive  congestion, 
the  causes  encountered  in  actual  practice  are  mostly  limited  to  valvular 
disease  of  the  heart  and  chronic  pulmonary  disease  involving  extensive 
areas  of  the  lung,  such  as  emphysema,  interstitial  pneumonia,  and  pleuris}', 
with  extensive  effusion  or  marked  adhesions.  Pressure  on  the  renal  veins 
by  tumors,  the  pregnant  uterus,  or  ascitic  fluid  acts  similarl}'. 

In  any  event  the  mechanism  of  its  production  is  the  same.  The  blood 
is  crowded  into  the  venous  side  of  the  vascular  system.  In  pulmonary  or 
pleural  disease  the  obstruction  begins  in  the  lungs  instead  of  in  the  heart, 
but  the  mechanism  is  the  same.  Pressure  by  tumor  on  the  renal  vein  is 
even  more  direct. 

Morbid  Anatomy. — The  kidney  of  cyanotic  induration  or  passive 
congestion  is  hard,  firm,  and  bluish-red  on  its  external  surface.  In  the 
earlier  stages  it  is  enlarged  simply  from  the  presence  of  the  large  amount 
of  blood  detained  in  its  vessels.  The  stellate  veins  are  unusually  distinct. 
The  capsule  strips  off  easily,  and  on  section  the  enlargement  is  found  to 
involve  the  cortex,  but  the  veins  of  both  cortex  and  medulla  are  engorged, 
that  of  the  straight  veins  causing  the  medulla  to  appear  darker  in  hue  than 
the  cortex.  The  Malpighian  bodies,  on  the  other  hand,  are  not  always 
engorged.  The  cut  surface  of  the  kidney  is  moist  and  succulent,  but  the 
microscope  reveals  no  further  changes  either  on  the  cortex  or  the  medulla, 
the  epithelium  being  unchanged. 

After  some  duration  the  kidney  is  slightly  if  at  all  larger  than  the  normal 
organ,  though  rarely  smaller.  The  other  superficial  characters  of  hardness, 
smoothness,  and  bluish-red  color,  however,  remain.  Sometimes  there 
appears  a  slight  tendency  to  lobulation.  At  this  stage  the  capsule  does 
not  strip  off  quite  so  easily,  and  may  drag  small  portions  of  the  parenchyma 
with  it.     There  may  then  be  seen  some  shallow  depressions.     On  section,  the 


PASSIVE  CONGESTION  OF  KIDNEY  709 

vessels  are  less  turgid,  and  the  relations  of  the  cortex  and  medi.illa  are  not 
much  altered.  There  may  be  a  slight  overgrowth  of  interstitial  tissue  and 
a  small-celled  infiltration  between  the  tubules.  The  Malpighian  bosdie  are 
sometimes  shriveled,  and  the  epithelium  of  the  tubules  is  granular  and 
slightly  fatty. 

Symptoms. — These  are  primarily  those  of  the  diseases  of  which  it  is 
the  consequence,  of  which  anasarca,  is  of  more  importance.  To  such  is 
superadded  scanty  urine  of  high  specific  gravity,  containing  usually  a  small 
amount  of  albumin  and  a  few  small  hyaline  casts. 

The  dropsy  first  involves  the  lower  extremities,  in  the  area  drained 
by  the  inferior  vena  cava.  There  also  occur,  however,  effusions  into  the 
pleural  sac  and  peritoneum,  and  the  hands  and  arms  may  be  involved. 

The  urine  is  scanty  and  of  high  specific  gravity,  often  1030  to  1035, 
and  even  higher.  It  is  turbid  with  urates,  depositing  a  copious  sediment 
of  them  and  of  uric  acid.  The  albumin  is  usually  small  in  quantity,  but 
may  become  larger  if  the  obstruction  to  the  movement  of  the  blood  is 
great.  The  casts  are  small,  transparent,  or  faintly  granular,  and  not 
numerous — indeed,  often  absent.  Blood  discs  are  sometimes  present.  The 
solids  are  secreted  in  normal  amount.  In  fact,  such  kidneys  can  appar- 
ently be  restored  to  their  normal  function  at  any  time  by  proper  treat- 
ment. Very  rarely  does  it  happen  that  an  intersital  nephritis  is  produced. 
Uremia  is  rare  in  this  form. 

Diagnosis. — Passive  congestion  exists  to  a  certian  degree  in  all  cases 
of  valvular  heart  disease  without  compensation,  but  higher  degrees  may 
be  suspected  when  the  urine  becomes  scanty  and  albuminous,  and  when 
all  the  symptoms  of  the  cardiac  affection  become  aggravated.  When 
the  physician  sees  the  patient  after  the  symptoms  of  passive  congestion 
have  become  marked,  it  is  often  a  nice  question  to  decide  which  of  the  two 
conditions  is  primary,  the  cardiac  or  the  renal  condition;  but  this  sub- 
ject will  be  further  considered  in  treating  of  the  relations  between  kidney 
disease  and  heart  disease. 

Prognosis. — With  the  addition  of  the  renal  complication,  the  incon- 
veniences and  annoyances  of  the  cardiac  disease  become  greatly  aggra- 
vated, while  the  difficulties  in  the  way  of  successful  treatment  are  greater. 
Yet  the  results  which  sorrietimes  follow  appropriate  and  energetic  treat- 
ment and  the  substitution  of  favorable  for  unafvorable  hygienic  surround- 
ings, such  as  succeed  the  admission  of  a  neglected  outcast  to  the  wards 
of  a  hospital,  are  often  astonishing.  Under  these  circumstances  it  is  not 
unusual  for  the  dropsy  to  decline,  the  albumin  and  casts  to  disappear,  and 
the  patient  to  be  restored  to  comparative  comfort.  In  the  meantime  the 
cardiac  decompensation  has  been  temporarily  retarded. 

Treatment. — As  intimated  under 'prognosis,  the  substitution  of  favor- 
able for  unfavorable  hygienic  surroundings, ,  if  the  former  exists,  is  the 
primary  requisite.  Shelter,  warmth,  test,  and  good  food  are  indispen- 
sable. After  this  digitalis  is  the  sheet-anchor,  for  evident  reasons.  We 
have  here  to  deal  with  a  dilated,  weak,  failing  heart,  unable  to  drive  the 
blood  forward'.  Its  power  must  be  increased,  and  we  have  a  remedy  capable 
of  doing  this  in  digitalis.  Sufficient  doses  must,  however,  be  given,  whether 
of  the  tincture,  powder,  or  infusion.     A  1/2  ounce  (15  c.c.)  of  the  infusion 


710  DISEASES  OF  THE  URINARY  ORGANS 

may  be  given  every  six  hours  to  an  adult;  of  the  tincture,  not  less  than  lo 
minims  (0.65  c.c),  or  twenty  drops,  to  be  reduced  when  diuresis  set  in. 
Under  such  doses,  if  the  cardiac  disease  is  not  too  advanced,  the  quantity 
of  urine  may  increase,  become  clear,  its  albumin  and  casts  diminish,  and 
with  these  also  the  dropsy,  dyspnea  and  restless,  sleepless  nights.  AU  that 
has  been  said  under  the  treatment  of  cardiac  valvular  disease  of  substitutes 
for  digitalis  is  applicable  here,  and  the  reader  is  referred  tc  that  section. 

Due  attention  must  also  be  paid  to  the  bowels,  for  the  sake  of  securing 
prompt  action  of  the  diuretics,  as  well  as  the  elimination  which  their  free 
action  accomplishes.  The  hydragogue  cathartics,  such  as  elaterium  and 
the  salines,  are  often  excellent  adjuvants. 

ACUTE  PARENCHYMATOUS  NEPHRITIS. 

Synonyms. — Acute  Nephritis;  Acute  Diffuse  Nephritis;  Acute  Desquama- 
tive Nephritis;  Acute  Tubal  Nephritis;  Acute  Bright's  Disease;  Acute 
Catarrhal  Nephritis;  Croupous  Nephritis;  Albuminous  Nephritis;  Hemor- 
rhagic Nephritis;  Acute  Albuminuria;  Acute  Renal  Dropsy. 

Definition. — Acute  parenchymatous  nephritis  is  an  acute  inflamma- 
tion of  the  kidney,  the  tubular,  vascular,  and  interstitial  tissues  being 
simultaneous!}^  involved  in  different  degrees  in  different  cases.  In  the 
majority  of  cases,  the  parenchyma,  or  secreting  structure,  is  first  and  most 
invaded,  whence  the  term  parenchymatous  nephritis,  although  diffuse 
nephritis  is  a  more  correct  term. 

Etiology. — Most  cases  of  acute  parenchymatous  nephritis  are  caused 
by  seme  poison  of  endogenous  or  exogenous  origin  which  is  carried  by 
the  circulation.  Instances  of  the  former  are  the  toxins  of  scarlet  fever 
or  diphtheria,  whence,  therefore,  it  is  frequent  in  children.  A  certain 
number  originate  from  exposiore  to  cold,  especially  cold  and  dampness,  when 
the  person  is  fatigued  or  exhausted  and  has  been  using  alcohol  to  excess. 
The  cold  here  probably  acts  as  the  exciting  cause  lowering  the  resistance  of 
the  kidney  to  the  circulating  poison.  When  acute  nephritis  supervenes 
on  scarlet  fever,  it  is  usually  not  until  the  end  of  the  second  week,  often 
when  convalescence  is  well  established.  It  may  occur  as  early  as  the 
tenth  day,  seldom,  if  ever,  later  than  the  thirty-first. 

Other  grave  infectious  diseases,  as  small-pox,  acute  endocarditis,  and 
acute  articular  rheumatism,  typhus  and  typhoid  fevers,  pneumonia,  malaria, 
tonsillitis,  measles,  erysipelas,  pyemia,  jaundice,  and  diabetes  have  been 
known  to  cause  it.  Skin  diseases,  as  well  as  extensive  burns  of  the  skin, 
are  acknowledged  causes :  the  former  rarely,  but  the  latter  almost  always  if 
the  bums  be  sufficiently  extensive.  Toxaemia  of  pregnancy  is  a  common 
cause.  This  is  of  extreme  importance  because  if  the  toxaemia  is  discovered 
before  the  nephritis  is  severe  the  cases  respond  well  to  treatment.  Probably 
the  eclampsia  which  sometimes  accompanies  this  condition  is  due  rather  to 
the  toxaemia  than  to  the  nephritis. 

In  looking  for  the  evidence  of  nephritis  in  acute  infectious  diseases, 
it  must  not  be  forgotten  that  intense  febrile  movement  may  cause  albumi- 
nuria, independently  of  any  structural  change  in  the  kidney  due  to  the 


ACUTE  NEPHRITIS  7 1 1 

toxic  agent.  When  thus  caused,  the  albuminuria  is  always  small  and  may- 
be disregarded. 

Of  exogenous  causes  certain  specific  poisons  of  vegetable  and  mineral 
origin  are  capable  of  producing  acute  nephritis.  Among  the  best  known 
of  these  substances  are  cantharides,  turpentine,  oil  of  mustard,  wormseed 
oil,  and  phosphorus;  in  a  less  degree,  the  mineral  acids,  arsenic,  nitrate  of 
sUver,  lead,  and  mercury.  Very  large  quantities  of  alcohol,  when  swallowed, 
have  caused  acute  nephritis. 

Uranium  nitrate,  potassium  chromate,  corrosive  sublimate,  cantharadin 
and  arsenic  are  favorite  poisons  used  in  the  production  of  experimental  nephri- 
tis the  first  three  producing  the  tubular  or  epithelial  form  while  arsenic  and 
cantharodin  produce  the  vascular  type.  Uranium  nephritis  associated 
with  an  excess  of  water  in  rabbits,  at  least,  is  accompanied  by  a  well-marked 
edema,  pointing  to  an  injurious  effect  on  the  blood-vessels  as  well.  More- 
over, the  serum  of  an  animal  with  uranium  nephritis  when  introduced 
in  an  animal  with  chromate  nephritis  causes  also  a  well-marked  edema. 

As  may  be  inferred  from  the  etiology,  acute  nephritis  is  often  a  dis- 
ease of  early  age,  although  when  due  to  cold  or  any  one  of  the  causes 
named  except  scarlatina,  it  is  as  much  more  likely  to  affect  adults  as  these 
latter  are  more  frequently^  subjected  to  such  causes.  It  is  rare  after  40, 
almost  inknown  after  50.  More  males  are  attacked  than  females  in  adult 
life,  evidently  because  they  are  more  frequently  exposed  to  the  causes.  But 
even  in  childhood  there  is  a  slight  preponderance  of  cases  in  boys  affected, 
which  can  hardly  be  thus  accounted  for. 

Morbid  Anatomy. — This  varies  with  the  stage  of  the  disease,  as  well 
as  its  severity.  In  the  first  place,  as  ordinarily  caused,  the  disease  is 
symmetrical,  both  organs  being  alike  involved.  In  the  fully  developed 
stage  the  kidneys  are  more  or  less  enlarged,  in  the  latter  stages  always 
so,  sometimes  to  more  than  twice  their  normal  voltune,  and  they  may 
weigh  from  eight  to  12  ounces  (240  to  360  gm.),  those  of  children  reaching 
the  former,  and  those  of  adidts  the  latter. 

The  capsule  strips  off  easily,  without  dragging  any  of  the  parenchyma 
with  it.  Bereft  of  its  capsule,  the  kidney  itself  is  softer,  inelastic,  and 
doughy.  Its  surface  is  smooth  and  exhibits  a  peculiar  mottled  appear- 
ance, which  is  due  to  the  fact  that  the  little  circlets  of  veins  which  form 
the  boundary  of  the  lobules  are  distinctly  injected,  while  the  area  sur- 
rounded by  each  circlet  is  paler  than  in  health,  and  in  the  more  advanced 
stages  even  yellowish- white  in  color.  This  "irregular  mixture  of  con- 
gestion and  anemia,"  as  Sir  George  Johnson  early  called  it,  is  further 
contributed  to  by  the  injection  of  other  veins  indistinct  in  health.  Spots 
of  hemorrhagic  extravasation  may  also  be  found  scattered  over  the  surface. 

On  section,  it  is  evident  that  the  enlargement  is  due  to  change  in  the 
cortex  and  the  interpyramidal  convoluted  portion.  The  cut  surface 
is  smeared  over  with  a  dark  red  or  chocolate-hued  blood,  but  on  scrap- 
ing or  washing  it  away  the  vessels  are  found  injected  like  those  of  the 
surface,  and  between  them  the  same  paleness  or  yeUowish-white  hue 
is  seen.  The  Malpighian  bodies  are  enlarged  and  distinct,  dark  red,  some- 
times pale.  Punctiform  hemorrhages  may  also  be  present,  as  on  the 
surface  of  the  organ.     The  pyramids  are  dark  red. 


712  DISEASES  OF  THE  URINARY  ORGANS 

Minute  Changes. — These  are  confined  almost  solely  to  the  labyrin- 
thine structure.  They  by  no  means -always  correspond  in  degree  with  what 
woiild  be  expected  from  the  symptoms,  being  often  entirely  inadequate  to 
explain  them.     The  changes  are  tubal,  glomerular,  and  interstitial. 

I.  Tubal  Changes. — These  vary  a  great  deal  with  the  stage  of  the 
disease.  The  earliest  change  assumed  by  the  cells  is  cloudy  swelling, 
a  result  of  increased  nutritive  activity.  In  this  state  the  cells  are  swollen 
and  "cloudy"  from  a  deposition  of  albuminous  granules,  which  may 
obscure  the  nucleus.  Although  kidneys  removed  after  death  from  cases 
of  acute  parenchymatous  nephritis  have,  as  a  nde,  advanced  far  beyond 
this  stage,  yet  it  is  often  possible  to  find  points  at  which  cloudy  swelling 
exists  alongside  of  more  advanced  stages,  while  alongside  of  these,  again, 
may  be  tubes  in  which  the  epithelium  is  normal.  The  swollen  cells  are 
larger,  and  the  tubes  are  therefore  distended,  increasingly  so  in  a  later  stage, 
with  granular  cells,  granular  debris,  and  often  red-blood  disks  and  leuko- 
cytes. Under  a  low  power,  the  tubules  appear  as  black,  more  or  less  opaque 
lines.  A  closer  examination  of  the  cells  at  this  stage,  as  obtained  by  scrap- 
ing, shows  them  to  be  granular  in  various  degrees.  In  some  the  nucleus  is 
still  visible,  in  others  demonstrable  by  the  aid  of  staining  fluids  onlj-,  and 
in  others  still  entirely  obscured.  Occasionally  a  few  fat  drops  may  be 
present.  In  other  situations  the  cells  are  so  closely  packed  in  the  tubules 
that  they  cannot  be  differentiated,  being  apparently  fused  in  one  con- 
tinuous, dark,  granular  mass.  It  is  to  these  tubules,  distended  with 
granular  cells  and  their  debris,  dark  by  transmitted  light,  but  white  bv 
reflected,  that  the  pale  or  white  color  seen  between  the  injected  blood- 
vessels is  due.  Casts  of  the  uriniferous  tubes  are  also  found  in  situ,  usually 
blood  casts  or  small  hyaline  casts.  Minute  extravasations  of  blood, 
visible  to  the  naked  eye,  have  been  referred  to.  Thej''  occupy  the  tubules, 
and  in  the  "hemorrhagic"  form  the  interstitial  tissue. 

2.  Glomerular  Changes. — The  glomerule  first  is  aft'ected.  The  capillaries 
of  the  tuft  are  distended  with  blood,  which  bursts  through  into  the  Mal- 
pighian  capsule,  distending  it  with  red  blood-corpuscles  and  leukocytes. 
In  a  more  advanced  stage,  the  glomeruli  ma3'  be  paler,  in  consequence  of 
the  proliferation  of  the  cells  lining  the  capsule  and  covering  the  glomerule 
(glomerulonephritis) . 

These  glomerular  changes  are  present  in  almost  all  cases.  They 
include  swelling  and  desquamation  of  the  capsular  epithelium,  and  an 
accumulation  of  cells  in  the  interior  of  the  capillaries  (intracapUlar)') . 
probably  due  to  a  proliferation  of  their  endothelial  lining  or  an  accumulation 
of  white  blood-cells,  or  thickening  and  hyaline  degeneration  of  the  capillary- 
walls.  The  last  named  vascular  lesion  is  found  in  experimentally  produced 
acute  nephritis'.  These  are  especially  frequent  in  nephritis  after  scarlet 
fever  or  diphtheria. 

3.  Interstitial  Changes. — In  mild  cases  there  is  no  interstitial  change, 
no  formation  or  deposit  of  new  material  between  the  tubes.  In  others 
there  is  a  serous  transudate,  with  few  leukocvtes  in  most  cases,  and  red 


'  See  the  studies  of  Perace,  Christian,  R.  M.  Smith  and  Walker  on  "Experimental  Renal  and  Cardio- 
renal  Disease"  published  in  the  "Journal  of  the  A.  U.  A.,"  the  "Archives  of  Medicine"  and  "Journal  of 
Experimental  Medicine,"  1909-1912. 


PLATE  VI. 

FIG.    1. 


1.— MYELOCYTES  ■li,:     ■■'    '"    .'.S 


FIG.    2.— STAINED     WITH      EOSI  N  -  H  AEMOTO  X  YLON .  A.— MYELOCYTES     OF     EHRLICH. 

B.— POLYNUCLEAR     LEUCOCYTES.  C— LYM  PH  OCYTE  .  D.— NUCLEATED     RED 

CORPUSCLE.         E.— DEGENERATED     NUCLEUS.  F.  — RED    CORPUSCLES. 


PLATE    EXHIBITING    STAINED    CORPUSCLES    FROM    THE    BLOOD 
OF    A    CASE    OF   LEUKHAEMIA. 


ACUTE  NEPHRITIS  713 

blood-disks.  In  severer  cases  there  is  a  large  outwandering  of  cells,  and 
a  small-celled  infiltrate  settles  itself  between  the  convoluted  tubes  and 
around  the  capsules.  In  cases  of  extreme  severity,  a  diffuse  nephritis 
involving  both  tubes  and  intertubular  tissue  may  be  present  from  the  outset. 
In  such  event,  the  latter  is  uniformly  pervaded  more  densely  in  certain 
places  by  leulcocytes. 

The  epithelial  lining  of  the  straight  tubes  of  the  pyramids  is  unchanged, 
but  the  tubes  themselves  often  contain  cellular  and  granular  material  which 
has  descended  from  the  convoluted  tubes. 

Serous  infiltration  and  effusion  are  present  in  various  tissues  when 
the  patient  is  dropsical  at  the  time  of  death.  Among  other  tissues  some- 
times thus  infiltrated  are  the  membranes  of  the  brain,  constituting  what 
is  known  as  edema  of  the  brain.  The  mucous  membrane  of  the  pelvis 
of  the  kidney  may  be  injected,  but  otherwise  imchanged. 

Symptoms. — The  mode  of  onset  of  acute  nephritis  is  not  always  the  same. 
Usually  it  is  sudden.  Less  frequently  the  illness  is  ushered  in  by  a  chUl  or 
chilliness.  More  often  the  first  observed  symptom  is  slight  swelling  or 
puffiness  in  the  face,  below  the  eyes,  associated  with  more  or  less  falling  off  in 
urinary  secretion.  This  edema  rapidly  extends  to  the  upper  extremities 
and  trunk,  and  thence,  if  the  disease  does  not  abate,  into  the  lower  extremi- 
ties and  abdominal  walls.  In  the  male,  the  scrotum  and  prepuce_are 
favorite  seats  of  swelling.  The  great  serous  sacs  are  the  last  to  fill  with 
fluid  in  acute  nephritis,  altiiough  in  bad  cases  ascites  not  infrequently 
occurs,  while  there  may  also  be  transudation  into  the  pleural  and  pericar- 
dial cavities.  The  degree  assumed  by  the  general  anasarca  is  sometimes 
enormous,  resulting  in  extreme  distortion.  The  eyes  may  be  actually 
closed  by  the  swelling,  and  movement  of  the  lower  limbs  rendered  almost 
impossible.  Dropsy  does  not  always  follow  the  order  here  named.  Much 
depends  upon  the  position  of  the  patient.  Thus,  if  he  be  upon  his  feet, 
the  latter  may  be  the  first  to  swell,  or  if  he  be  lying  in  the  recumbent 
position,  the  back  may  be  the  seat  of  the  first  swelling.  While  dropsy 
is  a  very  frquent  symptom  in  acute  nephritis,  it  is  not,  however,  always 
present.  It  is  more  particularly  in  the  nephritis  after  scarlet  fever  and 
exposure  to  cold  that  it  is  a  decided  and  almost  invariable  symptom.  After 
the  other  infectious  diseases, it  is  frequently  absent. 

Modem  studies  have  shown  that  changes  of  a  very  positive  character 
in  the  glomerular  capUlaries  occur  in  connection  with  experimentally 
induced  nephritis. 

In  view  of  the  fact  that  studies  in  experimental  nephritis  have  discovered 
in  the  capillaries  of  the  glomerule,  a  vascular  lesion  consisting  in  a  type  of 
hyaline  degeneration  favoring  the  transudation  of  serum,  and  since  these 
studies  tend  to  show  that  the  edema  of  nephritis  is  dependent  on  some 
vascular  lesion;  and  since,  moreover,  uranium  nitrate  which  produces  the 
glomerular  lesion  referred  to  is  the  one  which  experimentally  most  frequently'' 
leads  to  the  accumulation  of  fluid  in  the  cavities  and  subcutaneous  tissue 
associated  with  renal  lesion,  Christian  and  his  colleagues  made  a  series  of 
experiments  to  determine  whether  or  not  other  demonstrable  vascular 
lesions  resulted  from  the  subcutaneous  injection  of  uranium  nitrate  in  rab- 
bits.    These  resulted  in  the  conclusive  that  the  degenerative  condition  is 


714  DISEASES  OF  THE  URIXARV  ORGAXS 

limited  to  the  glomerular  capillaries  and  does  not  affect  the  other  small 
vessels  of  the  kidney  or  those  of  the  heart,  liver,  spleen  or  mesentery.  It 
is,  however,  likely  that  despite  the  absence  of  anatomical  lesion  some 
vasciUar  lesion  may  exist  as  is  shown  in  the  case  of  arsenic  which  producing 
a  paralysis  of  the  capillary  walls  allows  a  leakage  of  serum  tc  take  place, 
with  no  demonstrable  inflammatory  lesion. 

Not  infrequently  the  disease  is  ushered  in  by  nausea  and  vomiting  and 
very  rarely  by  uremic  symptoms  (see  p.  702). 

Fever  is  not  a  marked  symptom  in  acute  nephritis;  indeed,  it  is  gen- 
erally absent,  unless  as  a  part  of  the  disease  causing  it.  It  is  more  apt  to 
occur  in  children.  To  a  less  degree  the  same  is  true  of  pain.  It  is  mostly 
absent,  and  when  present  amounts  only  to  a  dull  ache,  as  a  rule.  Nausea 
and  vomiting  are  not  infrequent  in  the  beginning.  Sometimes  these  symp- 
toms usher  in  the  disease.  The  pulse  is  quite  characteristically  altered. 
While  not  materially  changed  in  rate,  it  exhibits,  especially  in  sphygmo- 
gram,  a  decided  increase  in  tension,  as  shown  by  the  broader  apex  and 
diminished  dicrotic  element.  Blood  pressure  is  increased,  but  much  less 
than  in  chronic  nephritis. 

Uremia. — At  almost  any  time  in  the  course  of  an  acute  nephritis  the 
patient  is  liable  to  uremia  with  the  train  of  nervous  symptoms  usually  known 
as  uremic.  Its  causes  and  phenomena,  so  far  as  known,  were  considered 
under  general  symptomatology,  page  702.  When  present,  it  adds  a  phase 
of  extreme  gravity. 

Changes  in  the  Urine  . — Simultaneously  with,  and  sometimes  earlier 
than,  the  dropsical  symptoms  are  diminution  in  the  quantity  and  alteration 
in  the  quality  of  the  urine.  The  former  may  amount  to  actual  suppres- 
sion. The  urine  is  darker  than  natural,  and  often  smoke-hued  from  the 
effect  of  the  natural  acid  reaction  on  a  small  quantity  of  blood.  Should 
the  urine  become  alkaline,  the  color  becomes  a  brighter  red.  The  hue  is 
more  positively  red  if  the  quantity  of  blood  is  large,  which  is  not  often  the 
case;  but  here  again  the  peculiar  tint  returns  if  the  blood  is  allowed  to  sub- 
side.    The  blood  may  disappear,  to  return  again. 

The  specific  gravity  of  the  urine  at  first  is  high- — 1025  to  103a — mainly 
due  to  the  diminished  quantity,  while  the  solids  remain  nearly  normal. 
Later,  if  the  symptoms  abate,  the  specific  gravity  diminishes  with  the 
increase  in  the  quantity;  or,  if  the  disease  lasts  for  any  length  of  time 
or  passes  over  into  the  chronic  form,  a  similar  reduction  in  weight  oc- 
curs; this  may  result  in  a  specific  gravity  as  low  as  loio. 

The  chief  alteration  is  the  presence  of  albumin.  This  is  generally 
large  the  urine  often  solidifying  on  the  application  of  heat  and  acid,  while  it 
constantly  contains  more  than  half  its  bulks.  This  albumin  is  derived  in 
part  from  the  extravasated  blood,  and  in  part  is  a  result  of  the  inflammatory 
action.  If  estimated  by  weight,  it  will  equal  0.5  to  i  per  cent.,  and,  in 
rare  instances  only,  1.5  per  cent. 

As  to  sediment,  the  urine  af  all  cases  of  acute  parenchymatous  neph- 
ritis deposits  a  sediment  which,  in  the  early  stages  at  least,  is  copious 
and  brownish  or  reddish-brown  in  hue;  later,  it  may  diminish  in  amount 
and  assume  a  lighter  color.  Microscopical  examination  reveals  this  de- 
posit to  be  made  up  mainly  of  casts  of  the  uriniferous  tubules,  free  cells 


ACUTE  NEPHRITIS  715 

from  these  same  tubiiles,  blood-corpusdes,  red  and  colorless,  and  very 
constantly  crystals  of  uric  acid,  together  with  granular  urates.  The 
casts  include  the  varieties  known  as  epithelial  casts,  blood  casts,  hyaline 
casts,  waxy,  and  dark  granular  casts.  Pus  casts  and  numerous  leuko- 
cytes are  also  sometimes  present.  The  hyaline  casts  are  probably  pure  fi- 
brin. The  epithelial  casts  consist  of  the  same  material,  to  which  epithe- 
lial cells  of  the  tubules  are  attached,  and  blood  casts  have  blood-corpus- 
cles caught  in  the  coagulated  exudate.  The  epithelium  thus  attached, 
as  well  as  that  which  is  found  free  in  the  urine,  is  variously  altered.  Some 
of  the  cells  are  merely  the  seat  of  cloudy  swelling,  others  are  decidedly 
granular,  while  others  again  are  converted  into  compound  granule  cells 
or  granular  fatty  cells  by  complete-  fatty  degeneration.  These  arise  as 
the  disease  advances.  Casts  containing  a  few  oil  drops  ma}^  also  be  pres- 
ent, but  much  oil  is  not  found  until  the  case  has  continued  for  some  time — 
in  fact,  become  chronic. 

Along  with  the  diminished  quantit}^  of  urine  is  often  met  a  disposi- 
tion to  frequent  micturition,  the  efforts  at  which  are  only  partially  suc- 
cessful, resulting  in  the  emission  of  from  a  few  drops  to  a  tablespoonful. 
This  frequent  desire  to  pass  water  is  a  purely  reflex  symptom,  the  blad- 
der being  free  from  disease.  It  sometimes  precedes,  in  point  of  time, 
all  other  symptoms.     It  is  by  no  means  constant. 

The  duration  of  acute  nephritis  is  variable — from  a  few  days  to  several 
months,  while  the  acute  form  may  become  chronic.  The  former  class 
of  cases  are  fatal,  for  none  which  recover  do  so  in  a  few  days.  The  most 
rapid  usually  required  a  month.  As  to  the  cases  of  longer  duration,  the 
possibility  of  recovery  at  any  time  cannot  be  denied,  but  nothing  is  better 
determined  than  that  the  longer  the  duration  the  more  difficult  the  cure. 
Of  course,  such  cases  are  no  longer  acute. 

Complications. — These  are  not  numerous  in  acute,  as  contrasted  with 
chronic  Bright's  disease,  and  some  which  are  described  as  complications 
are  not  really  such,  but  local  symptoms.  Thus,  edema  of  the  lungs  occurs 
as  a  part  of  the  general  tendency  to  dropsy,  due  to  cardiac  failure,  and 
may  be  a  grave  symptom,  resulting  in  death  by  suffocation.  It  is  not  the 
result  of  an  interciurent  bronchitis.  Pneumonia,  on  the  other  hand,  is 
an  occasional  true  complication.  Inflammation  of  the  serous  membranes 
is  more  truly  a  complication  but  not  every  case  in  which  there  is  effusion 
into  a  serous  cavity  is  inflammatory.  Such  effusions  may  be  local  dropsies. 
The  exudate  may  become  purulent,  thus  also  increasing  the  gravity  of 
the  case.  Pleurisy  is  the  most  frequent  form,  pericarditis  next,  and  peri- 
tonitis next.  The  tubercular  origin  of  the  graver  forms  of  pleurisy  occur- 
ring in  Bright's  disease  has  been  suggested. 

Hypertrophy  of  the  left  ventricle  is  not  a  frequent  complication  of  acute 
nephritis.  It  iS  a  well-recognized  one  of  chronic  Bright's  disease.  Time 
is  an  essential  condition  to  its  production.  It  is  not,  therefore,  until  the 
nephritis  has  existed  for  some  time  that  it  commonly  occurs.  It  does 
occasionally  happen  earlier.  Thus,  Dickinson  reports  a  case  recognized 
at  eight  weeks,  and  von  Leube  one  at  ten  days  succeeding  the  first  symp- 
toms. The  infallible  sign  of  hypertrophy  is  sharp  accentuation  of  the 
aortic  second  sound,  with  or  without  demonstrable  enlargement  of  the 


716  DISEASES  OF  THE  URINARY  ORG  AX  S 

normal  area  of  dullness.  Arterial  hypertension  present  to  a  degree  in  all 
is  less  marked  than  in  chronic  interstitial  nephritis. 

Allusion  has  been  made  to  gastric  symptoms  which  \'ery  commonly 
attend  acute  nephritis,  especially  after  scarlet  fever.  Samuel  Fenwick' 
and  Wilson  Fox^  have  shown  that  these  may  be  associated  with  organic 
changes  in  the  stomach.  Fen  wick  ascribes  them  to  gastritis,  as  evidenced 
by  increased  vascularity  of  the  mucous  membrane,  distention  of  the  tubes 
by  a  confused  mass  of  ceUs  and  granular  matter,  and  occasional  thickening 
of  the  basement  membrane.  To  these,  Fox  has  added  thickening  of  the 
intcrtubular  tissue. 

Notwithstanding  the  frequency  of  convtdsions  in  acute  nephritis, 
structural  alterations  in  the  brain  are  almost  unknown.  Apoplectic  effu- 
sions are  rare,  probably  because  of  the  integrity  of  the  blood-vessels  of  the 
brain  in  the  young,  in  whom  the  disease  mainly  occurs.  Blindness  which 
is  not  frequent.  Albuminuric  retinitis  does  not  occur  in  acute  parenchy- 
matous nephritis,  except  with  the  extremest  rarity. 

Diagnosis. — The  diagnosis  of  acute  parenchymatous  nephritis  is  ordin- 
arily quite  easy.  The  previous  history  of  health  the  usually  easily  recog- 
nizable cause,  the  suddenness  of  the  attack,  the  scanty'  and  bloody  urine 
with  its  high  specific  gravity,  the  copious  albuminuria,  the  blood  and 
epithelial  and  dark  granular  casts,  the  blood-corpuscles,  free  epitheliirm, 
and  granular  cells  in  the  urine — these  are  a  combination  of  symptom-s 
which  admit  of  only  one  interpretation.  At  a  later  stage,  the  absence  of 
one  or  more  of  these  symptoms  may  somewhat  increase  the  dilEculty,  but 
it  is  scarcely  possible  to  err  if  those  which  remain  are  duly  considered. 
It  must  be  remembered,  also  that  an  acute  condition,  such  as  this  described, 
may  supervene  upon  any  one  of  the  chronic  forms  of  Bright' s  disease  to 
be  described,  and  this  may  give  rise  to  some  difficulty  of  diagnosis,  but  if 
there  be  hypertrophy  of  the  left  ventricle,  it  is  likely  that  there  was  chronic 
disease  before;  in  the  latter  case,  too,  there  is  apt  to  have  been  anemia 
existing  for  some  time,  previous  edema,  headache,  and  other  symptoms  of 
chronic  Bright's  disease. 

Febrile  albuminuria  is  quite  often  mistaken  for  acute  nephritis  by 
those  who  have  had  little  experience,  though  the  distinction  is  easy.  In 
pure  febrile  albuminvuia,  the  quantity  of  albumin  is  very  small,  and  while 
there  may  rarely  be  a  few  hj-aline  casts,  there  are  no  blood-disks  and  no 
epithelial  casts.  The  absence  of  dropsy  is  of  no  significance,  for  in  the 
acute  nephritis  of  the  infectiotis  diseases,  except  scarlet  fever  and  diph- 
theria, there  is  seldom  dropsy.  There  may  also  be  febrile  albuminuria  in 
scarlet  fever  which  is  quite  different  from  the  nephritis  occasioned  by 
this  disease.  It  occurs  early,  and  in  this  stage  the  other  features  of  febrile 
albuminuria  are  present,  wlule  the  scarlatinal  nephritis  does  not  come  on, 
as  already  stated,  until  after  the  end  of  the  second  week. 

While  the  glomerular  changes  referred  to  are  more  usual  in  scarla- 
tinal nephritis,  there  is  no  certain  way  of  recognizing  such  condition,  and 
the  term  glomerulo-nephritis,  which  is  applied  to  the  nephritis  associated 


I  Samuel  Fenwick.  "The  Morbid  States  of  the  Stomach  and  Doude 
>  Wilson  Fox,  "  Medico-Chirurg.  Transac,"  vol.  xli.,  p.  361. 


ACUTE  NEPHRITIS  717 

with  these  changes,  is  scarcely  justified  from  the  clinical  standpoint 
because  there  are  no  symptoms  by  which  it  can  be  recognized. 

The  diagnosis  of  uremia  commonly  easy,  is  sometimes  difficult.  This 
is  especially  the  case  when,  instead  of  the  usual  complex  list  of  symptoms 
detailed  on  page  702,  there  are  but  one  or  two.  By  no  means  every  ner- 
vous manifestation  conicident  with  Bright's  disease  is  uremic.  On  the 
other  hand,  localized  convulsions  and  hemiplegias,  commonl)-  ascribed 
to  some  anatomical  lesions  in  the  brain,  are  often  uremic  in  origin.  Given, 
however,  a  case  of  sudden  convulsions  or  coma,  or  even  muscular  twitching, 
if  it  is  associated  with  scanty  urine  and  greatly  diminished  urea  excretion, 
it  may  be  ascribed  to  uremia,  provided  there  is  no  cause  which  will  explain 
it  more  satisfactorily. 

We  are  pajdng  less  attention  of  late  to  the  estimations  of  iirea  in  the 
urine  as  an  aid  to  the  diagnosis  of  uremia  because  of  other  factors  and 
especially  food  effects  on  the  quantity.  On  the  other  hand  the  estimation 
of  urea  in  the  blood  has  acquired  greater  importance  from  these  experi- 
ments of  C.  A.  Herter  and  A.  J.  Wakeman^  who  showed  that  a  positive 
increase  in  the  urea  of  the  blood  succeeded  upon  extirpation  of  the  kidneys 
from  a  normal  average  per  cent,  of  0.037  to  an  average  of  0.315  per  cent,  in 
dogs.  Similar  increase  in  the  urea  of  the  blood  was  obser\^ed  bj-  the 
experimenters  in  several  cases  of  uremia  (See  also  p.  702  et.  seq.). 

Uremia  has  been  mistaken  for  opium  and  alcohol  intoxication,  and  it  must 
be  admitted  that  the  coma  in  all  three  is  very  much  alike.  But  one  need 
only  be  forewarned  to  prevent  such  error.  In  opium-poisoning  the  pupils 
are  contracted,  in  alcoholism  they  are  dilated;  in  tiremia  they  var}'. 

The  phthalein  test  is  of  utmost  value  in  deciding  as  to  whether  symp- 
toms under  observation  are  due  to  renal  insufficiency  or  not. 

Prognosis. — Grave  as  this  disease  is  justly  considered,  recoveries  from 
it  are  numerous  and  the  prognosis  is  generally  favorable.  Even  without 
treatment,  cases  may  recover,  and  more  recoveries  follow  a  judicious 
treatment.  The  prognosis  should,  however,  always  be  guarded,  as  insidious 
causes  may  produce  death  when  it  is  least  expected.  Among  the  most 
important  of  these  is  uremia. 

B  artels  said  that  death  from  uremia  in  acute  nephritis  has  never 
occurred  in  his  experience,  except  when  the  disease  has  resulted  from 
scarlatina  or  diphtheria;  but  Dickinson  narrates  a  fatal  case  resulting 
from  exposure,  in  which  death  was  preceded  b}^  coma  and  other  sji'mp- 
toms  of  evident  uremic  origin,  and  Tyson  has  observed  similar  cases. 

Pulmonary  edema  is  a  cause  of  sudden  death,  the  patient  drowning, 
as  it  were,  in  his  own  secretions.  Its  onset  is  characterized  b}-  short- 
ness of  breath,  frothy  expectoration,  and  abundant  small  rales. 

The  symptoms  of  gravest  import  are,  therefore,  those  of  uremia,  mani- 
fested in  any  one  or  all  the  various  ways,  the  presence  of  any  of  the  com- 
plications alluded  to,  and  especially  suppression  of  urine.  Cases  shoidd 
not,  however,  be  despaired  of,  even  when  there  is  complete  suppression  of 
urine.  Always,  however,  this  is  the  gravest  of  symptoms,  and  death 
generally  ensues  within  a  couple  of  days  after  it  sets  in.  The  possibility 
of  sudden  death  should  always  be  borne  in  mind,  and  mentioned  to  the 

J  "Blood  Changes  in  Double  Nephrectomy,"  "  Journal  of  Experimental  Medicine,"  vol     v.,  iSpPo  ' 


718  DISEASES  OF  THE  URINARY  ORGAXS 

relatives  of  the  patient,  although  the  number  of  cases  in  which  this  occurs 
is  not  very  great.  Of  course,  the  longer  the  duration  of  the  case  the  less 
the  likelihood  of  recovery. 

Treatment. — Many  cases  of  acute  nephritis  recover  under  the  con- 
ditions of  rest,  quietude,  and  warmth,  and  it  is  further  certain  that,  what- 
ever other  means  of  treatment  are  used,  these  three  conditions  are  ab- 
solutely necessary  to  recovery.  A  patient  with  acute  Bright's  disease, 
therefore,  whatever  its  mode  of  origin,  should  be  put  to  bed,  kept  quiet, 
and  covered  warmly. 

The  diet  of  patients  with  acute  Bright's  disease  should  be  of  the  simplest 
and  easiest  of  digestion,  and  should  contain  a  minimum  of  proteids.  The 
irritability  of  the  stomach  in  this  disease  has  been  alluded  to,  and  it  is 
important  that  food  should  be  adapted  to  it.  Milk  may  be  considered  the 
typical  food,  not  merely  because  of  its  easy  assimilation  and  nutri  ious 
character,  but  because  there  is  abundant  testimony  to  prove  that  albu- 
minuria diminishes  under  its  use,  while  the  amount  of  nitrogen  contributed 
to  the  blood  is  less  than  by  animal  flesh.  The  combination  of  lime-water, 
and  still  better  of  carbonated  water  or  Vichy,  with  milk,  is  an  eminently 
suitable  one.  Koumys,  Zoolak  and  buttermilk  are  also  suitable.  While 
solid  animal  food  is  not  to  be  recommended,  weak  animal  broths  may  be 
permitted,  to  break  up  the  monotony  of  a  pure  milk  diet.  Beef-teas  and 
extracts  should  be  prohibited  as  harmful.  Rice  and  farinaceous  preparations 
generally  are  suitable  adjuvants  to  the  milk  diet. 

We  should  seldom,  however,  be  satisfied  with  this  treatment  alone. 
The  selection  of  other  measures  will  depend  somewhat  upon  the  severity 
of  the  case.  If  the  urine  be  suppressed,  dry  cups,  or,  in  severe  cases,  wet 
cups  to  the  loins  may  divert  the  blood  and  relieve  the  stagnation  which 
always  exists  in  the  acutely  inflamed  kidney.  Cups  shovdd  be  followed 
by  a  warm  poultice  to  the  same  region,  which,  indeed,  should  be  used 
under  any  circumstances,  whether  the  cupping  is  necessary  or  not.  Dry 
cups  should  not  be  allowed  to  remain  on  one  spot  longer  than  to  secure 
a  bright  redness,  after  which  they  must  be  withdrawn  or  moved  to  another 
spot  in  the  vicinitj'.  By  allowing  them  to  remain  too  long,  the  blood  is 
stagnated  in  the  capillaries,  its  onward  movement  prevented,  and  there  is, 
therefore,  no  derivation  of  blood  from  the  involved  organ. 

The  foregoing  measures  have  for  their  object  the  direct  relief  of  the 
congestion  of  the  kidney.  This  is  further  accomplished  by  purgation, 
which  supplements  the  action  of  the  kidney.  But  a  purgative  is  early 
employed  not  more  for  this  purpose  than  to  promote  the  action  of  other 
remedies.  Absorption  is  slow  when  the  blood-vessels  are  congested  and 
there  is  a  sluggish  current.  The  cathartic  relieves  this  turgor,  and  after 
its  effect  prompt  absorption  and  action  of  other  remedies  may  be  looked 
for.  The  purgative  most  suitable  is  a  saline.  A  simple  dose  of  bitartrate 
of  potassium,  simple  magnesia  for  children,  citrate  of  magnesium,  or 
Epsom  salt  for  adtdts  will  be  sufficient.  The  indication  is  to  get  a  watery 
stool  as  soon  as  possible.  In  view  of  the  fact  that  the  stomach  is  often 
sensitive,  it  is  desirable  to  use  an  aperient  which  is  not  nauseous  or  ir- 
ritating, and  to  this  end  some  one  of  the  delicate  effervescing  prepara- 
tions so  common  in  modern  pharmacy  may  be  used. 


ACUTE  NEPHRITIS  719 

Next,  or  simultaneously,  the  action  of  the  skin  should  be  promoted. 
This  is  done  by  maintaining  warmth  and  avoiding  cold,  as  already  insisted 
upon.  But  we  are  not  confined  to  these  protecting  measures.  The  skin 
may  be  made  to  do  the  work  of  the  kidney  itself,  and  thus  one  of  the  most 
alarming  dangers  of  Bright's  disease,  uremic  intoxication,  averted,  while 
at  the  same  time  the  congestion  of  the  kidney  is  also  relieved.  The  class 
of  remedies  which  produces  this  action  are  diaphoretics  (warmth  described 
is  one  of  these) ,  and  of  the  simple  remedies,  none  is  better  than  the  ordinary 
sweet  spirit  of  niter,  especially  if  it  be  combined  with  neutral  mixture  and 
small  doses  of  ipecacuanha.  If  more  active  measures  are  required,  pilocar- 
pin  may  be  given  with  caution  in  doses  of  from  1/24  to  1/12  grain  (0.0027 
.to  0.0054  gm.).  The  further  use  of  this  important  remedy  -will  be  again 
referred  to  in  treating  uremia. 

Another  method  of  accomplishing  the  same  end  is  by  warm  baths, 
or,  better  still,  by  the  warm  pack,  in  which  the  patient  is  wrapped  in 
a  sheet  wrung  out  in  warm  water  and  then  enveloped  in  a  sufficient  number 
of  blankets.  Perspiration  is  thus  copiously  induced,  and  when  thus 
caused  is  agreeable  and  never  attended  by  the  faintness  which  sometimes 
follows  the  use  of  the  hot-air  bath.  In  an  ordinary  severe  case  of  acute 
Bright's  disease,  a  single  pack  of  this  kind  will  often  remove  all  urgent 
symptoms  and  happily  inaugurate  the  convalescence.  It  may,  however, 
be  repeated  daily,  if  necessary.  Hot  air  or  hot  steam  packs  are  more 
easily  given  with  one  of  the  various  forms  of  cabinets  on  the  market. 

Diuretics  are  not  indicated  in  the  early  stages  of  Bright's  disease,  they 
should  be  deferred  until  the  measures  just  described  have  been  employed. 
Digitalis  is  the  diuretic  most  to  be  relied  upon.  It  is  necessary,  however, 
to  have  a  reliable  preparation,  and  unless  one  is  sure  of  the  quality  of  the 
tincture,  it  is  best  to  use  a  freshl}''  prepared  infusion. 

Digitalis  should,  therefore,  be  given  in  sufficient  doses — 1/2  to  i  fluidram 
(2  to  4  c.c.)  of  the  infusion  to  children,  and  2  fluidrams  to  .1/2  fluidounce 
(8  to  16  c.c.)  to  adults — repeated  every  four  hours,  until  an  appreciable 
effect  is  produced  on  the  rate  of  the  pulse,  when  it  should  be  diminished. 
Not  until  then  can  we  look  for  a  diuretic  action.  We  prefer  at  first  to  give 
it  alone.  Later  it  may  be  combined  with  acetate,  citrate,  and  bitartrate  of 
potassium.  The  diuretic  action  of  these  salts  probably  depends  upon  the 
impetus  they  give  to  osmosis  of  fluids  holding  them  in  solution,  thus  filling 
the  blood-vessels,  which,  in  their  turn,  give  out  water  to  flush  the  kidney. 
To  adults,  20  grains  (1.3  gm.)  of  either  may  be  given  every  two  or  three 
hours,  freely  diluted,  because  water  itself  is  an  excellent  diuretic;  from  5 
to  10  grains  (0.32  to  0.648  gm.)  to  children,  as  often.  An  important  object, 
too,  is  to  maintain  an  alkaline  urine,  which  tends  to  dissolve  exudates. 
For  this  purpose,  the  alkaline-mineral  waters  are  also  useful,  or  what  is 
commonly  known  as  cream-of-tartar  tea  may  be  drank  instead  of  water. 
A  teaspoonful  of  potassium  bitartrate  is  put  into  a  pint  of  boiling  water, 
and  taken  cold  as  drink  is  wanted. 

Fisher's  Alkaline  Treatment  of  Acute  Nephritis. — Prof.  Martin  H.  Fisher^ 
premising  that  all  the  changes  that  characterize  nephritis,  viz.,  the  albu- 

>  Nephritis  and  Experimental  Study  of  Its  Nature,  Cause,  and  Principles  of  Relief.  The  1911  Cart- 
wright  Prize  Essay,  N.  Y.,  1912. 


720  DISEASES  OF  THE  URINARY  ORGANS 

mintiria,  the  specific  morphological  changes  noted  in  the  kidneys,  the 
associated  production  of  casts,'  the  qualitative  variations  in  the  dissolved 
solids  are  due  to  a  common  cause — the  abnormal  production  or  accumula- 
tion of  acid  in  the  cells  of  the  kidney — concludes  that  the  entire  purpose  of 
our  therapy  must  be  to  get  alkali  into  the  patient  to  neutralize  the  acids 
present.  To  this  end  he  recommends  administration  by  the  rectum  of 
sodium  bicarbonate  crystallized,  20  grams,  sodium  chloride,  14  grams, 
and  water  enough  to  make  1000  c.c.  This  is  administered  high  up  in  the 
bowel  by  the  drop  (Murphy)  method  at  the  body  temperature.  In  a  typical 
case  with  anuria,  in  an  hour  and  ten  minutes  30  c.c.  of  blood>'  urine  were 
passed  and  in  an  hour  80  c.c.  more. 

From  then  on  the  "urine  fairly  streamed  out"  and  b}^  the  fourth  day 
albumin  and  casts  had  entirely  disappeared. 

Prof.  Fisher's  book  contains  the  reports  of  niunerous  cases  in  which  it 
was  brilliantly  successful.  Dr.  H.  Lowenburg'  of  Philadelphia  also  re- 
ported at  the  recent  meeting  of  the  Medical  Society  of  the  State  of  Pennsyl- 
vania three  cases  with  like  success.  It  is  evident  that  this  treatment 
by  introducing  chloride  of  sodium  in  this  blood  involves  \'iews  counter  to 
those  who  advocate  the  salt-free  diet  in  nephritis  associated  with  dropsy. 
Treatment  of  Acute  Uremia. — The  alarming  and  dangerous  character 
of  the  symptoms  cf  this  condition  demand  a  separate  consideration  of 
the  measures  required  in  their  treatment.  The  treatment  which  has  just 
been  described  is  such  as  would  be  called  for  by  an  ordinary  case  of  acute 
nephritis  of  a  decided  character.  The  tendency  of  it  will  be  to  prevent 
■  the  retention  of  those  toxic  matters,  whatever  their  precise  natiure,  which 
constitute  the  cause  of  uremia.  But  all  efforts  in  this  direction  sometimes 
fail,  and  we  are  called  upon  to  contend  with  convulsions  or  coma,  or,  more 
frequently,  both.  How  shall  they  be  met?  The  indication  has  already 
been  explained.  Elimination  is  demanded.  The  kidneys  are  not  acting, 
and  the  secretion  of  urine  is  suppressed.  There  remain,  therefore,  but  the 
bowels  and  skin  to  operate  upon.  But  the  patient  is  unconscious  and 
cannot  swallow  voluntarily.  Such  remedies,  must,  therefore,  be  used  as 
do  not  require  his  cooperation.  '  These  are  croton  oil  and  elateritim.  Of  the 
former,  2  drops,  slightly  diluted  with  plain  oil  or  glycerin,  rasLj  be  carried 
into  the  back  part  of  the  throat,  or,  in  case  of  extreme  necessity,  undiluted, 
may  be  introduced  into  the  mouth,  whence  it  is  quickly  absorbed.  Its 
operation  may  be  facilitated  by  a  rectal  injection.  Of  elaterium,  a  quarter 
of  a  grain  (0.0165  g^n.)  in  solution  may  be  administered  by  the  mouth. 

In  like  manner,  the  skin  may  be  made  to  substitute  the  action  of  the 
kidney.  The  vapor  or  hot-air  bath  or  hot  pack  should  at  once  be  availed 
of.  The  vapor  may  be  conveyed  tinder  the  bed  clothes  by  a  pipe  from  a 
vessel  of  water  heated  by  a  spirit-lamp,  the  patient,  with  the  exception  of  his 
head,  being  well  covered  with  a  mackintosh  and  blanket.  An  ordinary' 
rain-spout  may  be  used.  Hot  air  may  be  similarly  conveyed,  but  does 
not  act  so  quickly.  Its  action  may  be  favored  by  moistening  the  skin. 
The  hot  pack  is  also  ver\-  efficient  and  less  uncomfortable.  One  of  the 
various  forms  of  cabinets  is  better. 

I  Proctoclysis  as  a  Curative  and  Prophylactic  Agent  in  Primary  and  Secondary  Acute  Nephritis  in 
Children.     Read  before  the  Medical  Society  of  Pennsylvania,  Sept.  26,  1912. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS  721 

Pilocarpin  may  be  used  hypodermically.  One  Vs  grain  (0.006  gm.)  of 
hydrochlorate  may  be  thus  administered,  and  if  perspiration  does  not  set 
in  in  a  half-hour,  it  may  be  repeated.  Its  action  is  also  greatly  facilitated 
by  warmth  applied  to  the  patient. 

If  the  convulsions  continue,  blood-letting  may  be  practised,  to  be  followed 
by  an  intravenous  injection  of  normal  salt  solution. 

The  hydrate  of  chloral  is  one  of  the  most  valuable  remedies  for  the 
convulsion  and  should  be  one  of  the  first  measures  tried.  In  the  case  of  an 
adult,  a  dram  (4  gm.)  in  solution  may  be  injected  into  the  rectum;  15  to  30 
grains  (i  to  2  gm.)  for  a  child.  Its  use  is  sometimes  followed  by  the  prompt- 
est favorable  results.  Chloroform  may  also  be  used  to  control  the  convulsion 
while  the  eliminating  measures  are  acting. 

The  use  of  opium  requires  mention.  The  caution  which  has  always 
been  suggested  in  its  use  is,  in  the  main,  a  wholesome  one,  and  I  should 
prefer  to  produce  hypnotic,  sedative,  and  antispasmodic  effects  by  chloral 
and  the  bromids  whenever  it  is  possible.  At  the  same  time  there  can  be 
no  doubt  that  it  may  be  used  cautiously  with  great  benefit.  It  was  in  the 
convulsions  of  acute  nephritis  that  the  late  Professor  Loomis,  of  New  York 
City,  recommended  it,  although  its  wider  use  has  grown  out  of  this  sugges- 
tion. His  practice  was  to  treat  cases  of  uremic  convulsions  in  acute 
nephritis  with  hypodermic  injections  of  large  doses  of  morphin — 1/2  grain 
(0.033  gm-)  or  more. 

The  same  measures  which  have  been  detailed,  excepting  the  general 
blood-letting  and  chloral,  may  also  be  employed  in  the  treatment  of  sup- 
pression of  urine  or  of  obstinate  dropsy  without  uremic  symptoms,  with 
such  modifications  as  circumstances  may  suggest,  due  regard  being  paid 
to  the  strength  of  the  patient.  They  will  be  further  referred  to  when 
discussing  the  treatment  of  the  chronic  forms  of  Bright' s  disease. 

Sooner  or  later,  also,  in  the  treatment  of  acute  parenchymatous  nephritis 
supporting  measures  are  rendered  necessary  to  repair  the  losses  which  the 
blood  suffers  by  the  albuminuria,  and  to  some  extent  also  by  the  depleting 
measures  of  treatment.  These  effects  should  indeed  be  anticipated  by 
proper  diet,  tonics,  especially  iron  or  strychnine,  as  indicated.  These  meas- 
ures will  also  be  more  particularly  aUuded  to  in  the  treatment  of  chronic 
Bright's  disease. 

Treatment  of  Complications. — Complications  should  be  treated  by 
remedies  called  for  by  such  conditions  independent  of  the  renal  cause. 
Effusions  into  the  plural  cavities  and  abdomen  are  often  best  relieved 
by  paracentesis  or  aspiration. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Synonyms. — Chronic  Diffuse  Nephritis;  Chronic  Tubal  Nephritis;  Chronic 
Catarrhal  Nephritis;  Large  White  Kidney. 

Definition. — A   chronic   diffuse   hyperplastic    process    in    the    kidney, 
involving  the  epithelium,  glomeruli,   and  interstitial  tissue. 
I  «    Etiology. — This    cannot    always    be    traced.     While    it    is    frequently 
a  continuation  of  acute  nephritis,   more  frequently  it  originates  de  novo. 


722  DISEASES  OF  THE  URINARY  ORGANS 

To  cases  in  the  former  category  scarlatina  and  pregnancy  contribute  the 
greater  number.  To  the  second  class  belong  insidious  cases,  the  cause 
of  which  is  often  not  treaceable.  Habitual  exposure  to  cold  and  dam])- 
ness,  such  as  residence  in  damp,  cold  houses,  may  cause  sorhe.  Tubercular 
disease  of  the  lungs  is  an  undoubted  cause.  Great  stress  is  laid  by  German 
writers  upon  malarial  poisoning  as  a  cause.  Out  of  1832  cases  of  malaria 
collected  at  Johns  Hopkins  Hospital  there  were  25  with  nephritis.  It 
may  be  the  case  in  more  southern  parts  of  the  United  States,  where  malarial 
poisoning  is  more  intense  than  in  the  Middle  States.  Alcohol  is  a  cause, 
and  the  nephritis  of  confirmed  drunkards  and  the  employees  of  breweries 
may  be  thus  accounted  for,  though  it  cannot  be  denied  that  the  exposure 
to  which  some  of  the  former  class  are  subjected  may  be  responsible.  Males, 
and  of  these  young  adults,  are  the  more  frequent  subjects.  Sepsis  in 
prolonged  surgical  affections  may  produce  chronic  nephritis. 

Morbid  Anatomy. — There  are  two  distinct  stages  in  the  morbid  an  at-. 
omy  of  chronic  parenchymatous  nephritis  if  the  disease  is  of  sufficient 
duration — viz.,  the  stage  of  enlargement,  represented  by  the  large  white 
kidney,  and  that  of  contraction,   or  the  fatty  and  contracting  kidney.     A 
special  variety  is  chronic  hemorrhagic  nephritis. 

I.  Stage  of  Enlargement. — There  are  few  more  striking  objects  in  mor- 
bid anatomy  than  a  typical  large  white  kidney.  The  kidney  is  large,  smooth, 
white,  or  slightly  tinged  with  yellow;  weighs  generally  from  seven  to  ten 
ounces  (217  to  310  gm.),  but  is  often  much  heavier.  It  is  usually  doughy, 
but  sometimes  elastic  in  consistence.  The  capsule,  which  may  be  thinner 
than  in  health,  strips  off  easily,  but  occasionally  drags  a  little  cf  the  paren- 
chyma with  it.  When  the  smooth  white  surface  thus  uncovered,  is  examined, 
the  little  capillary  circlets  bounding  the  lobules  in  the  normal  organ  are  in 
some  places  indistinct,  in  others  conspicuous;  the  same  is  true  of  the  stellate 
veins  of  Verheyn.  Numerous  3'ellow  specks  are  seen  scattered  over  the  sur- 
face. Hemorrhagic  extravasations  are  also  occasionally  present,  but  very 
much  more  rarely  than  in  the  acute  form.  Alongside  of  these  the  greater 
translucency  of  more  nearly  normal  areas  results  also  in  a  characteristic 
mottled  hue.  On  section,  it  is  evident  that  the  enlargement  resides  alto- 
gether in  the  cortex,  which  is  also  anemic,  its  intense  white  contrasting 
strongly  with  the  pink  hue  of  the  cones,  which,  though  paler  than  in  health, 
are  much  less  so  than  the  cortex.  Closer  examination  of  the  cut  cortex  re- 
veals the  same  yellow  specks  as  found  on  the  external  surface.  They  con- 
tribute, with  similar  less  decided  alterations,  to  form  a  series  of  dull  white 
striae  which  alternate  with  somewhat  broader,  translucent  striae  radiating 
toward  the  surface;  the  former  correspond  to  the  area  of  the  convoluted 
tubules  and  Malpighian  bodies — the  labyrinth — the  latter  to  that  of  the 
medullary  rays. 

The  pelvis  of  the  kidney  in  chronic  parenchymatous  nephritis  may  be 
the  seat  of  catarrhal  swelling  and  a  slight  degree  of  hyperemia. 

Minute  Change. — Microscopic  examination  of  thin  sections  shows  the 
involvement  of  tubes,  blood-vessels  and  intertiibidar  substance.  Of  the  former, 
many  arc  found  choked  with  granular  cells  and  the  graniolar  debris  of 
cells,  causing  them  to  appear,  under  the  microscope,  as  black,  opaque  lines 
by  transmitted  light,  very  similar,  indeed,  to  the  tubes  in  acute  nephritis. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS  '  723 

In  other  situations  the  tubules  are  filled  with  fat  globules  and  fatty  cells. 
In  places  the  lumen  of  the  tubes  is  preserved,  in  others  not.  Other  cells 
are  the  seat  of  hyaline  change.  Others  still  are  nearly  normal.  The  parts 
presenting  a  yellow  tinge  are  those  in  which  the  fat  has  replaced  the  normal 
protoplasm,  and  this  is  the  composition  of  the  yellow  specks  already  al- 
luded to  as  visible  to  the  naked  eye.  They  represent  a  coil  of  tubules  filled 
with  oil  drops  or  fatty  cells.'  Certain  tubules  contain  casts,  often  of  the 
waxy  kind.  Sometimes  they  are  very  numerous.  Rarely,  hemorrhagic 
extravasations  are  found  in  the  tubules. 

The  capillaries  of  the  cortex  are  completely  or  nearly  empty  of  blood, 
which  has  been  expressed  from  them  by  the  distended  tubules.  To  this 
and  to  the  fatty  cells  is  due  the  extreme  whiteness  of  these  kidneys,  whence 
the  name  large  white  kidney.  Many  of  the  glomeruli  are  enlarged,  their 
capsules  thickened,  their  vessel-walls  thickened  and  hyaline,  their  capil- 
lary and  glomendar  epithelium  proliferated  and  degenerated. 

The  pyramids  in  chronic  parenchymatous  nephritis  are  more  changed 
than  in  the  acute  form,  but  the  changes  in  them  are  quite  secondary.  They 
are  sometimes  a  little  paler,  owing  partly  to  a  granular  and  fatt)^  altera- 
tion in  the  cellular  lining  of  the  straight  tubules,  and  partly  to  the  presence 
of  cells  pushed  down  from  the  cortex  above  them.  On  the  other  hand, 
they  may  be  congested  and  darker  in  color.  The  straight  tubes  of  the  cones 
as  well  as  the  looped  tubes  of  Henle  often  contain  waxy  casts. 

In  chronic  parenchymatous  nephritis  the  interstitial  tissue  is  always 
increased,  it  may  be  said,  as  a  rule  in  proportion  to  the  duration  of  the  dis- 
ease. It  is  difficult  to  say  when  this  overgrowth  begins  in  any  given  case. 
Langhans  reports  a  case  in  which  death  occurred  five  weeks  after  the  ap- 
pearance of  the  first  symptoms,  directly  traceable  to  a  thorough  wetting, 
in  which  the  stroma  was  markedly  thickened.  And  in  a  case  of  Dickinson's 
already  alluded  to,  intertubular  cellular  formation,  "though  approximating 
as  much  to  pus  as  to  fiber,"  was  found  within  six  weeks  of  the  onset.  Again, 
cases  of  much  longer  duration  may  be  entirely  without  it.  Interstitial  fibro- 
sis may,  however,  be  considered  as  a  superaddition  of  chronicity,  and 
whenever  a  case  is  distinctly  chronic,  it  may  be  inferred,  with  tolerable 
certainty,  that  it  is  present.  In  this  overgrowth  the  quantity  of  the  con- 
nective tissue  between  the  tubules  varies  extremely,  being  sometimes  so 
slight  as  to  be  discoverable  only  by  the  microscope  in  thin  sections;  at 
other  times  it  is  appreciable  to  the  naked  eye.  Minute  examination  shows 
the  thickened  trabeculje  to  consist  of  numerous  round  and  oval  nuclei, 
between  which  may  be  homogeneous  or  more  or  less  distinctly  fibrillated 
intercellular  substance. 

2.  The  Stage  of  Atrophy. — The  Fatty  and  Contracting  Kidney  or  Small 
White  Kidney.—^The  interstitial  new  formation  previourly  referred  to  pos- 
sesses the  properties  usual  to  new  connective  tissue.  Produced  primarily 
to  replace  destroyed  tubular  structure,  it  shrinks  and  gradually  contracts 
the  previously  enlarged  organ,  while  obliterating  in  turn  a  corresponding 
amount  of  the  same  structure.     The  extent  of  contraction  varies  greatly, 

1  No  satisfactory  explanation  has  yet  been  offered  of  the  great  differences  in  the  degree  of  fatty  degen- 
eration in  the  different  kidneys  of  chronic  parenchymatous  nephritis  or  in  different  parts  of  the  same 
kidney.      Dickinson  says  the  ceils  have  a  greater  tendency  to  be  fatty  when  cold  is  the  cause. 


724  ■        DISEASES  OF  THE  URINARY  ORGANS 

increasing  with  the  duration  of  the  process.  The  kidney  may  continue  as 
large  and  even  larger  than  the  normal  organ,  though  smaller  than  the 
large  white  kidney,  and  its  surface  is  uneven,  lobulated,  rough,  and  gran- 
ular. Its  capsule  does  not  strip  off  easily,  as  from  the  large,  smooth  organ, 
but  drags  with  it  considerable  of  the  tubular  structure.  The  capsule  re- 
moved, however,  the  surface  of  the  kidney  exhibits  between  the  constric- 
tions the  same  pallid,  speckled  appearance,  distinct  stellate  veins,  etc. 
already  described;  and  on  section  the  cortex  exhibits  the  same  anemic 
appearance,  but  may  be  narrowed.  Microscopically,  sections  exhibit  the 
same  alternation  of  groups  of  normal  and  choked  tubules  alongside  of  ether 
places  in  which  the  tubules,  together  with  the  Malpighian  bodies  at  their 
extremities,  are  obliterated.  Between  them  is  found  a  large  amount  of 
interstitial  tissue,  and  the  Malpighian  bodies  are  surrounded  by  concentric 
layers  of  the  same.  Even  minute  cysts,  the  result  of  obstruction  of 
tubules  by  the  constricting  tissue,  are  found.  The  secondary  origin  of  this 
form  of  kidney  is  not  conceded  by  everyone,  an  independent  primary 
origin  being  claimed  for  it. 

3.  A  special  form  of  this  stage  is  chronic  hemorrhagic  nephritis.  In 
this  form  brown  hemorrhagic  foci  are  scattered  throughout  the  cortex 
between  and  in  the  tubes.  The  organ  is  still  larger  than  normal,  and  pre- 
sents in  other  respects  the  histology  of  this  stage. 

It  not  infrequently  happens  that  along  with  the  changes  constituting 
chronic  parenchymatous  nephritis  are  found  also  those  of  amyloid  disease 
Thus,  in  a  large  white  kidney  the  Malpighian  bodies  will  often  strike  the 
mahogany-red  reaction  with  iodin  characteristic  of  this  condition,  although 
the  alteration  may  not  be  recognizable  by  the  naked  eye.  Occasionally 
the  change  may  even  affect  the  afferent  and  efferent  vessels. 

Symptoms. — There  are  few  distinctive  symptoms  of  chronic  parenchy- 
matous nephritis.  When  not  a  sequel  of  acute  nephritis  it  often  begins 
insidiously,  and,  after  a  variable  period  of  indescribable  ill  health,  includ- 
ing often  digestive  derangements,  an  anemic,  waxy  appearance  develops, 
with  puffiness  of  the  face  and  swelling  of  the  feet.  Ultimately,  the  anasarca 
may  become  general,  involving  the  face,  hands,  feet,  legs,  thighs,  and 
trunk.  The  serous  sacs  also  frequently  contain  fluid,  almost  always  in 
advanced  cases.  The  swelling  may  be  confined  to  the  extremities  or  to 
the  face,  and  may  even  be  limited  to  more  unusual  situations,  as  the  scro- 
tum. On  the  other  hand,  dropsy  is  often  entirely  wanting,  but  as  a  rule  it  is 
manifest  sooner  or  later,  and  no  symptom  gives  the  patient  so  much  in- 
convenience. In  advanced  cases,  the  legs  and  thighs  are  twice  their  normal 
thickness.  They  are  so  heavy  he  can  scarcely  lift  them,  while  they  are 
often  excoriated  and  moist  with  exuding  serum,  and  smarting  with  irritation. 
Sometimes,  as  the  result  of  spontaneous  rupture  of  the  skin,  the  flow  of 
serum  is  profuse,  saturating  the  bed-clothing  and  even  dropping  upon  the 
floor;  often  vAfh  relief  to  the  patient. 

Another  very  frequent  symptom  is  anemia,  producing  a  peculiar  trans- 
lucent waxy  appearance,  quite  characteristic  and  often  alone  sufficient  to 
suggest  the  disease.  But  there  may  be  very  slight  degrees  which  do  not 
attract  attention.  Again,  the  debility  of  those  suffering  from  advanced 
chronic  Bright's  disease  is  very  striking.     If  able  to  walk,  they  soon  get 


CHRONIC  PARENCHYMATOUS  NEPHRITIS  725 

out  of  breath — are  soon  exhausted.  Dyspnea,  especially  on  exertion,  is 
therefore  a  frequent  symptom,  and  sometimes  is  extreme. 

The  Urine. — The  urine  is  diminished,  although  somewhat  variable  in 
quantity.  It  is  often  turbid,  reddish-yellow,  specific  gravity  changing  as 
the  quantity,  highly  albuminous,  and  deposits  often  bulky,  cloudy  sediment. 
At  other  times  the  sediment  is  scanty.  The  quantity  of  urine  also  increases 
as  the  patient  improves  or  as  the  stage  of  contraction  is  entered  upon,  so 
that  it  may  even  exceed  the  normal.  The  albumin,  while  also  large,  varies 
as  to  its  percentage  amount  with  the  quantity  of  urine  passed — from  five- 
tenths  to  two  per  cent.,  or  from  one-half  to  three-fourths  of  the  volume  of 
the  urine  tested.  The  amount  of  albumin  lost  in  the  urine  is  sometimes  very 
large.  It  has  even  occurred  that  the  percentage  proportion  of  albumin  in 
the  urine  has  exceeded  that  in  the  serum  of  the  blood  from  the  same  patient. 
The  quantity  of  albumin  has  very  little  effect  upon  the  specific  gravity. 
Indeed,  the  lighter  urines  are  generally  those  which  have  the  larger  amount 
of  albumin,  because  highly  albuminous  urines  often  contain  little  urea. 

The  sediment  is  made  up  of  variously  granular  casts,  among  which  the 
dark  granular  are  conspicuous  by  their  numbers  and  size,  and  especially 
their  width.  There  are  also  found  oil-casts  and  casts  containing  entire  and 
fragmentary  epithelial  cells,  which  are  likewise  granular  and  oily.  Finally, 
yellow  waxy  casts  are  found.  Casts  vary  in  number,  being  sometimes 
scanty,  but,  as  a  rule,  they  increase  with  the  development  of  the  disease  and 
grow  less  as  it  mends.  Occasionally  they  are  entirely  absent  for  a  time, 
even  in  this  form  of  Bright's  disease,  sometimes  as  the  result  of  treatment, 
when  such  absence  may  be  considered  a  favorable  sign.  Sometimes,  on  the 
other  hand,  the  tubules  are  choked  with  them,  and  the}^  do  not  descend  into 
the  urine.  Compound  granule  (granular  fatty)  cells  and  other  forms  of 
fatty  renal  cells  are  often  numerous.  Leukocytes  are  also  often  very 
numerous,  while  red  corpuscles  may  be  present  and  in  the  hemcrrhagic 
form  very  numerous. 

Uremia  is  infrequent  in  chronic  parenchymatous  as  compared  with  acute 
nephritis  and  contracted  kidney.  It  is  more  frequent  after  the  stage  of  con- 
traction is  reached. 

The  Stage  of  Contraction. — Are  there  any  symptoms  by  which  we  can 
recognize  the  stage  of  secondary  contraction,  which  takes  place  sooner  or 
later,  provided  the  patient  lives  ?  The  most  reliable  evidence  that  this  has 
occurred  is  the  presence  of  hypertrophy  of  the  left  ventricle  and  accentua- 
tion of  the  aortic  second  sound,  although  the  possibility  of  an  earlier  hyper- 
trophy cannot  be  denied.  The  increased  vascular  tension,  mentioned  as 
presenting  itself  even  in  acute  nephritis,  continues  in  the  chronic  variety  to 
stimulate  the  heart  to  more  forcible  contraction,  which  must  sooner  or  later 
result  in  hypertrophy.  As  already  stated,  time  is  required  to  reach  this 
stage,  and  by  the  time  hypertrophy  is  developed,  contraction  of  the  kidney 
is  likely  to  have  occurred.  Long  duration  of  the  disease  also  affords  pre- 
sumptive evidence  that  contraction  has  taken  place.  If  a  case  of  undoubted 
parenchymatous  nephritis  continues  under  observation  for  a  year  or  more, 
the  process  of  contraction  is  likely  to  have  commenced. 

The  dropsy  diminishes  and  may  disappear  as  the  stage  of  contraction  is 
entered  upon.     So,  also,  the  urine  changes  in  its  properties.     The  quantity, 


72G  DISEASES  OF  THE  URIXARV  ORGANS 

previously  small,  is  increased,  while  the  specific  gravity  falls  below  normal — 
loio  to  1015;  the  quantity  of  dbumin  is  also  much  smaller  than  during  the 
stage  of  inflammation.  In  these  respects — absence  of  dropsy,  larger  amount 
of  urine,  and  smaller  amount  of  albumin — it  resembles  the  true  contracted 
kidney  of  interstitial  nephritis,  with  which,  indeed,  it  may  be  confounded 
in  the  absence  of  a  previous  history.  But  the  casts  continue  to  be  quite 
numerous,  and  exhibit  much  the  same  character  that  they  do  in  the  stage  of 
enlargement,  although  they  too  may  be  few,  and  if  we  have  not  a  knowledge 
of  previous  history;  the  diagnosis  between  contraction  secondary  to  previous 
enlargement  and  primary  contraction  the  result  of  interstitial  nephritis  may 
be  impossible.  Uremia  is  more  common  in  the  stage  of  contraction  than 
that  of  enlargement. 

In  the  hemorrhagic  form  the  urine  almost  constantly  contains  blood. 
The  quantity  varies  somewhat  and  is  diminished  while  the  patient  is  in 
bed,  but  reappears  the  moment  he  arises. 

The  duration  of  chronic  parenchymatous  nephritis  is  variable,  from  a  few 
months  to  years.  Some  mild  forms  last  a  long  time,  causing  comparatively 
little  inconvenience. 

Complications. — The  complications  of  chronic  parenchymatous  nephritis 
are  the  same  as  those  of  acute.  Edema  of  the  lungs,  bronchitis,  pneumonia, 
and  inflammation  of  serous  membranes  are  all  liable  to  occur.  Hypertrophy 
of  the  left  ventricle  is  more  common  than  in  acute  nephritis,  but  much  less 
so  than  in  interstitial  nephritis.  Derangements  of  digestion  are  ver}^  fre- 
quent, sometimes  due  to  a  more  advanced  stage  of  the  structural  changes 
described  under  acute  nephritis.  The  acute  blindness,  unattended  by  retinal 
changes,  described  as  occurring  in  the  uremia  of  acute  nephritis,  rarely 
happens.  Retinal  changes  while  occurring  are  still  uncommon  as  compared 
with  interstitial  nephritis,  under  which  they  will  be  described. 

Diagnosis. — Many  cases,  especially,  if  advanced,  are  ver\-  easy  of  diagno- 
sis. The  anemia  of  the  patient,  the  dropsy,  the  diminished  urine  of  medium 
specific  gravity,  the  usually  large  amotmts  of  albumin,  the  numerous  dark 
granular,  and  waxy  casts  of  large  diameter,  free  fatty  cells,  and  fatty  granular 
cells,  especially  if  we  are  able  to  trace  a  history  of  long  duration,  all  point 
to  the  disease;  and  if  there  is  an  antecedent  histor}'  of  scarlatina  or  exposure 
to  cold,  pregnancy,  or  long  exposure,  probability  becomes  certainty. 

The  symptoms  of  amyloid  or  lardaceous  kidney  ver\r  closely  resemble 
those  of  the  large  white  kidney,  and  it  has  been  mentioned  that  the  same 
causes  are  capable  of  developing  both.  It  is  often  impossible  to  say  which 
form  of  disease  is  present.  It  has  usually  been  considered  that  if  there  is 
enlargement  of  the  liver  and  spleen,  or  persistent  diarrhea,  and  the  cause 
is  one  which  may  produce  lardaceous  disease,  it  is  certain  that  the  latter 
condition  exists;  but  obsen'ation  has  shown  that  the  first  two,  at  least, 
may  be  present,  together  with  all  the  causes  and  other  symptoms  which  are 
regarded  as  favoring  lardaceous  disease,  and  ^-et  the  disease  be  parenchymat- 
ous nephritis;'  while  the  usual  causes  of  lardaceous  disease  may  operate  to 
produce  it  in  the  liver,  leaving  the  kidney  intact.  As  a  rule,  there  is  not  so 
much  dropsy  in  lardaceous  disease,  casts  are  more  scanty,  and  generally 

'  See  an  article  bv  Paul  Fiirbringer,  "  Zur  Diagnose  der  amyloiden  Entartung  der  Nieren,"  "Virchow'3 
Archiv."  Bd.  l!i.xi.,  i'877.  S.  400. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS  727 

hyaline,  granular,  and  waxy;  hypertrophy  of  the  heart  and  uremia  and 
albuminuric  retinitis  do  not  occur.  Often,  too,  the  two  forms  of 
disease  coexist,  either  as  the  result  of  the  same  cause,  or  the  amyloid 
disease  may  be  the  result  of  long-continued  parenchymatous  nephritis. 

Many  mild  cases  are  not  easily  distinguished  from  interstitial  nephritis. 
The  last  is  characterized  by  higher  blood  pressure,  by  hypertrophy  of  the  left 
ventricle,  often  sclerotic  arteries  and  polyuria,  while  remaining  symptoms 
are  often  quite  similar. 

The  stage  of  contraction  is  more  dififictJt  of  recognition  unless  we  have 
had  the  case  for  some  time  under  observation  and  are  able  to  trace  its  con- 
tinuation with  the  stage  of  inflammation.  The  resemblance  to  the  con- 
tracted kidney  of  interstitial  nephritis  is  even  closer  in  the  third  stage  of 
parenchymatous  nephritis.  But  here,  again,  the  albuminuria  is  likely  to  be 
larger  and  the  casts  more  numerous,  including  the  numerous  varieties  men- 
tioned instead  of  the  scanty,  small  hyaline  casts  which  attend  interstitial 
nephritis.  In  the  latter  the  quantity  of  urine  exceeds  the  normal,  while  in 
the  former,  although  the  quantity  is  larger  than  in  the  stage  of  enlargement, 
it  is  still  less  copious  than  in  true  interstitial  nephritis. 

Prognosis. — This  is  unfavorable  so  far  as  recovery  is  concerned.  Well- 
marked  cases  terminate  usually  within  two  years,  and  sometimes  within  a 
few  months.  Many  cases,  however,  may  be  very  much  prolonged,  and  if 
they  reach  the  stage  of  contraction,  the  patient  may  be  tolerably  comfort- 
able for  some  time.  But  sooner  or  later  the  heart  fails,  the  dropsy  returns, 
and  the  patient  dies  of  exhaustion,  of  intercurrent  disease,  or  some  one  of  the 
complications.  Of  the  former,  edema  of  the  lungs  or  of  the  glottis  and  pneu- 
monia are  particularly  dangerous. 

Treatment. — While  it  occasionally  happens  that  spontaneous  recoveries 
from  acute  nephritis  occur,  this  is  not  the  case  with  the  chronic  form. 
Here  the  expectant  plan  cf  treatment  does  not  suffice.  As  a  rule  the  patient 
with  chronic  parenchymatous  nephritis,  if  left  alone,  grows  slowly  worse, 
and  although  it  may  result  in  treatment  may  not  often  cure,  marked  improve- 
ment and  may  long  avert  the  fatal  end.  There  is  always  an  intermediate 
stage  between  that  cf  acute  nephritis  and  the  large  white  kidney,  from  which 
recovery  may  take  place. 

The  chief  indications  in  the  treatment  of  chronic  parenchymatous  neph- 
ritis are  two  : 

1.  To  improve  the  quality  of  the  blood,  which  may  have  became  anemic 
and  further  contaminated  with  urea,  purin  bcdies  and  allied  excrementitious 
matter. 

2.  To  combat  the  symptoms  and  complications  which  form  a  source  of 
great  inconvenience  and  danger  to  the  patient. 

I.  The  first  of  these  indications  is  chiefly  fulfilled  by  the  use  of  iron 
and  strj'chnin,  nourishing  food  of  a  suitable  kind,  a  proper  hygiene.  Iron  is 
regarded  by  many  as  almost  a  specific  in  chronic  parenchymatous  nephritis, 
and  is  prescribed  constantly  in  the  most  reckless  and  thoughtless  manner. 
Large  doses  of  iron  should  not  be  given.  They  are  useless,  lock  up  the  secre- 
tions, cause  headache,  and  increase  the  danger  of  uremia.  The  well-known 
Basham's  mixture  is  a  great  favorite.  It  is  really  a  solution  of  acetate  of 
iron,  and,  being  made  by  adding  to  tincture  of  the  chlorid  of  iron  acetic 


728  DISEASES  OF  THE  URINARY  ORGANS 

acid  and  solution  of  the  acetate  of  ammonia,  has  the  advantage  of  at  least 
tending  to  diuresis.  But  the  tincture  of  the  chlorid  of  iron  alone  is  an 
efficient  preparation  which  is  always  accessible,  and  when  combined  with 
the  sweet  spirit  of  niter  and  freely  diluted,  is  perhaps  as  efficient  as  Basham's 
mixture.  Only  a  few  drops  should  be  given.  To  either  one  quinin  and 
strychnin  may  be  added,  if  desired. 

With  regard  to  diet,  while  it  is  true  that  a  sufficient  amount  of  food  of 
good  quality,  is  desired,  those  articles  should  be  selected  which  contain  a 
minimum  of  nitrogen.  Experience  has  shown  that  when  the  appetite  is 
good  and  large  quantities  of  meat  are  eaten,  uremia  has  been  more  frequent, 
whereas  when  the  appetite  has  been  bad  and  little  food  taken,  uremia  in 
chronic  nephritis  is  uncommon.  While,  therefore,  it  is  not  necessary  to  omit 
all  proteid  food,  it  is  desirable  to  limit  it,  and,  while  drawing  upon  the  vege- 
table kingdom  for  food,  to  make  up  the  deficiency  in  meats  by  the  free  use 
of  milk.  The  good  results  of  the  milk  treatment  in  cases  of  chronic  neph- 
ritis are  generally  acknowledged  and  are  evidenced  by  improvement  in  all  the 
symptoms.  From  2  to  3  quarts  (2  to  3  liters)  a  day  may  be  talcen.  The 
milk  should  not  be  skimmed,  but,  if  rich  may  be  diluted  for  by  retaining  the 
cream  the  casein  is  maintained  in  smaller  proportion,  while  fat  always  suit- 
able is  in  good  shape  to  be  assimilated.  Rich  milk  is  not  desirable.  It  may 
be  diluted  with  Vichy  or  carbonated  water,  or  Apollinaris.  It  is  not,  of  course, 
always  necessary  to  confine  the  patient  to  a  pure  milk  diet,  but  it  should  at 
all  times  constitute  a  large  part  of  the  food.  In  ordinary  cases  the  milk 
may  be  supplemented  by  the  softer  juicy  vegetables,  especially  bj^  the  cereals 
which  with  cream  and  sugar  are  admirably  suited  to  such  cases.  Bread  of 
all  kinds  not  too  fresh  or  hot  is  suitable  and  bread  and  milk  are  ideal  food. 
An  egg  may  be  added  once  a  day  or  even  a  small  piece  of  meat  of  any  kind. 
Fruits  are  eminently  suitable  while  tea  and  coffee  in  moderation  need  not  be 
excluded. 

Next  to  diet,  rest  is  a  most  useful  measure  in  chronic  nephritis,  and  an 
albuminuria  reduced  to  a  minimimi  while  the  patient  is  up  may  often  be 
further  reduced  by  putting  him  to  bed.  The  beneficial  effect  of  rest  upon 
edema  due  to  any  cause  is  too  well  recognized  to  require  other  than  an 
allusion.  The  advantages  of  rest  in  bed  are,  however,  sometimes  more  than 
counterbalanced  by  the  disadvantage  to  the  patient  of  confinement  and  want 
of  fresh  air  and  outdoor  life.  These,  of  course,  must  be  weighed,  and  that 
one  adopted  which  ser\'es  the  patient  best. 

Under  hygienic  measures  is  included  suitable  clothing.  That  next  the 
body  shovild  be  of  wool  or  linen  for  it  must  be  remembered,  on  the  one 
hand  that  the  skin  is  a  powerful  adjuvant  to  the  kidney  in  its  eliminating 
fimctions,  and.  on  the  other  hand,  that  any  interference  -u-ith  the  action 
of  the  skin  must  throw  more  work  on  the  kidney.  Cold  produces  such 
interference,  while  warmth  promotes  the  action  of  the  skin,  and  no  texture 
prevents  the  former  or  secures  the  latter  more  effectually  than  wool.  For 
the  same  reason,  while  the  maximum  amount  of  fresh  air  is  desirable, 
cold  and  dampness  should  be  avoided  or  sufficiently  guarded  against. 

'.The  more  usual  formula  for  Basham's  mixture  is  as  follows:  I^  Tinct.  feir.  chlorid.,  f  3ij  (7.4  cc.^ 
Acid.  acet.  destillat..  f  5ij  (7.4  c.c.) ;  Liq.  ammon.  acetatis.  f  5iij  (90  c.c);  Curacoa;  vel  syrupi  simpl.,  AquE: 
aa  q.  s.  ad  j  5vj  (180  c.c).  M.  et  Sig.  Teaspoonful  or  dessertspoonful  twice  a  day.  in  half  a  tumbler  of 
water.  If  the  mixture  becomes  turbid,  it  is  probably  because  some  of  the  acetic  acid  has  evaporated  when 
a  few  more  drops  may  be  added  to  clear  it  up. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS  729 

2.  The  second  indication  is  to  combat  the  symptoms  and  complications 
which  cause  inconvenience  or  jeopardize  life.  These  symptoms  are  those 
of  dropsy,  effusions  into  the  serous  cavities,  and  congestions.  The  patients 
suffering  from  them  are  usually  confined  to  the  house,  or  go  out  of  it  at  so 
great  inconvenience  as  to  make  it  intolerable  to  do  so.  Of  dropsy,  there  is 
abundant  evidence  to  the  naked  eye. 

With  regard  to  ptirgatives  and  diuretics,  nothing  need  be  added  to  what 
has  already  been  said  under  acute  nephritis  (p.  718,  719).  But  as  to 
measures  which  promote  a  decided  action  of  the  skin  should  be  added  the 
warm  bath,  the  Turkish  bath,  warm-pack  bath,  and  the  hot-air  or  vapor  bath 
already  alluded  to.  Any  of  these  may  be  used  as  convenience  or  the  patient's 
choice  may  determine,  while  the  frequency  with  which  they  should  be  used 
depends  on  the  urgency  of  the  case. 

The  "warm"  is  a  very  pleasant  form  of  bath.  The  patient  is  ^Tapped 
up  in  a  warm  wet  sheet,  further  enveloped  in  a  sufficient  number  of  blankets. 
A  very  comfortable  sweat  generallj^  ensues,  which  is  continued  for  an  hour. 
In  the  use  of  the  warm  bath  the  patient  is  immersed  at  a  temperature  of 
about  104°  P.  (40°  C),  and  kept  there  for  from  half  an  hour  to  an  hour. 
He  is  then  removed  and  wrapped  in  blankets.  Pilocarpin  may  be  used 
tentatively.  Some  caution  must  be  observed  in  the  use  of  pilocarpin  because 
of  its  tendency  to  produce  edema  of  the  lungs.  They  may  be  used  about 
as  often  as  the  baths,  usually  on  alternate  daj's,  occasionally  daily,  with 
advantage. 

The  judicious  use  of  aperients  is  an  efficient  means  of  depleting  the  blood 
and  reducing  dropsy.  The  selection  must  depend  on  the  urgencjr  of  the  case, 
as  sufficient  has  been  said  in  treating  of  acute  nephritis.  But  in  many  cases 
of  chronic  nephritis  a  stage  is  finally  reached  at  which  all  treatment  of  the 
kind  described  fails  to  relieve  the  dropsy,  which  becomes  eventually  the  sorest 
burden  of  the  malady.  The  body  becomes  greatly  increased  in  weight,  the 
integument  of  the  extremities  is  stretched  almost  to  bursting,  and  sometimes 
it  does  rupture,  followed  by  leakage,  which,  although  in  one  way  inconven- 
ient, is  in  others  a  great  relief  to  the  patient.  Acting  upon  this,  ph3'sicians 
have  long  been  in  the  habit  of  puncturing  the  swollen  parts  to  drain  away  the 
fluid  and  diminish  tension.  It  is  a  common  practice  to  make  a  number  of 
minute  punctures  with  a  needle  or  sharp-pointed  bistoury,  but  free  incisions 
may  be  made  on  the  inner  or  outer  side  of  the  ankle  of  each  leg.  Free  drain- 
age is  thus  secured,  often  with  great  relief.  Southey's  tubes  may  be  substi- 
tuted at  convenient  places.  They  are  introduced  by  means  of  a  little  trocar 
and  after  this  is  withdrawn  fine  india-rubber  tubing  is  attached  to  the  little 
cannula  and  carried  to  a  suitable  vessel  outside  the  bed.  Some  remarkable 
recoveries  have  followed  incisions. .  Great  care  should  be  taken  to  keep  the 
tubes  clean,  as  thej^  are  liable  to  become  dirtj^  and  clogged. 

Bearing  in  mind  the  effect  of  chlorid  retention  on  renal  dropsy  suc- 
cessful treatment  would  naturally  be  favored  by  the  elimination  from  the 
diet  of  articles  rich  in  chlorids,  seeking  thus  to  reduce  the  chlorids  ingested  to 
two  or  three  grams  (30  to  45  grains)  daily.  This  is  accomplished  by  a  diet 
including  eggs,  unseasoned  meat,  milk  and  unsalted  butter,  bread  without 
salt,  fresh-water  fish,  potatoes,  rice,  fresh  vegetables,  fruits  and  chocolate. 

So  too,  recalling  the  work  of  Pearce  alluded  to,  as  to  the  effect  of  plethoric 


730  DISEASES  OF  THE  URINARY  ORGAXS 

hydremia  on  favoring  edema,  measures  to  diminish  hydremia  should  be 
used.  These  would  include  iron,  so  popular  in  chronic  Bright's  disease  in 
the  shape  of  Basham's  mixture;  but  in  these  cases  the  stomach  has  generally 
been  tried  to  the  utmost,  so  that  the  method  of  using  iron  hypodermieally 
commends  itself.  The  citrate  of  iron  is  commonly  used.  It  is  put  up  in 
ampules  containing  3/4  grain  (0.05  gram)  and  sodium  glycerophosphat  i  1/2 
grains  (o.  i  gram)  and  injected  into  the  muscles  in  the  arm  or  elsewhere  every 
other  day.  It  may  be  best  at  first  to  use  only  half  the  contents  of  one  am- 
pule.    The  treatment  should  be  kept  up  some  time. 

The  treatment  of  the  complications  is  in  no  way  different  from  that  of 
the  same  conditions  under  other  circumstances.  The  point  to  be  impressed 
is  the  importance  of  being  constantly  on  the  lookout  for  them.  Effusions 
into  serous  cavities  are  probably  the  most  important.  Edema  of  the  glottis 
requires  especial  allusion,  as  a  complication  most  alarming  and  threatening 
to  life.  Inhalations  of  steam  may  be  tried,  but  prompt  punctures  or  incisions 
are  the  only  certain  means  of  relieving  the  patient  and  saving  life. 

There  are  no  measures  directly  curative  in  acute  or  chronic  nephritis — • 
that  is,  remedies  which  by  their  direct  action  remove  the  morbid  state. 
All  that  can  be  done  is  to  place  the  patient  in  a  condition  most  favorable 
for  nature's  kidnly  offices,  which  are  always  exerting  themselves  toward 
cure.  This  is  accomplished  by  the  measures  recommended,  which  also 
eliminate  the  mechanical  and  poisonous  products  which  interfere  with 
recovery. 

Operative  Treatment. — Decapsulation  of  the  kidney  as  a  cure  for 
chronic  nephritis  was  proposed  by  the  late  George  M.  Edebohls,  the  sug- 
gestion growing  out  of  some  results  of  operation  for  floating  kidnej^  in  per- 
sons who  happened  to  have  coincident  chronic  parenchymatous  nephritis. 
His  results  were  published  in  the  "Medical  News,"  April  22,  1899.  His 
first  thought  was  that  the  cure  of  Bright's  disease  was  due  to  correction  of  the 
displacement  of  the  kidney,  and  it  was  not  until  after  three  secondan.^ 
operations  upon  kidneys  which  had  been  anchored  some  time  previously, 
that  he  discovered  the  essential  condition  underlying  the  cure  to  be  decap- 
sulation, or  decortication.  The  last  paper  of  Edebohls  read  before  the  Sec- 
tion on  Surgery  and  Anatomy  of  the  American  Medical  Association,  June 
19,  1908,^  was  based  on  a  total  of  102  cases,  of  which  33  were  claimed  to  be 
complete  cures,  2 1  received  no  benefit,  and  48  experienced  amelioration  short 
of  cure.  Of  the  2 1  not  benefited  ten  died  soon  after  the  operation,  from  the 
effects  of  the  operation.  In  29  cases  he  operated  on  both  kidneys  at  one  sit- 
ting. The  operation  consists  in  stripping  off  the  capsule  and  cutting  it 
away  entirely,  close  to  its  junction  with  the  pelvis  of  the  kidney. 

The  success  of  the  operation  is  seemingly  due,  as  Edebohls  suggests, 
to  arterial  hyperemization  of  the  kidney,  whereby  an  increased  and  adequate 
blood-supply  is  furnished  which  permits  an  absorption  of  interstitial  and  in- 
tertubular  inflammatory  products,  thus  relieving  the  tubules  and  glomeruli 
from  the  pressure  previously  interfering  with  their  function.  The  operation 
should  be  done  on  certain  cases.  Many  cases  have  been  reported  with  al- 
most immediate  relief,  but  most  of  them  have  had  fatal  relapses  and  appar- 


'  Published  in  the  Jour.  American  Medical  Association,  Jan.  i6,  1909.     The  paper  i 
cf  Edebohl'  illness,  by  Samuel  Lloyd.     Edebohls  died  Aug.  8    1908. 


INTERSTITIAL  NEPHRITIS  731 

ently  all  of  them  still  have  albumin  and  tube  casts  in  the  urine.     Two  of  our 
cases  died  on  the  operation  table. 


CHRONIC  INTERSTITIAL  NEPHRITIS. 

Synonyms. — Contracted  Kidney;  Chronically  Contracted  Kidney;  Renal 
Cirrhosis;  Cirrhotic  Kidney;  Granular  Degeneration;  Granular  Kidney; 
Red  Granular  Kidney;  Gouty  Kidney;  Renal  Sclerosis. 

Definition. — Chronic  interstitial  nephritis  is  a  chronic  process  resulting 
ultimately  in  a  shrunken  kidney,  in  which  there  has  been  extensive  destruc- 
tion of  the  tubular  substance  and  overgrowth  of  interstitial  connective  tissue. 

Etiology. — Of  the  recognized  forms  of  Bright's  disease,  interstitial 
nephritis  shares  with  chronic  parenchymatous  nephritis  a  large  number  of 
instances  in  which  the  cause  is  undiscoverable.  There  are,  however,  some 
well-determined  causes.  There  are  certain  cases  of  interstitial  nephritis 
which  are  unquestionably  the  result  of  the  exigency  of  our  modem  life.  In 
all  probability  the  kidney  lesion  is  secondary  to  the  arteriosclerosis  which 
results  from  the  manner  of  life.  Anxiety;  business  care;  worrj^  particularly 
when  accompanied  by  overwork,  physical  or  mental;  eating  at  irregular 
times  of  improper  food  or  improper  amounts  of  food,  unquestionably  gives 
rise  to  a  large  number  of  cases  of  arterio-sclerosis,  accompanied  by  high 
blood-pressure.  In  a  great  many  instances  there  is  connected  with  this 
condition,  a  true  interstitial  inflammatory  condition  of  the  kidney,  but  the 
kidney  condition  is  surely  a  result  of  the  primary  cause  just  as  is  the 
arterial  condition  in  these  cases.  Nevertheless,  the  case  finally  resolves 
itself  into  one  of  insufficient  kidney  elimination  and  becomes  literally 
chronic  Bright's  disease.  Gout  is  associated  with  so  many  cases  of  con- 
tracted kidney  that  the  term  gouty  kidney  has  become  a  well-recognized 
synonym  for  the  product  of  interstitial  nephritis.  There  are  probably 
no  cases  of  gout  which  have  continued  for  any  length  of  time  which  are 
not  accompanied  by  interstitial  nephritis.  Uric  acid  and  allied  substances 
in  the  blood  are  probably  the  exciting  cause.  Another  well-recognized 
cause  is  lead  in  lead-poisoning,  the  absorbed  lead  acting  like  the  poison  of 
gout.  Hence  painters,  glaziers,  workers  in  lead  in  any  form,  are  frequent 
victims. 

Long-continued  cystitis,  especially  following  gonorrhea,  is  a  cause  in  a 
few  instances,  the  inflammation  traveling  up  the  ureter  to  the  pelvis  of  the 
kidney  and  thence  to  the  intertubular  tissue.  The  result  of  such  extension 
may  be  either  fibroid  or  suppurative  nephritis. 

Hereditary  influence  is  occasionally  a  cause  of  contracted  kidney.  A 
remarkable  case  occurred  in  the  practice  of  one  of  us.  A  man,  aged  30,  had 
granular  kidneys.  His  father  and  mother  both  died  of  Bright's  disease,  aged 
56  and  63  years.  A  brother  aged  37.  Two  children  of  this  brother  when 
four  and  seven  years  of  age,  and  a  sister  all  had  Bright's  disease.  A  brother, 
aged  26,  and  a  sister  aged  34,  have  as  yet  exhibited  no  signs  of  Bright's 
disease.  A  maternal  cousin  died  of  undoubted  Bright's  disease,  and  other 
members  of  the  family  belonging  to  previous  generations  died  with  symp- 
toms which   suggest  Bright's  disease.     There  is  no  gout  in  the  family. 


732  DISEASES  OF  THE  URINARY  ORGANS 

Dickinson  also  relates  the  history  of  a  family  in  which  a  hercditar}'  albu- 
minuria existed  independent  of  gout. 

Prolonged  passive  congestion,  due  to  valvular  heart  disease,  may  become 
a  cause  of  granular  kidney.  The  same  may  be  said  of  stone  in  the  kidney 
causing  numerous  attacks  of  nephritic  colic.  Typical  chronic  interstitial 
nephritis  occasionally  ensued  on  such  attacks  of  nephritic  colic.  Typical 
chronic  interstitial  nephritis  occasionally  ensues  on  such  attacks  of  nephritic 
colic. 

Interstitial  nephritis  is  commonly  a  disease  of  middle  age,  the  majority 
of  persons  in  whom  it  is  discovered  being  past  40.  Under  20  it  is  uncommon, 
but  studies  by  Heubner,'  and  Brill  report  33  cases  of  interstitial  nephritis 
the  youngest  was  18  and  in  Dickinson's  308  cases  the  youngest  was  11. 
Cases  as  young  as  five  years  are  reported. 

It  must  be  remembered  that  there  is  a  tendency  to  overgrowth  in  the 
interstitial  tissue  of  the  kidney,  as  of  other  organs,  in  old  age.  Hence  the 
term,  sensile  atrophy  of  the  kidney.  It  is  not  safe,  therefore,  to  caU  every 
instance  of  atrophied  kidney  met  in  the  postmortem  room  a  case  of  inter- 
stitial nephritis.  The  clinical  history,  or  some  one  of  the  well-marked  symp- 
toms of  the  disease,  as  albuminuria  or  uremic  symptoms,  should  have  pre- 
ceded to  sustain  the  diagnosis. 

As  to  sex,  nearly  twice  as  many  men  have  the  disease  as  women, 
because  of  the  more  frequent  exposure  of  the  former  to  the  causes  cf  the 
affection. 

Morbid  Anatomy. — In  interstitial  nephritis,  both  kidneys  are  involved, 
■  but  there  is  often  a  marked  difference  in  the  extent  of  the  disease  in  each. 

Macroscopically,  the  organs  are  evidently  smaller  than  in  health,  often 
less  than  half  as  large.  Next  to  this  reduction  in  size,  the  most  striking 
feature  of  the  contracted  kidney  is  its  uneven  or  granular  surface,  which  is, 
however,  not  always  recognizable  untU  after  the  capsule  is  removed.  Very 
characteristic  also  is  the  presence  of  cysts  with  more  or  less  clear  watery  or 
gelatinous  contents,  often  visible  through  the  capsule.  These  are  not 
invariabl3%  but  quite  frequently',  present.  The  capsule,  itself  thickened, 
strips  off  with  difficulty,  dragging  portions  of  the  secreting  structure  with 
it.  Owing  to  the  resistance  which  the  blood  meets  in  its  passage  through 
the  kidney,  a  larger  portion  of  it  passes  out  of  the  organ  by  way  of  the  cap- 
sule; hence  the  blood-vessels  of  the  latter  are  dilated,  as  are  also  the  lymph- 
spaces. 

Bereft  of  its  caps'.ile,  the  kidney  is  hard,  granular,  tough,  and  usually 
darker  than  in  health,  whence  one  of  its  names,  the  "red  granular  kidney." 
This  color  is  in  strong  contrast  to  the  white  or  slightly  }'ellow  tinge  of  the 
fatty  and  contracting  kidney,  and  although  it  is  not  always  marked,  and 
sometimes  even  substituted  by  a  paleness,  it  is  still  easUy  distinguished 
from  that  of  the  contracting  kidney  of  parenchymatous  nephritis.  The 
granules  on  the  surface  of  the  contracted  kidney  are  distinct  round  and 
oval  elevations  of  the  surface,  ranging  in  size  from  that  of  a  pin's  head  to 
that  of  a  pea,  or  from  1/25  to  1/5  inch  (i  to  5  mm.).  Those  of  smaller 
size  are  most  numerous,  and  at  first  correspond  with  the  lobules,  the  bases  of 


^  Brill  and  Libman. — Contributions  to  the  subjects  of  "Chronic  Interstitial   Nephritis 
Jour,  of  Experimental  Medicine,"    vol.  iv.,  1899,  p.  S41. 


INRESTITIAL  NEPHRITIS  733 

which  are  visible  on  the  surface  of  the  normal  organ.  The  larger  ones 
result  from  the  coalescence  of  two  or  more  of  the  smaller.  The  granules 
themselves  are  of  a.  lighter  color  than  the  depressed  circlets  between  them, 
which  are  tinted  with  vascularity  and  have  a  purplish  or  faint  red  hue.  The 
cysts  already  referred  to  are  now  more  distinct  (after  removal  of  the  capsule) , 
and  vary  greatly  in  size.  While  equaling  in  minuteness  the  smallest  of  the 
granules,  some  of  them  are  as  large  as  a  walnut.  The  larger  are  apt  to  be 
ruptures  on  stripping  off  the  capsule. 

On  section,  it  is  at  once  evident  that  the  reduction  in  size  of  the  kidney 
is  largely  due  to  a  narrowing  of  the  cortex,  although  the  medulla  is  also 
contracted.  The  former  may  not  be  more  than  from  i/8  to  i/6  inch  (3  or 
4  mm.)  in  width,  and  exhibit  every  degree  between  this  and  the  normal. 
The  Malpighian  bodies  are  smaller,  less  numerous,  and  can  scarcely  be 
detected  by  the  naked  eye,  while  the  small  arteries  are  more  prominent 
from  the  thickening  of  their  walls.  Increased  density  and  firmness  of  the 
organ  are  apparent.  In  a  gouty  subject,  linear  chalk-marks  of  sodium 
urate  may  be  present,  more  particularly  in  the  pyramids  of  straight  tubules, 
and  are  contained  within,  as  well  as  between,  the  latter.  The  little  cysts 
referred  to  as  seen  on  the  surface  may  also  be  scattered  throughout  the 
section  from  cortex  to  papiUse,  but  they  are  more  numerous  in  the  former. 
They  are  not  always  present.  The  pelvis  of  the  kidney  may  be  tmaltered. 
It  is  sometimes  enlarged,  and  the  calices  are  elongated  from  retraction  of 
the  pyramids.  On  the  other  hand,  if  the  kidney  is  very  much  reduced  in 
size,  the  capsule  may  be  pursed  up  and  proportionately  smaller. 

Minute  Structure. — Minute  examination  of  thin  sections  through  the 
cortex  clearly  reveals  the  condition  to  be  an  excess  of  connective  tissue, 
with  destruction  of  the  tubules  and  blood-vessels.  The  process  is  best 
studied  if  the  sections  include  the  capsular  edge,  as  the  disease  progresses 
from  without  inward.  In  such  sections  may  be  seen  extensive  tracts  of 
connective  tissue  separating  the  tubules,  which,  in  healthy  kidneys,  are 
closely  in  contact  without  appreciable  intertubular  substance.  The  tubules 
themselves  appear  in  places  quite  normal ;  in  others  they  are  represented  by 
fragmentary  portions  in  which  the  cells  are  still  unchanged;  in  others, 
again,  the  cells  exhibit  a  granular  degeneration;  some  tubes  are  evidently 
dilated;  others  still  are  completely  shriveled,  while  it  is  evident  from  the 
larger  areas  of  connective  tissue  that  many  have  completely  disappeared. 
In  a  few  tubules  waxy  casts  are  present.  The  Malpighian  bodies  are  sur- 
rounded by  concentric  layers  of  nucleated  connective  tissue.  Many  of 
them  are  shriveled  and  atrophied,  and  an  attempt  to  inject  them  with 
colored  injecting  fluids  fails  either  partially  or  completely.  Some  thus 
altered  lie  detached  from  the  tubules,  with  which  they  should  be  continuous. 
The  granules  on  the  surface  of  the  kidneys  are  resolvable  by  the  microscope 
into  tubules,  some  of  which  are  in  a  tolerably  perfect  state,  some  decidedly 
dilated. 

The  cysts  originate  partly  in  dilatations  of  obstructed  segments  of  the 
uriniferous  ttibules  and  partly  in  dilated  Malpighian  capsules.  Proof 
of  the  latter  mode  of  origin  is  found  in  the  fact  that  compressed  capillary 
tufts  are  sometimes  found  lying  up  against  one  side  of  the  wall  of  the  cyst. 
The  same  overgrowth  of  connective  tissue  may  be  seen  in  the  pyramids. 


734  DISEASES  OF  THE  URIXARV  ORGAXS 

but  it  appears  later,  extends  more  slowly,  and  never  reaches  the  degree  found 
in  the  cortex. 

The  blood-vessel  of  the  contracted  kidney  is  the  seat  of  important  changes. 
In  the  first  place,  it  shares  with  the  tubules  the  compressing  effect  of  the 
contracting  new  formation.  As  the  result  of  this,  a  part  of  the  capillary 
system  is  destroyed,  and  in  the  part  thus  destroyed  are  many  capillary 
coils  in  the  Malpighian  bodies.  Hence,  as  many  afferent  arterioles  send 
their  blood  directly  into  the  second  capillary  network,  which  is  also  cut  down 
by  the  pressure.  The  vessels  which  remain  are  often  sclerotic,  dilated,  and 
twisted,  and  in  consequence  of  the  destruction  of  numerous  Malpighian 
bodies  send  much  of  their  blood  out  through  the  capsule  of  the  kidney. 
The  intima  is  thickened,  and  the  media  and  adventitia  are  invaded  by 
hyperplastic  connective  tissue,  but  always  to  a  less  degree.  Even  arterioles 
whose  walls  have  thus  been  thickened  become  involved  in  the  atrophic 
processes  affecting  the  glandtdar  tissue  of  the  organ,  and  ultimately  disappear. 

Associated  with  these  changes  are  a  general  arteriosclerosis  and  hyper- 
trophy of  the  left  ventricle  of  the  heart,  sometimes  also  cf  the  right.  The 
final  effect  of  these  alterations  is  to  produce  a  brittleness  in  the  arteriole 
walls,  which  disposes  them  to  rupture  on  very  slight  increase  of  intravascu- 
lar pressure.  Hence  the  frequent  fatal  termination  of  cases  of  interstitial 
nephritis  by  apoplexy,  also  the  frequent  nasal  and  retinal  hemorrhages  which 
characterize  the  disease. 

The  retinal  changes — retinitis  albuminurica — symptoms  of  which  form 
so  important  a  part  of  the  symptomatology  of  chronic  interstitial  nephritis, 
are  various  and  vary  with  the  stage  of  each  case.  Many  cases  arc  first 
diagnosed  by  the  ophthalmic  surgeon.  The  changes  include  serous  swelling 
of  the  disk  and  surrounding  retina,  hemorrhagic  extravasations,  dirty  white 
splotches,  representing  fatty  degeneration;  also  dilatation  of  the  veins  and 
capillaries,  with  fatty  degeneration  and  sometimes  hyaline  thickening  of 
their  walls. 

Symptoms. — The  great  obscurity  as  to  the  origin  of  a  large  majority  of 
cases  of  contracted  kidney  is  only  equaled  by  the  insidiousness  of  their 
approach.  The  beginning  of  the  disease  is  certainly  not  characterized  by 
any  distinctive  symptoms,  and  its  progress  is  often  unmarked  by  any,  until 
those  of  lu^emia  point  to  the  beginning  of  the  end.  To  the  observing  physi- 
cian some  obscure  symptom  may  suggest  an  examination  of  the  urine,  or 
the  peculiar  tense  and  bounding  pulse  of  hypertrophy  of  the  left  ventricle, 
or  the  more  tangible  symptoms  of  a  slight  swelling  of  the  feet  or  ankles, 
recognizable  only  at  night  or  through  the  unexpected  tightness  of  a  boot, 
may  lead  to  the  same  examination.  An  accidental  recognition  of  greatly 
incresaed  blood  pressure  may  suggest  the  disease. 

Changes  in  the  Urine. — Attention  being  called  to  the  urine,  it  will  be 
found  to  present  characters  which  are  more  or  less  distinctive  and  lead 
easily  to  a  diagnosis.  When  freshly  passed,  it  is  acid  in  reaction,  copious, 
often  exceeding  the  normal  amount,  and  never  scanty,  except  in  the  last 
stages  of  the  disease.  The  quantity  is  often  60  (1800  c.c),  and  may  reach 
90  ounces  (2700  c.c).  The  patient  very  commonlj^  must  rise  at  night, 
probably  not  more  than  once  or  twice,  to  void  urine.  There  may  be  corre- 
sponding thirst.     Consequently,  the  urine  is  light  in  color  and  of  low  spe- 


INTERSTITIAL  NEPHRITIS  735 

cific  gravity — 1005  to  1015 — and  contains  a  trifling  or  moderate  flocculent 
sediment.  It  is  generally  albuminous,  but  the  albumin  is  small  in  amount 
and  may  be  temporarily  absent,  or  it  may  be  absent  before  a  meal  and  pres- 
ent after  it.  Later,  however,  the  albumin  becomes  constant.  It  seldom 
exceeds  one- tenth  the  bulk  of  fluid  tested,  and  is  very  constantly  a  great  deal 
less,  showing  a  delicate  line  of  white  by  Heller's  nitric  acid  test.  Tube-casts 
are  present,  but  not  usually  numerous.  They  are  almost  solely  hyaline  and 
pale  granular.  Some  of  the  hyaline  casts  are  delicately  so,  requiring  delicate 
illumination  for  their  detection;  others  are  distinct  and  sharj^ly  cut;  others 
still  contain  two  or  three  glistening  oil  drops.  Casts  may  at  times  be  absent 
and  again  reappear,  as  is  the  case  with  albumin.  Toward  the  termination 
of  cases  of  interstitial  nephritis  the  urine  diminishes  in  quantity,  the  specific 
gravity  increases,  and  the  casts  become  much  more  numerous,  and  include 
among  them  highly  granular  or  dark  granular  and  occasionally  even  blood- 
casts  in  addition  to  those  mentioned,  and  there  are  sometimes  a  few  blood- 
disks  earlier. 

As  to  the  other  symptoms,  a  feeling  of  unaccountable  weakness  or  of 
being  tired  is  very  often  present,  but  it  is  a  symptom  which  occurs  in  man}' 
conditions,  and  should  only  be  considered  as  suggestive.  Slight  edema 
about  the  feet  and  ankles  is  often  present,  being  so  slight  as  to  escape 
detection,  or  it  is  discovered  accidentally.  When  present  it  is  significant,  but 
it  is  often  entirely  wanting. 

Hypertrophy  of  the  left  ventricle  of  the  heart  without  valvular  disease 
is  so  constant  as  to  be  alone  suggestive  of  the  disease.  No  case  of  interstitial 
nephritis  has  existed  for  any  length  of  time  without  this  condition  super- 
vening, and  as  few  cases  are  discovered  until  they  have  existed  for  some 
time,  few  are  found  without  hypertrophy.  In  more  than  one-half  of  cases, 
at  least,  hypertrophy  is  evident.  It  is  recognized  at  first  not  so  much  by 
the  resulting  enlarged  percussion  area  as  by  the  sharp  accentuation  of  the 
aortic  second  sound.  Corresponding  to  this,  the  pulse  is  hard  and  resisting, 
indicating  high  tension  and  thickening.  These  two  symptoms  have,  there- 
fore, great  diagnostic  value.  Sclerosis  is  distinguished  from  tension  by 
obliterating  the  blood-current  by  pressure  and  feeling  the  artery  beyond 
this  point.  The  sclerosed  vessel  continues  tangible;  that  of  simple  high 
tension  disappears.  A  symptom  of  this  stage  is  often  an  uncomfortable 
pulsation  felt  in  the  head  and  even  in  other  parts  of  the  body. 

It  is  not  easy  to  estimate  the  exact  number  of  cases  of  pure  interstitial 

nephritis  associated  with  hypertrophy  of  the  different  cavities  of  the  heart. 

The  observations  of  Hasenfeld,  in  1897,  and  von  Hirsch,  in  1900,  found 

hypertrophy  of  all  chambers  in  over  75  per  cent.     Von  Buhl's  results  are 

essentially  the  same.     Recently  some  attempts  were  made  to  settle  this 

question  by  Nathaniel  Bowditch  Pctter"^  and  Horace  Oertel,  of  the  New 

York  City  Hospital,  resulting  as  follows: 

286  Autopsies,  113  Cases  of  Nephritis. 

Per  cent,  of  Per  cent,  of  Per  cent,  of 

Hyp.  of  Hyp.  of  Normal  or 

L.  V.  L.  &  R.  V.  Atro.  Heart. 

Of  66  chronic  interstitial                                              30. 5  1 1 . 5  58 

Of  22  arteriosclerotic  interstitial,                               27  9  64 

Of  25  chronic  parenchymatous,                                  12  4  84 

1  "Cardiac  Hypertrophy  as  Observed  in  Chronic  Nephritis,"  by  Nathan  el  Bowditch  Potter.     "Journal 
or  the  American  Medical  Association,"  October  27,  1906. 


736  DISEASES  OF  THE  URINARY  ORGANS 

These  observers  did  not  follow  Miiller's  accurate  method  or  it  is  probable 
they  would  have  found  a  large  proportion  of  cases  in  which  the  left  ven- 
tricle and  both  ventricles  were  enlarged.  Of  the  cases  of  atrophic  or  normal 
hearts  generally  associated  with  deficient  nutritive  power  they  found  a  num- 
ber in  which  there  was  reason  to  believe  the  heart  was  originall}-  hypertro- 
phied  and  became  later  atrophic. 

An  increase  of  blood-pressure  as  recognized  by  the  sphygmomanometer  is 
a  very  characteristic  and  diagnostic  sign,  the  measure  being  anything  above 
1 60,  and  as  high  as  250  millimeters  of  mercury.  Some  observations  by  Dr. 
Robert  I.  Lee  on  Pathological  Findings  in  Renal  Hypertention  published 
in  the  "Journal  of  the  American  Medical  Association,"  vol.  Ivii.,  p.  1179, 
give  an  idea  of  increased  blood-pressure  as  produced  by  renal  disease.  Dr. 
Lee  followed  to  the  autopsy  table  53  cases  in  which  the  blood-pressure  was 
over  160.  In  38  cases  or  71  per  cent,  renal  lesions  were  fotmd.  In  seven 
of  the  38  cases  or  13  per  cent,  of  the  whole  series  the  lesions  were  essentially 
confined  to  the  kidneys.  Five  of  these  seven  cases  showed  pathologic 
changes  classified  as  chronic  glomerulonephritis,  one  as  subacute  glomerulo- 
nephritis and  one  as  chronic  interstitial  nephritis.  The  blood-pressure 
ranged  from  165  to  240  millimeters.  Some  kidney  lesion  was  present  at 
necropsy  in  71  per  cent,  of  the  cases  of  hypertensions.  Theo.  C.  Janeway 
found  some  kidney  lesions  present  in  79  out  of  100  cases  of  hypertension  which 
came  to  autopsy.' 

1.  Hypertension  may  arise  through  purely  quantitative  reduction  of 
kidney  substance  below  the  factor  of  safety. 

2.  Hypertension  may  arise  in  connection  with  the  unknown  intoxication 
which  causes  disturbances  of  the  central  nervous  system  and  which  we 
call  uremia. 

3 .  Hypertension  may  arise  in  primary  irritability  of  the  vasoconstricting 
mechanism  from  unknown,  probably  extrarenal  causes,  which  lead  eventually 
to  arteriolar  solerosis.  In  this  type  the  disease  in  the  kidney  is  the  sequence, 
not  the  cause,  of  the  generalized  vascular  lesion. 

As  the  disease  becomes  more  advanced  there  are  added  cardiac  symptoms, 
including  dyspnea,  palpitation,  and  reduplication  of  the  first  sound.  The 
last  is  probably  due  to  a  want  of  synchronism  in  the  systole  of  the  two 
ventricles.  There  is  usually  no  murmur,  because  there  is  no  valvular  dis- 
ease. The  latter  may  be  present.  The  patient  may  have  had  valvular  dis- 
ease prior  to  the  renal  malady,  or  the  latter  itself,  by  its  long  continuance, 
may  have  produced  endocarditis  and  atheroma  w\lh.  an  aortic  sj'stolic  mur- 
mur. There  may  be  a  mitral  murmur  due  to  relative  insufficiency.  Val- 
vular disease  is,  however,  unusual.  The  hypertrophy  of  the  heart  is  conserva- 
tive, and  all  goes  well  as  long  as  the  power  of  the  heart  lasts.  When  the  lat- 
ter begins  to  fail  and  dilatation  appears,  the  blood-pressure  diminishes,  and 
wAth.  it  begins  a  train  of  symptoms,  among  which  diminished  secretion  of 
urine  and  dropsy  are  the  most  conspicuous,  along  wth  gallop  rhj-thm,  dysp- 
nea, palpitation,  and  dizziness.  These  symptoms  may  again  be  averted  for 
a  time  by  hypertrophy  of  the  right  ventricle,  which  is  a  further  effort  to 
correct  disturbed  compensation.     Among  derangements  of  breathing  must 

*  Wh'le  printing  this  edition  Dr.  Janeway's  latest  paper  on  Nephritic  Hypertension  has  appeared  in  the 
"American  Journal  of  the  Medical  Sciences"  for  May.  1913.  He  concludes  that  in  the  main  the  hyper- 
trophied  heart  may  be  looked  upon  as  the  result  of  a  persistent  high  blood-pressure. 


INTERSTITIAL  NEPHRITIS  737 

be  included  Cheyne-Stokes  breathing,  commonly  toward  the  end  of  the 
disease. 

Dimness  of  vision  due  to  retinitis  albuminurica,  already  described  on 
page  702  is  a  characteristic  symptom.  It  is  often  the  first  recognized,  and 
hence  the  diagnosis  is  frequently  first  made  by  the  ophthalmologist.  It  is  a 
sign  of  advanced  disease.  Some  assign  two  years  as  the  limit  of  life  after  its 
recognition,  but  this  is  too  unfavorable  a  prognosis.  The  atheroma  of  the 
blood-vessels  is  the  cause  of  another  symptom  which  frequently  determines 
the  mode  of  death — rupture  of  a  blood-vessel  in  the  brain :  in  a  word,  apo- 
plexy. This  accident  is  more  usual  late  in  life,  but  Dickinson  reports  a  case 
in  which  cerebral  hemorrhage  occurred  in  a  girl  of  1 2 .  The  proportion  of 
cases  of  recognized  interstitial  nephritis  in  which  this  happens  is  not  large, 
but  many  cases  of  apoplexy  are  directly  traceable  at  autopsy  to  unsuspected 
renal  cirrhosis.  Dickinson  believes  that  of  fatal  cases  of  apoplexy,  one-half 
are  preceded  by  this  form  of  disease.  Hemorrhages  in  other  situations  are 
referable  to  this  same  altered  state  of  the  blood-vessels,  as,  for  example,  into 
the  retina,  from  the  nose,  and  even  into  the  stomach.  Sudden  blindness,  in 
addition  to  the  dimness  of  vision  due  to  retinitis  albuminurica,  is  a  symptom 
which  occasionally  presents  itself.  Amaurosis  and  amblyopia  also  occur,  and 
may  disappear,  but  dimness  of  vision  due  to  retinitis  albuminurica  is  a  per- 
manent symptom,  though  I  have  seen  it  improve  under  treatment.  Audi- 
tory disturbances  also  occur,  such  as  ringing  in  the  ears,  with  dizziness  and 
more  or  less  deafness. 

The  termination  by  uremia  occurs  more  frequently  in  this  than  in  any 
other  form  of  Bright's  disease.  Headache,  drowsiness,  convulsions,  stupor, 
delirium,  maniacal  excitement,  Venal  asthma,  restlessness,  nausea,  vomiting — - 
any  one  of  these  sj^mptoms  may  usher  in  the  dreadful  train  which  is  so  likely 
to  be  fatal.  E.  C.  Seguin  (in  1880)  especially  called  attention  to  occipital 
headache  as  a  symptom  of  uremia.^  Von  Leube  considers  that  even  the 
intermittent  headaches  which  occur  in  this  disease,  and  which  very  closely 
resemble  migraine,  are  probably  due  to  uremia.  Occipital  headache  occurs 
too  frequently  unassociated  with  any  symptoms  of  nephritis  to  justify 
attaching  much  importance  to  it  as  a  symptoms  of  uremia.  Another 
form  of  headache  characterized  as  uremic  is  a  brow  headache  passing 
off  at  10  or  II  in  the  morning.  Temperature  follows  the  same  rule  in 
uremia  as  in  other  forms  of  nephritis.  The  convulsion  is  commonly 
associated  with  a  rise  of  temperature.  Dyspeptic  symptoms,  with  obstinate 
vomiting,  particularly  in  the  morning  on  rising,  are  apt  to  usher  in  a  chronic 
uremia.  Diarrhea  is  less  common,  but  also  sometimes  occurs  toward  the 
close,  when  it  may  be  very  difficult  to  control. 

The  duration  of  this  form  of  renal  disease  is  indefinite.  Always  a 
chronic  process,  it  may  last  for  years  undiscovered,  and  when  discovered 
before  it  is  too  far  advanced,  the  knowledge  of  its  presence  will  suggest 
measures  of  precaution  and  treatment  which  may  so  prolong  life  that  it 
need  only  be  determined  by  its  natural  limit  or  some  other  disease.  Yet 
complete  recovery  from  well-established  interstitial  nephritis  is  unlcnown. 

Complications. — These  include  bronchitis,  pericarditis,  pleurisy,  pneu- 
monia,, and,  more  rarely,  endocarditis,  peritonitis,  intertubiilar  gastritis, 

^  "Archives  of  Medicine,"  vol,  iv,,  No.  i,  New  York,  August,  1880 


738  DISEASES  OF  TEE  URINARY  ORGANS 

and  even  inflammation  and  ulceration  of  the  bowels.  But  all  inflammatory 
complications,  except  bronchitis,  pleurisy,  and  pericarditis,  are  less  frequent 
than  in  acute  nephritis.  My  own  experience  accords  more  nearly  with  the 
latter.  Pericarditis  is  the  most  serious  complication  occurring.  Pleurisy 
and  pneumonia  are  also  of  tolerably  frequent,  Stewart  found  the  former  in 
IS  percent,  of  his  cases  and  pneumonia  in  7  percent.  Acute  endocarditis 
and  peritonitis  occur  very  seldom; 

Diagnosis. — The  diagnosis  of  an  interstitial  nephritis  is  usually  easy, 
if  in  any  way  an  examination  of  the  urine  is  suggested.  The  increased 
quantity,  the  low  specific  gravity,  small  albuminuria,  delicate  hyaline,  pale 
granular  casts,  and  hypertrophy  of  the  left  ventricle,  even  in  the  absence 
of  other  symptoms,  are  sufficiently  distinctive.  The  conditions  which 
should  suggest  such  an  examination  are  a  feeling  of  constant  weariness, 
slight  swelling  of  the  feet,  drowsiness,  frequent  headaches,  confused  intellect, 
dyspeptic  s^^mptoms,  obstinate  nausea,  delirium,  coma,  and  convulsions. 
High  arterial  tension  should  always  suggest  examination  of  the  urine.  It 
must  be  remembered,  however,  that  albumin  and  casts  may  be  present  in 
the  urine  of  individuals  with  high  blood  pressure  without  the  renal  lesion 
they  suggest  being  the  important  one  in  the  case. 

The  special  condition  from  which  it  is  most  difficult  to  distinguish  it  is 
the  milder  form  of  chronic  diffuse  or  parenchymatous  nephritis,  especially 
if  the  latter  has  reached  the  contracting  stage.  In  fact,  the  symptoms  are 
often  identical,  and  unless  the  history  helps  us,  it  may  beimpossible  to  decide. 
The  evidences  of  decided  fatty  change,  such  as  the  oil-cast  or  free  fatty 
renal  cell  in  the  urine,  settle  the  question  in  favor  of  chronic  diffuse  nephritis. 

Assistance  in  the  diagnosis  between  these  two  conditions  may  be  had 
from  the  phenolphthalein  test.  The  application  of  this  has  shown  that  in 
contracted  kidney  insufficiency  of  function  is  much  more  marked  than  in 
parenchymatous  nephritis. 

It  is  important,  if  possible,  to  distinguish  between  interstitial  nephritis 
with  secondary  arterial  sclerosis  and  general  arterial  sclerosis  with  secondary 
contracted  kidney,  but  it  is  not  always  easy  to  draw  a  sharp  line  between 
these  two  conditions.  Both  are  insidious,  in  both  there  is  the  absence  of 
dropsy  except  in  the  very  last  stages  of  primary'  renal  sclerosis,  though  here 
it  is  also  rare,  while  it  is  wanting  throughout  in  general  arterio-sclerosis. 
In  both  there  is  a  scanty  albuminuria  with  very  few  hyaline  casts,  but  if  the 
opportunity  presents  to  study  urine  for  a  time,  it  may  be  found  that  the 
albumin  and  casts  appear  earlier  in  the  primar}'  renal  cases.  Indeed,  in 
general  arterio-sclerosis  there  is  often  no  albuminuria  whatever,  even  though 
hyaline  casts  are  present.  In  general  arterio-sclerosis  there  are  often  brain 
symptoms  {simulated  tiremia)  due  to  anemia  and  imperfect  circulation, 
namely,  vertigo,  tinnitus  and  amaurosis.  In  the  latter  condition  retinal 
changes  occur  earlj^  but  they  are  not  those  of  retinitis  albuminurica  and 
hemorrhage  into  the  retina.  As  pointed  out  by  de  Schweinitz,  there  is 
thickening  of  the  arteries  which  compress  the  veins  where  they  cross  them. 
These  changes  may  occur  early.  Retinitis  albuminurica,  hemorrhages,  and 
more  serious  derangements  of  vision  occur  only  when  the  kidney  lesion  is 
primary.  An  important  symptom  characteristic  of  general  arterio-sclerosis 
is'a  tendency  to  emaciation  and  loss  of  weight,  a  change  of  color,  a  pallor,  and 


INTERSTITIAL  NEPHRITIS  739 

loss  of  vigor  which  is  characteristic.  The  condition  of  the  arteries  inter- 
feres with  an  adequate  nutritive  supply  and  the  patient  wastes  as  well  as 
grows  weaker  and  anemic.  Perhaps  the  most  characteristic  difference  is 
found  in  the  blood-pressure.  In  general  arterio-sclerosis  blood-presstu-e 
may  be  increased,  but  not  nearly  as  much  as  in  renal  sclerosis  where  the 
systolic  pressure  is  often  170  to  220  mm.  as  contrasted  with  an  average 
normal  of  115  to  140  mm.  An  important  etiologico-pathological  difference 
is  claimed  by  Gull  and  Sutton  for  the  kidneys.  According  to  them,  the 
destruction  of  renal  tubules  is  due  to  the  pressure  of  new  connective  tissue 
itself  resulting  from  the  arterial  changes,  whereas  in  primary  contracted 
kidney  the  renal  parenchyma  dies  first  and  is  replaced  by  connective  tissue 
secondarily. 

We  have  attempted  to  tabulate  these  differences  between  the  two  condi- 
tions as  follows: 


Primary  Chronic  Interstitial  Nephritis.  Primary  General  Arteriosclerosis. 

1.  Causes  of  chronic  interstitial  nephri-  i.  Same  causes, 
tis,  such  as  overeating  and  drinking,  gout, 

diabetes,  syphilis,  lead  intoxication,  etc. 

2.  Characteristic   insidious    onset,    in-  2.  Early      appearance      of      arterial 
eluding     digestive     derangements,     small  changes. 

albuminuria,  few  casts,   with  little  or  no 
evidence  of  arterial  change  at  first. 

3.  Edema,  never  at  first,  later  rare.  _  3.  Same. 

4.  Arterial  pulsation  often  very  annoy-  4.  No  pulsation  in  head  01  elsewhere, 
ing. 

5.  Vertigo  infrequent.  5.  Vertigo  common. 

6.  Albuminuric    retinitis    and    hemor-  6.  Retinal  changes,   but  not  hemor- 
rhages into  retina.  rhage,  nor  retinitis  albuminurica. 

7.  Hypertrophy  of  one  or  both  ventri-  7.  Rather  less  frequent, 
cles  rather  more  frequent. 

8.  High  blood-pressure  and  high  arte-  8.  Moderate   or   lowered   blood-pres- 
rial    tension   before   vascular    change,    is  sure,  moderate  arterial  tension, 
evident. 

9.  True  uremia.  9.  Simulated  uremia,  due  to  changes 

in  the  circulation  in  the  cortex. 


Strictly  speaking,  all  nephritis  is  primarily  parenchymatous  or  tubular, 
but  in  what  is  known  as  chronic  interstitial  nephritis  the  changes  are  slower 
and  the  replacement  by  connective  tissue  more  prompt  and  rapid,  so  that 
the  interstitial  element  predominates  and  the  cells  are  destroyed  more 
rapidly. 

Diabetes  insipidus  is  comparable  to  contracted  kidney  in  the  increased 
quantity  of  urine  of  low  specific  gravity,  but  there  is  no  albumin,  casts 
are  absent,  and  the  urine  is  much  more  copious. 

Prognosis. — The  prognosis  is  unfavorable  as  to  recovery,  but  favorable 
as  to  prolongation  of  life  if  the  diagnosis  be  made  sufficiently  early.  Cases 
with  casts  and  small  albuminuria  may  continue  under  observation  for  many 
years.  If  the  diagnosis  be  delayed  until  the  onset  of  uremic  symptoms, 
little  can  be  expected.  But  even  at  this  stage,  energetic  treatment  may  stUl 
avert  the  immediate  danger  and  prolong  the  patient's  life.  The  possible 
sudden  occurrence  of  convtilsions  and  coma,  and  of  death  therefrom,  should 
always  be  remembered  and  impressed  upon  the  relatives  of  the  patient. 
These  constitute  unfavorable  symptoms,  to  which,  toward  the  end,  Cheyne- 
Stokes  breathing  may  be  added.     It  is  important  to  remember  that  many,  of 


740  DISEASES  OF  THE  URINARY  ORGANS 

the  mild  cases  in  which  for  years  the  symptoms  are  so  little  pronounced  that 
it  is  hard  to  believe  there  is  anything  wrong,  terminate  in  apoplexy. 

Treatment. — From  what  has  been  said  under  prognosis,  it  is  evident 
that  the  most  hopeful  result  to  be  expected  from  treatment  is  the  protection 
of  the  patient  from  the  consequences  of  his  malady,  rather  than  the  restora- 
tion of  the  kidney  to  its  normal  condition.  Our  power  in  the  former  respect 
depends  largely  upon  the  stage  at  which  the  disease  is  discovered.  If 
detected  at  a  period  in  which  the  urine  is  abundant,  the  albuminuria 
small,  the  casts  few,  and  there  is  no  edema,  the  indications  are : 

1.  To  maintain  the  integrity  of  the  blood,  by  preventing  the  accumu- 
lation of  toxins  in  the  blood. 

2.  To  treat,  as  they  arise,  the  accidents  and  complications  which  are 
often  so  dangerous  to  the  patient. 

The  first  of  these  is  best  accomplished  by  dietetic  and  hygienic  measures, 
aided  by  the  use  of  a  few  remedies.  First,  as  to  food,  all  that  was  said 
under  chronic  parenchymatous  nephritis  is  applicable  to  interstitial  nephri- 
tis, because  the  appetite  is  still  good,  and  a  suitable  selection  can  be  exercised. 
As  the  toxic  agents,  whatever  they  are,  have  their  chief  source  in  the  pro- 
tein elements  of  food,  it  is  plain  that  the  larger  the  quantity  of  such  food 
consumed,  the  larger  is  the  accumulation  of  toxins.  Now,  while  it  is  not 
possible  nor,  perhaps,  desirable  to  exclude  all  nitrogenous  food,  it  may  be 
largely  reduced.  This  is  accomplished  by  the  substitution  of  all  or  a  part 
of  animal  flesh  by  milk  and  vegetables.  On  such  a  system  the  patient  with 
contracted  kidney  may  maintain  apparently  perfect  health  for  many 
years. 

Alcoholic  beverages  should  be  prohibited.  In  those,  however,  v.'ho  have 
been  habitual  drinkers,  the  reduction  must  be  slow  and  it  may  be  necessary 
to  continue  small  amounts  of  alcohol. 

What  has  been  said  of  clothing,  fresh  air,  and  exercise  in  connection  with 
chronic  parenchymatous  nephritis  is  even  more  applicable  to  interstitial 
nephritis.  Warmth  of  the  body,  maintained  by  woolen  or  linen  garments 
next  the  skin  to  encourage  its  action,  and  the  avoidance  of  damp  and  cold, 
which  check  it,  are  peremptory.  The  wetting  of  the  body  by  rain,  or  of 
the  feet  alone,  has  frequently  been  the  exciting  cause  of  a  fatal  uremic 
attack.     Heavy  shoes  should  be  woni  in  damp  weather. 

In  this  connection,  sea-bathing  requires  mention.  It  is  well  known  that 
sea-bathing  sometimes  induces  albuminuria  in  normally  constituted  persons, 
or,  at  least,  in  individuals  at  other  times  free  from  albuminuria.  This  is 
probably  due  to  a  temporan,^  congestion  of  the  kidney,  from  introversion  of 
the  blood  kept  up  by  the  duration  of  the  bath.  Still  more  mischievous, 
therefore,  must  be  the  effect  of  prolonged  sea-bathing  upon  one  whose  kid- 
neys are  already  damaged  and  incompetent  to  perform  their  office.  Sea- 
bathing, therefore,  or  any  form  of  cold  bathing,  should  be  interdicted  to  the 
patient  with  contracted  kidney,  or,  indeed,  with  any  form  of  chronic  neph- 
ritis. Sea-bathing  is  especially  mentioned  because  it  is  considered  healthful, 
and  persons  remain  in  the  water  so  long  at  a  time.  On  the  other  hand,  a 
daily  warm  bath  at  bedtime,  and  especially  an  occasional  Turkish  bath,  is 
advantageous. 

For  the  same  reason  residence  in  a  warm,  equable  climate  is  often  of  sig- 


INTERSTITIAL  NEPHRITIS  741 

nal  service  in  interstitial  nephritis;  and  cases  are  reported  in  which  the  al- 
bumin has  disappeared  and  symptomatic  recovery  taken  place  during  such 
residence. 

Prolonged  bodily  or  mental  fatigue  shotdd  also  be  avoided  by  these 
patients,  as  they  have  been  known  to  be  the  exciting  cause  of  uremia  and 
death;  especially  are  they  so  when  associated  with  free  eating  and  drinking. 
The  patient  shotdd  live  a  life  as  easy  and  as  free  from  any  of  these  influences 
as"  his  circumstances  will  permit. 

As  to  drugs,  they  are  of  limited  utility.  The  moderate  use  of  tonics, 
including  strychinin,  and  iron,  is  useful  to  combat  the  tendency  to  anemia 
and  weakness,  which  sooner  or  later  follows.  In  this  form  of  Bright's 
disease  even  more  than  in  chronic  parenchymatous  nephritis,  is  the  indis- 
criminate use  of  iron  to  be  guarded  against.  Iron  in  contracted  kidney,  as 
often  used,  is  a  harmful  drug.  It  locks  up  secretions,  causes  headache, 
and  increases  the  danger  of  uremia.  Only  when  there  is  evident  anemia, 
as  shown  by  blood  examinations,  should  it  be  used,  and  then  only  in  ver}- 
small  doses.  Elimination  is  favored  by  stimulating  the  secretion  of  the 
skin,  and  this  is  best  accomplished  by  an  occasional  warm  bath,  or,  expe- 
cially,  a  Turkish  bath,  with  thorough  friction  and  protection  from  cold 
by  woolen  underclothing.  The  Turkish  bath  is  an  admirable  remedial 
measure,  especially  before  the  disease  is  too  far  advanced. 

Diuretics  are  not  indicated  in  the  earlier  stages,  because  the  secretion  of 
urine  is  already  free.  The  bowels  should  be  kept  regular  by  the  use  of  the 
natural  aperient  waters,  the  Hunyadi,  Friedrichshalle,  Apenta,  Veronica  and 
Rakoczy,  or  an  occasional  blue  pill,  or  a  dose  of  magnesium  sulphate.  Of 
course,  later  in  the  disease,  when  the  heart  begins  to  fail  and  the  urine  is 
scanty,  both  diuretics  and  purgatives  are  indicated.  The  same  principles 
are  to  govern  us  in  using  them  as  have  already  been  laid  down  under  acute 
nephritis.  Very  high  arterial  tension  sometimes  demands  treatment.  A 
certain  amount  is  a  result  of  the  conservative  train  of  symptoms,  beginning 
with  hypertrophy  of  the  left  ventricle,  and  is  necessary;  but  when  a  resulting 
throbbing  is  unpleasantly,  appreciable,  especially  if  there  is  throbbing  head- 
ache with  flashes  of  light  at  each  pulsation,  tension  should  be  lowered. 
However,  this  must  be  done  with  caution  and  with  rest  and  hygiene  rather 
than  with  drugs. 

Nitroglycerine  is  of  little  value  unless  given  in  huge  doses.  Aconite  or 
veratrum-  viride  may  be  used  in  the  cases  where  the  blood  pressure  itself 
is  the  cause  of  symptoms  and  needs  lowering. 

The  second  indication  mentioned,  the  treatment  of  the  complications  and 
accidents  incident  to  the  condition,  resolves  itself  into  the  treatment  of  the 
bronchitis,  the  pericarditis,  the  pleurisy,  pneumonia,  endocarditis,  gastric 
and  intestinal  disorders,  which  have  been  named  as  occurring,  and  especially 
of  the  most  serious  calamity  of  all,  uremia.  The  treatment  of  the  complica- 
tions is  that  of  the  same  conditions  under  other  circumstances.  Paracente- 
sis is  a  measure  which  is  often  of  signal  service  in  effusions  into  the  chest,  and 
occasionally  of  the  pericardium. 

Dyspeptic  symptoms  are  best  treated  by  diet,  regulation  of  exercise  and 
the  use  of  nux  vomica  and  one  of  the  mineral  acids.  Hypnotic  sedative, 
and  antispasmodic  effects,  when  desired,  should  be  produced  by  spulphonal, 


742  DISEASES  OF  THE  URINARY  ORGANS 

trional,  veronal,  chloral,  and  bromids.  Opium  may  be  used  tentatively. 
It  is  not  as  dangerous  as  is  constantly  thought  to  be  the  fact. 

Finally,  as  to  the  treatment  of  uremia,  the  measures  described  in  the 
treatment  of  uremia  in  acute  nephritis  are  to  be  used.  Apoplexy,  which  is 
not  an  infrequent  termination  of  the  disease,  in  consequence  of  the  ather- 
omatous state  of  the  blood-vessel  walls,  is  recognizable  by  the  paralysis, 
general  or  partial — most  frequently  hemiplegia — which  accompanies  the 
unconsciousness.  Remedies  are  here  generally  futile,  but  such  may  be  used 
as  are  indicated  for  apoplexy.  The  upright  position,  bleeding,  and,  if 
the  patient  survives  the  immediate  accident,  nitro-glycerine,  iodid  of  potas- 
sium, with  a  view  to  promoting  absorption  of  the  extravasated  clot,  may  be 
used.  Hemorrhages  in  other  situations,  as  from  the  nose  or  alimentary 
canal,  are  treated  by  the  same  measures  as  when  they  occur  under  other 
circumstances.  The  close  resemblance  at  times  of  the  symptoms  of  uremia 
to  those  of  apoplexy  should  be  remembered. 

As  to  special  treatment,  or  treatment  directed  to  the  removal  of  the 
interstitial  overgrowth  in  the  kidney,  there  is  none.  Theoretically,  the 
iodid  of  potassium  ought  to  be  of  service.  Unfortunately,  the  pecidiar 
requirements  of  its  administration — viz.,  the  length  of  time  during  which 
the  patient  must  take  the  remedy  before  any  results  may  be  expected,  and 
the  consequent  difficulty  in  accumulating  a  sufficient  number  of  cases — are 
such  that  it  is  almost  impossible  to  determine  whether  it  can  be  of  any  ser- 
vice or  not.  Owing  to  these  difficulties,  it  is  doubtful  whether  its  exact 
possibilities  have  as  yet  been  determined.  There  can  be  no  disadvantage  in 
administering  it  if  the  dose  is  so  small  as  not  to  derange  the  stomach.  Very 
rarely  can  more  than  a  few  grains  daily  be  given.  Bichlorid  of  mercury, 
in  long-continued  use  in  doses  of,  at  first,  1/24  grain  (0.0027  gm.),  and 
later  1/50  grain  (0.0013  g™-).  kept  up  a  long  time,  followed  by  improve- 
ment. Improvement  in  the  imparied  vision  of  alubuminvuic  retinitis 
follows  its  use.  Certainly  in  the  event  of  a  clear  syphilitic  origin,  the 
iodid  of  potassivun  should  be  used. 

Operative  treatment  by  decapsulation  has  been  applied  in  contracted  kid- 
ney as  well  as  in  chronic  parenchymatous  nephritis.  Indeed,  some  believe 
it  more  indicated  in  chronic  interstitial  nephritis.  Our  own  experience  would 
indicate  that  it  is  more  likely  to  be  successful  in  chronic  diffuse  nephritis. 
See  treatment  of  chronic  parenchymatous  nephritis,  p.  730. 

Serum  Treatment. — So  far  the  serum  treatment  of  Bright's  disease,  some 
efforts  made  abroad  by  Dieulafoy,  Renault,  Vitzone,  and  others  have 
not  resulted  in  its  extensive  use.  The  sterilzied  serum  and  defibrinated 
blood  of  the  goat  have  been  used  and  even  extracts  of  the  kidney  of  pigs. 
Fifteen  c.c.  of  sterilized  serum  were  injected  into  the  subcutaneous  tissue  of 
the  abdominal  walls,  it  is  said,  with  striking  results  in  one  or  two  cases. ' 

AMYLOID  DISEASE  OF  THE  KIDNEY. 

Synonyms. — Lardaceous  Disease;  Albuminoid  Disease;  Waxy  Kidney; 
Depurative  Disease. 

Definition. — A  morbid  state  of  the  kidney  in  which  its  structural  ele- 
ments are  more  or  less  infiltrated  A\dth  a  substance  of  albuminous  composi- 


AMYLOID  KIDNEY  743 

tion  and  the  luster  of  bacon,  best  recognized  by  the  deep  mahogany  red  color 
it  strikes  when  treated  with  a  solution  of  iodin.  Osier  rightly  says,  "it  has 
no  claim  to  be  regarded  as  one  of  the  varieties  of  Bright's  disease,  because 
it  is  generally  a  part  of  a  wide-spread  amyloid  degeneration." 

Etiology. — The  most  frequent  cause  of  lardaceous  disease  is  profuse 
and  long-continued  suppuration,  such  as  occurs  in  chronic  bone  disease, 
whether  tuberculous,  syphilitic,  or  traumatic  in  origin,  or  such  discharge  as 
constitutes  the  expectoration  in  cases  of  chronic  phthisis  and  chronic  bron- 
chitis with  bronchiectasis.  Syphilis  itself,  independently  of  the  tertiary 
conditions  which  it  produces,  is  a  frequent  cause  of  lardaceous  disease. 
Cachectic  states  of  any  kind,  chronic  dysentery,  ulceration  of  the  bowels, 
and  chronic  albuminuria  are  possible  causes. 

Either  sex  is  equally  subject  to  lardaceous  disease,  but  as  men  are  more 
frequently  exposed  to  its  causes,  it  is  in  them  rather  more  common.  Very 
young  children  are  rarely  affected,  for  evident  reasons,  but  in  young  persons 
from  1 1  to  3  o  it  is  most  frequent.  After  3  o  it  grows  gradually  rarer.  Tuber- 
culous hip  disease  in  children,  especially,  is  a  cause. 

Morbid  Anatomy. — The  incipient  stages  seldom  present  alterations 
recognizable  by  the  naked  eye,  unaided  by  reagents.  But  if,  after  section 
of  the  kidney,  the  cortex  be  treated  by  a  solution  of  iodin  and  iodid  of 
potassium,  1  numerous  mahogany-red  points  make  their  appearance,  or  if 
by  a  solution  of  violet  anUin,  as  many  red  or  pink  points  these  are  the 
Malpighian  bodies,  whose  capillary  tufts  are  the  first  to  be  affected  by  the 
change.  The  kidney,  in  this  early  stage,  is  normal  in  size  or  very  slightly 
enlarged.  Its  capsule  strips  off  readily,  revealing  no  changes,  or  a  paleness 
or  translucency  which  readily  escapes  notice,  but  may  be  recognized  at  the 
edges  of  a  thin  section.  Very  often,  too,  they  are  completely  overshadowed 
by  other  changes,  for  amyloid  kidney  is  most  frequently  a  superadded  event 
in  the  course  of  chronic  diffuse  nephritis  while  the  same  may  happen  in 
interstitial  nephritis.  The  large  white  kidney  of  chronic  parenchymatous 
nephritis  is  especially  apt  to  exhibit  a  slight  degree  of  lardaceous  change, 
which  may  altogether  escape  notice  unless  iodin  is  used.  Hence,  iodin 
should  be  tried  upon  all  kidneys  removed  at  autopsy. 

In  a  more  advanced  stage  of  uncomplicated  lardaceous  change  the 
kidneys  are  both  enlarged,  usually  symmetrically,  but  the  extreme  degrees 
of  enlargement  are  commonly  associated  with  fatty  epithelium.  Such 
organs  were  a  pair  weighing  23  ounces  (715  gm.)  which  came  under  Dickin- 
son's^  notice.  Johnson^  refers  to  a  case  in  which  the  two  kidneys  weighed 
28  ounces  (870  gm.).  Rindfieisch*  has  seen  a  single  instance  of  that  very 
rare  condition,  complete  lardaceous  infiltration — including  the  basement 
mem  brane  of  the  uriniferous  tubes,  as  well  as  the  capillaries,  the  kidney 
being  enlarged  to  nearly  twice  its  normal  size.  In  the  simple  forms  of  lar- 
daceous disease  the  capsule  is  not  adherent,  but  if  interstitial  changes  coexist 
to  any  extent,  it  is  adherent.     The  surface  of  the  kidney  is  pale  and  anemic; 

*  The  Iodin  Test  Solutions. — The  best  test  solution  for  macroscopic  purposes  is  one  made  by  dissolving 
2  1/2  grains  {0.16  gm.)  of  iodin  by  the  aid  of  five  grains  (0.32  gm.)  of  iodid  of  potassium  in  one  fluidounce 
{30  c.c.)  of  water.  The  solution  contains  about  one-half  of  one  per  cent,  of  iodin.  For  microscopic  prep- 
arations a  solution  weaker  than  the  foregoing,  or  a  one-quarter  of  one  per  cent.,  of  iodin  dissolved  by  twice 
the  quantity  of  iodin  of  potassium,  is  more  suitable,  and  sometimes  a  solution  containing  as  much  iodin  as 
water  alone  will  take  up  answers  best. 

2  Dickinson,  op.  cit.,  p.  249. 

2  Johnson,  op.  cit.,  p.  104. 

<  Rindfleisch,  "Path.  Histology,"  "New  Syd.  Soc.  Trans.,"  1873,  vol.  ii.,  p.  167. 


744  DISEASES  OF  THE  URINARY  ORGANS 

occasionally,  the  stellate  veins  are  conspicuous.  The  characteristic  trans- 
lucency  may  even  be  recognized  in  the  organ  in  bulk,  but  it  is  more  striking 
in  sections.  When  the  change  is  present  in  high  degree,  the  edges  of  a  thin 
section  are  almost  as  translucent  as  a  similar  section  of  bacon.  On  laying 
open  the  kidney  the  cortex  is  seen  to  be  enlarged;  it  is  pale,  anemic,  waxy,  firm 
and  resisting.  The  pyramids  are  normal  in  hue  and  area.  The  iodin  solu- 
tion added  to  such  a  kidney  produces  its  peculiar  coloration  not  merely  in 
the  Malpighian  capillaries,  but  also  in  the  afferent  and  efferent  vessels  and 
the  vasa  recta  of  the  pyramids:  In  a  still  later  stage,  that  of  atrophy,  the 
kidney  becomes  contracted,  rough,  and  even  distorted  in  shape.  The 
capsule  is  adherent,  and  on  section  the  cortex  is  found  narrowed,  sometimes 
as  much  so  as  in  the  contracted  kidney  of  interstitial  nephritis. 

Minute  Changes. — To  microscopic  examination  in  the  first  stage,  the 
Malpighian  bodies  exhibit  a  lustrous  or  waxy  appearance.  They  are  en- 
larged and  the  capillar^'  walls  thickened.  At  this  stage  there  is  no  visible 
alteration  in  the  tubules  or  in  their  epithelium.  In  the  second  stage  larger 
vessels  are  involved,  the  vasa  afferentia  and  efterentia  in  the  cortex;  the 
vasa  recta  of  the  cones;  also  the  second  capillary  network  of  the  cortex, while 
an  exudation  occurs  into  the  tubules  of  a  glistening  material  which  may  form 
casts.  Such  casts  sometimes  strike  the  mahogany  red  reaction.  At  other 
times  they  have  the  composition  of  ordinary  hyaline  casts.  It  is  to  be 
remembered,  however,  that  similar  waxy  casts  are  found  in  the  tubules 
in  other  forms  of  chronic  and  even  acute  renal  disease. 

The  arteriole  walls  are  thickened  by  involvement  of  both  interna  and 
media.  This  thickening  is  attended  by  an  extraordinary-  distinctness  of 
the  muscular  fiber-cells  of  the  circidar  coat.  Later,  the  basement  membrane 
an;  epithelial  lining  may  be  invaded,  the  cells  swollen,  translucent,  and 
apparently  fused.  It  is  also  quite  usual  for  the  epithelium  of  the  cells  to  be 
fatty,  and  the  capillary  walls  to  contain  aggregations  of  fat  drops,  while 
the  urine  in  the  later  stages  may  contain  oU  casts  and  fatty  cells. 

In  what  has  been  called  the  third  or  contracting  stage  of  lardaceous 
kidney,  but  which  may  be  the  ordinary,'  contracted  kidney  on  which  the 
amyloid  change  has  been  grafted,  minute  examination  reveals,  in  addition 
to  the  appearances  described,  hypernucleated  intertubal  overgrot\i;h.  Cysts 
are  occasionally  present  for  the  same  reason  as  in  the  granular  con- 
tracted kidney ;  in  like  manner  superficial  granulations. 

Symptoms. — One  who  has  had  syphilis,  or  who  has  phthisis,  bone- 
necrosis,  or  other  affection  causing  an  exhaustive  drain,  may  acquire  this 
form  of  kidney  disease  without  appreciable  addition  to  his  symptoms. 
A  marked  cachexia  may  be  present.  The  albuminuria  may  be  larger  than 
that  of  a  chronic  nephritis.  There  may  be  numerous  casts  of  ever}'  variety 
except  epithelial  and  blood-casts,  including  waxy  casts  which  are,  however, 
not  distinctive.     Uremia  is  rare. 

Senator  announced  some  years  ago  that  scrum  globulin  is  increased  in 
the  urine  of  amyloid  kidney.  Hj^pertrophy  of  the  left  ventricle  or  high 
arterial  tension  are  not  conspicuous. 

But  lardaceous  disease  of  the  kidney  almost  never  occurs  alone.  It  is 
alwaj's  accompanied  by  similar  changes  in  the  liver,  spleen,  and  often  of  the 
intestinal  canal.     Hence,  evidences  of  alterations  in  these  organs  are  more 


AMYLOID  KIDNEY  745 

or  less  marked.  Thus,  the  percussion  areas  of  the  liver  and  spleen  are 
almost  always  enlarged,  and  the  blood-vessels  of  the  stomach  and  intestines 
are  often  involved.  In  the  former  event  obstinate  vomiting,  and  the  latter 
equally  obstinate  diarrhea,  results.  The  latter  is  far  more  frequent  than  the 
former. 

As  to  duration,  the  disease  generally  runs  a  very  chronic  course,  which 
is  limited  only  by  the  malady  of  which  it  is  a  complication.  As  such  it  is 
always  of  shorter  duration  than  interstitial  nephritis,  and  may  be  shorter 
than  chronic  parenchymatous  nephritis,  although  the  latter  affection  and 
lardaceous  disease  more  closely  resemble  each  other  in  respect  to  duration. 
When  obstinate  diarrhea  and  vomiting  supervene,  the  end  is  usually  not 
remote. 

Diagnosis. — There  are  some  instances  in  which  lardaceous  disease  is 
easily  recognized.  If  a  patient  has  had  syphilis  with  secondary  and  tertiary' 
symptoms,  or  has  long  been  a  victim  to  phthisis,  and  he  is  discovered  to  be 
edematous  and  to  have  a  large  albuminuria,  with  an  increased  amount  of 
serum  globulin,  with  waxy  hyaline  and  fatty  casts  and  an  enlarged  liver  and 
spleen  and  obstinate  diarrhea,  there  can  be  little  doubt  but  that  there  is 
lardaceous  disease.  But  when  neither  of  these  two  general  diseases  is  pre- 
sent, or  the  phthisis  has  not  existed  a  very  long  time,  or  there  is  not  de- 
cided evidence  of  enlarged  liver  and  spleen,  we  cannot  be  certain.  While  it  is 
never  safe  to  diagnose  lardaceous  disease  without  the  presence  of  enlarged 
liver  and  spleen,  such  enlargement  on  the  other  hand,  even  when  associated 
with  large  albuminuria  does  not  necessarily  imply  amyloid  kidney.  The 
symptoms  and  course  of  the  disease,  particularly  in  its  latter  stages,  are  so 
like  those  of  chronic  parenchymatous  nephritis  that  it  is  often  impossible  to  sep- 
arate the  two.  Further,  there  is  every  reason  to  believe  that  chronic  neph- 
ritis is  sometimes  caused  by  the  same  dyscrasic  conditions  as  produce  the 
lardaceous  disease.  In  such  cases,  too,  therefore,  a  diagnosis  is  impossible. 
Finally,  the  two  conditions  may  exist  jointly. 

Amyloid  kidney  is  hardly  likely  to  be  confounded  with  chronic  interstitial 
nephritis  as  each  has  distinctive  signs,  apart  from  those  common  to  both. 

Prognosis. — In  prognosis  much  depends  upon  the  presence  or  absence 
of  the  original  disease  causing  the  amyloid  change.  If  the  former  cannot  be 
cured,  the  latter  is  not  likely  to  be.  If  the  original  disease  is  curable  and  the 
patient  young,  there  are  no  limits  to  the  possibilities,  although  it  is  scarcely 
likely  that  the  kidney  is  ever  restored  to  its  normal  state.  Complete 
restoration  of  function  is,  however,  possible.  If  the  patient  be  past  middle 
life,  even  if  the  original  disease  has  disappeared,  recovery  is  less  likely  and 
if  the  blood-vessels  of  the  stomach  and  intestines,  as  attested  by  vomiting 
and  diarrhea,  are  invaded,  the  disease  is  rapidly  fatal. 

Treatment. — Of  the  lardaceous  disease  it  may  be  said  with  greater 
emphasis  than  of  any  other  form  of  renal  disease,  "an  ounce  of  prevention  is 
worh  a  pound  of  cure. ' '  A  due  appreciation  by  surgeons  and  syphilographers 
of  the  causes  of  amyloid  kidney  would  prevent  the  occurrence  of  many  cases, 
the  timely  amputation  of  a  limb  long  the  seat  of  suppuration  and  the 
thorough  treatment  of  syphilis  being  often  all  that  is  needed.  To  this  end 
also  frequent  examinations  of  the  urine  should  be  made  by  those  in  charge 
of  suppurating  diseases,  while  albuminuria  should  be  the  signal  for  prompt 


746  DISEASES  OF  THE  URINARY  ORGANS 

interference,  if  such  be  possible.  Especially  they  who  are  watchful  should  be 
in  charge  of  children  with  hip-disease. 

In  syphilis  the  faithful  and  persistent  use  of  remedies  for  a  sufficient  time 
after  all  the  symptoms  of  the  primary  and  secondary  stages  have  dis- 
appeared is  essential.     See  treatment  of  syphilis. 

If  the  cause  continues  to  exist,  the  treatment  of  the  amyloid  disease  is 
the  treatment  of  the  former — ^if  it  be  syphilis,  iodid  of  potassium,  mercurials 
and  salvarsan;  if  phthsis,  cod-liver  oil,  iron,  creasote  and  creasotal,  quinin, 
an  abundance  cf  nourishing  food,  in  which  milk  and  cream  should  be 
conspicuous,  alcohol,  and  restorative  measiu-es  generally,  together  with 
fresh  air  and  suitable  exercise.  Supposing  the  original  disease  to  have 
disappeared,  the  treatment  indicated  is  that  of  chronic  parenchymatous 
nephritis,  for  the  details  of  which  the  reader  is  referred  to  the  section  on 
that  disease. 

SUPPURATIVE  INTERSTITIAL  NEPHRITIS  AND 
PYELONEPHRITIS. 

Synonyms. — Septic  and  Pyemic  Nephritis;  Interstitial  Suppurative 
Nephritis;  Surgical  Kidney;  Abscess  of  the  Kidney. 

Definition. — Supptirative  nephritis,  due  to  invasion  of  the  kidney  or  its 
pelvis  by  pathogenic  bacteria,  either  by  way  of  the  circulation  or  the  urinary 
tract.  A  milder  nonsuppurative  grade  of  this  disease,  characterized  by 
cicatricial-like  markings  on  the  capsule  of  the  kidney  and  sometimes  by 
firm  adhesions  between  the  capsule  and  its  fatty  surroundings,  may  be 
named  capsulitis  or  perinephritis . 

Etiology. — Often  this  form  of  nephritis  starts  in  the  pelvis  of  the  kidney 
as  a  pyelitis,  and  thence  extends  into  the  interstitial  tissue  of  the  organ. 
Such  a  condition  is  preeminently  a  ^yeZonephritis.  It  maj'-  also  start  in 
the  interstitial  tissue  of  the  substance  of  the  organ  as  the  result  of  infectious 
embolism  or  traumatism  or  obstruction  of  the  tubules  by  concretions. 
Late  studies  have  shown  that  infection  from  the  systemic  circulation  by 
pathogenic  organisms  is  more  frequent  than  supposed.  This  is  especially 
true  of  tuberculous  abscess.  The  process  may  be  limited  to  the  kidney,  its 
pelvis  or  maj^  ultimately  invade  both.  It  is  often  impossible  to  separate 
the  two  conditions  in  diagnosis,  and  I  do  not,  therefore,  separate  the  two 
diseases,  that  is  processes  in  the  kidney  from  those  of  its  pelvis. 

A  frequent  contagium  bearer  is  retained  decomposed  urine.  Retention 
may  be  due  to  stricture  of  the  urethra  or  even  phimosis,  to  stone  in  the 
bladder  or  ureter  or  pelvis  of  the  kidne3^  Perhaps  there  are  alwaj-s  bacteria 
ready  to  avail  themselves  of  favorable  conditions,  but  a  favorite  route  of 
introduction  is  by  unclean  catheters.  In  many  of  these  cases  inflammation 
of  the  bladder  is  an  intermediate  state.  Calcvilous  concretions  in  the  sub- 
stance of  the  kidnej'  also  furnish  conditions  favorable  for  the  action  of 
bacteria  of  suppuration. 

Injections  emboli  cause  a  small  number  of  cases  of  suppurative  nephritis. 
The  emboli  are  usually  derived  from  the  valves  of  the  heart  in  cases  of 
lolcerative  endocarditis,  but  they  may  also  arise  in  putrid  wounds,  stumps,  or 
other  seats  of  putrid  inflammation.     The  abscesses_found  in  the  kidney  in 


PYELONEPHRITIS  747 

common  with  other  organs  in  pyemia  are  thus  produced.  Tubercle  bacilli 
are  also  causes,  entering  by  either  of  the  routes  named,  producing  tubercu- 
lous pyelonephritis.  Among  the  organisms  found  in  the  urine  and  held 
responsible  are,  besides  the  tubercle  bacillus,  the  bacterium  coli  commune,  the 
proteus  Hauser,  the  streptococcus  and  staphylococcus.  Parturition  is  not 
an  infrequent  medium  of  introduction  of  pathogenic  bacteria,  while  the  in- 
fectious fevers  are  recognized  causes. 

Traumatic  agencies  such  as  blows,  kicks,  or  penetrating  wounds  in  the 
neighborhood  of  the  kidney,  or  falls  from  a  distince  and  striking  upon  the 
sharp  edge  of  a  fence  or  similar  object,  may  also  cause  suppurative  nephritis. 

Suppurative  nephritis  may  occur  at  any  age  subject  to  the  operation  of 
the  cause.     The  youngest  patient  I  ever  had  was  two  years  old. 

Morbid  Anatomy. — The  appearances  vary  necessarily  with  the  stage  of 
the  disease  and  also  somewhat  with  the  cause.  In  an  earlier  stage,  if  the 
inflammation  pass  from  below  upward,  as  is  most  frequently  the  case,  the 
mucous  membrane  of  the  pelvis  is  first  affected,  being  swollen  and  dirty 
gray  in  color,  sometimes  visibly  congested.  Later,  the  pelvis  and  calices 
may  be  dUated  and  the  papillae  flattened.  The  distention  may  go  on  at 
the  expense  of  the  kidney  until  the  whole  organ  is  converted  into  a  pus-sac 
bounded  by  a  varying  remnant  »f  renal  tissue.  Such  sac  may  be  a  constant 
source  of  pus,  or  if  complete  obstruction  occurs,  the  pus  may  become 
inspissated  and  cheesy.  The  ureter  is  also  often  dilated,  sometimes  resem- 
bling, in  consequence  of  such  extreme  dilatation,  the  intestine. 

In  tuberculosis  extending  via  the  urinary  tract  the  apices  of  the  cones 
are  also  invaded,  it  may  be  from  the  mucous  membrane  by  continuity,  or  by 
direct  lodgment  of  the  bacillus.  Successive  portions  of  the  kidney  sub- 
stance break  down,  and  the  ultimate  product  will  be  the  same,  a  sac  filled 
with  liquid  pus  or  cheesy,  putty-like  substance. 

In  other  instances,  especially  when  the  kidney  is  invaded  by  way  of  the 
vascular  or  lymphatic  system,  as  in  pyemic  abscess,  foci  of  suppuration  a 
millimeter  and  upward  in  diameter  are  scattered  in  the  cortex  and  separated 
by  sound  renal  tissue.  They  are  surrounded  by  an  intensely  red  border, 
are  often  visible  through  the  cortex,  and  may  be  ruptured  by  dragging  off 
the  capsvile.  On  section  at  an  early  stage,  linear  streaks  of  pus  raay  be 
found  in  the  medulla. 

At  a  later  stage  these  little  collections  of  pus  unite  to  form  larger  ones, 
these  again  to  form  others  still  larger,  destroying  the  tubular  structure  of 
the  kidney  as  they  encroach  upon  it,  and  it  is  at  this  stage  that  cases  of 
pyelonephritis  not  infrequently  terminate  unfavorably  and  the  specimens 
come  under  observation.  At  first  each  of  the  abscesses  thus  formed  is 
confined  to  the  region  of  a  single  pyramid,  and  it  not  infrequently  happens 
that  a  kidney  is  partitioned  off  into  spaces  corresponding  with  these.  Before 
this  occurs,  however,  the  abscess  bursts  through  the  papilla  and  calyx  into 
the  pelvis  of  the  kidney.  Thus,  in  an  opposite  direction  from  that  first 
described,  the  kidney  may  again  be  converted  into  a  purulent  sac. 

When  the  abscess  is  embolic  in  origin,  its  seat  is  at  first  occupied  by  an 
area  of  intense  hyperemia,  resulting  in  hemorrhagic  extravasation,  which 
takes  place  also  into  the  tubules,  causing  bloody  urine.  To  this  succeeds 
suppuration.     The  size  and  number  of  the  abscesses  depend  upon  that  of 


748  DISEASES  OF  THE  URINARY  ORGANS 

the  plug  obstructing  the  blood-vessels,  which  is  usually  one  of  the  inter- 
lobvdar  arteries  or  a  vas  afferens.  The  embolic  abscesses  may  also  be  multi- 
ple, in  consequence  of  the  breaking  of  the  embolus  into  a  number  of  minute 
fragments.  When  the  cause  is  traumatic,  the  process  is  not  so  easily  defined. 
Circumscribed  abscesses  may  occur,  or  the  kidney  may  be  converted  into  a 
soft,  pulpy  mass,  a  mixture  of  pus,  blood,  and  broken-down  renal  substance. 

In  the  variety  described  as  capsulitis,  cicatricial  markings  or  adhesions 
to  adjacent  tissue  constitute  its  morbid  anatomy. 

Symptoms. — The  symptoms  of  this  condition  are  not  numerous  and, 
apart  from  the  characters  of  the  urine,  are  not  very  distinctive,  while  the 
urine  often  fails  to  furnish  any  information.  In  milder  degrees  of  pelvic 
inflammation  before  the  kidney  is  invaded  there  may  be  no  symptoms.  Pain 
and  tenderness  are  the  constant,  but  considerable  inroads  maj'  be  made 
before  pain  results.  On  the  other  hand,  it  is  often  very  severe,  whUe  the 
tenderness  over  the  region  of  the  kidney  is  pronounced.  This  tenderness  is 
the  most  distinctive  and  valuable  symptom.  Usually  the  severest  pain  is  in 
the  renal  region,  whence  it  radiates  toward  the  front  of  the  abdomen  and 
groin,  and  may  be  accompanied  by  retraction  of  the  testicle.  When  the 
condition  is  the  result  of  impacted  Calculus,  the  seat  of  the  impaction  is 
the  primary  seat  of  pain.  It  may  be  between  the  umbilicus  and  the  pubis 
when  the  stone  is  low  down  in  the  ureter.  The  pain  is  always  intermittent 
to  a  degree,  sometimes  totally  so,  but  generally  it  is  more  or  less  constant, 
increased  paroxysmally.  Various  positions  are  assumed  b}'  the  patient  with 
a  view  to  easing  the  pain,  among  which  lying  on  the  face  is  not  infrequent. 

A  distinct  tumor  may  sometimes  be  discovered  by  palpation  and  percus- 
sion in  the  region  of  the  kidney.  This  implies  an  enlargement  of  the  organ, 
due  either  to  its  conversion  into  a  purulent  sac,  or  an  augmentation  of  its 
size  owing  to  the  distention  of  its  pelvis  with  pus  or  calculi  or  both.  Very 
frequently  it  is  due  to  perinephric  invasion. 

Fever  is  also  a  remittent  symptom.  Possibly  in  a  verj^  few  latent  cases 
it  may  be  altogether  absent,  but  except  in  these  there  is  always  elevation  of 
temperature,  with  corresponding  frequency  of  the  pulse.  These  latter  at 
times  become  decided,  and  in  advanced  stages  the  fever  is  septic,  being 
followed  by  profuse  sweats.  In  acute  cases,  especially  pyemic,  the  begin- 
ning of  suppuration  is  often  marked  by  a  chill  and  high  fever  or  succession 
of  chills,  but  in  other  instances  it  is  quite  impossible  to  recognize  the  begin- 
ning of  the  suppurative  stage. 

The  characters  oj  the  urine  may  be  nil  or,  as  intimated,  quite  distinctive. 
Except  in  acute  infectious  cases,  the  urine  almost  invariably  sooner  or  later 
contains  pus,  and  unless  it  does  contain  pus,  no  certain  diagnosis  can  be  made. 
Blood  is  also  a  very  constant  constituent  from  cases  of  suppurative  nephritis, 
but  while  such  urine  is  scarcely  ever  examined  by  the  microscope  without 
discovering  a  few  blood  disks,  the  quantity  is  often  not  large  enough  to  be 
recognizable  to  the  naked  eye.  The  quantity  of  pus  varies  greatly.  While 
it  may  be  so  copious  as  to  produce  a  heavy  white  opaque  deposit  one-sixth 
to  one-fifth  the  bulk  of  urine,  it  may  be  represented  by  little  more  than  a  trace. 
This  variation  will  occur  at  dift'erent  times  in  the  same  case.  Pus  from  the 
kidney  and  its  pelvis  is  usually  distinguished  from  that  formed  in  the  bladder 
by  the  absence  of  that  glariness  so  characteristic  of  the  latter,  due  to  admix- 


PYELONEPHRiriS  749 

ture  with  mucus  and  decomposition  products.  Pus  from  the  pelvis  of  the 
kidney  is  rarely  fetid,  as  compared  with  pus  from  the  bladder. 

The  urine  is  usually  diminished  in  quantity.  Complete  suppression  is 
not  uncommon  toward  the  close  of  extreme  cases.  Notwithstanding  such 
diminution,  the  color  may  be  pale  and  the  specific  gravity  low,  owing  to  the 
small  proportion  of  solids ;  the  range  of  specific  gravity  in  a  single  case  being 
from  1003  to  1016.  In  reaction  the  urine  is  faintly  acid,  neutral,  or  alkaline, 
and  though  often  prone  to  rapid  decomposition,  is  less  so  than  the  urine  of 
cystitis.  It  is  always  albuminous,  but  the  quantity  of  albumin  is  never  very 
large,  and  varying  generally  pari  passu  with  the  quantity  of  pus  and  blood. 
When  more  albumin  is  present  than  is  thus  accounted  for,  it  is  likely  that 
the  parenchyma  of  the  kidney  in  general  has  become  involved.  Such  cases, 
are,  therefore,  more  serious.  In  such  cases,  too,  tube-casts,  commonly  rare 
in  suppurative  nephritis,  may  appear. 

It  sometimes  happens  that  there  is  a  sudden  increase  in  the  quantity 
of  pus  in  the  urine,  followed  by  a  gradual  diminution,  or  the  urine,  previously- 
clear,  may  suddenly  become  loaded  with  pus.  Such  occurrences  indicate  the 
removal  of  a  temporary  obstruction  to  the  descent  of  the  pus,  or  the  rupture 
of  an  abscess  from  the  kidney  into  its  pelvis.  It  is  barely  possible  that  small 
portions  of  the  substance  of  the  kidnej^  may  be  thus  discharged,  and  identified 
by  the  microscope.  Occasionally,  also,  the  abscess,  instead  of  rupturing 
into  the  pelvis  of  the  kidney,  perforates  into  the  perinephric  tissue,  bur- 
rowing in  different  directions  and  producing  fistulous  openings.  Per- 
forations may  thus  take  place  posteriorly  in  the  lumbar  region,  or  anteriorly 
at  the  groin,  into  the  colon,  and  more  rarely  into  the  lungs  and  liver,  and 
even  into  the  peritoneal  sac. 

The  course  and  duration  of  suppurative  nephritis  vary  greatly.  Trau- 
matic cases  are  comparatively  rapid,  either  toward  recovery  or  death. 
Pyemic  cases  may  run  their  course  in  48  hours,  and  are  invariably  fatal. 
But  cases  due  to  other  causes — viz.,  impacted  calculus,  tubercidosis,  stone 
in  the  bladder,  or  cystitis — may  be  prolonged  indefinitely,  while  some  termi- 
nate without  being  discovered.  Sooner  or  later  the  patient  generally  suc- 
cumbs to  exhaustion,  but  life  may  be  sustained  for  years  with  paroxysms  of 
the  severest  suffering  and  a  surprising  degree  of  destruction  of  the  kidneys. 
The  greatest  danger  to  those  thus  a_ffected  is  intercurrent  illness  which  is  always 
more  serious  and  more  apt  to  terminate  unfavorably.  It  is  then  that  the 
kidneys,  previously  surprisingly  sufficient  in  eliminating  power,  give  way  in 
this  respect,  the  symptoms  of  uremia  supervene,  and  the  patient  dies  of 
this  complication.  It  is  well  known  that  the  operation  for  stone  is  much 
more  likely  to  be  followed  bj'  a  fatal  result  when  the  patient  happens  to  have 
a  surgical  kidney. 

There  are  no  complications  peculiar  to  suppirrative  interstitial  nephritis 
save  those  mentioned  as  causing  it;  or  as  resulting  from  unusual  accidents, 
such  as  rupture  and  perforation  into  neighboring  organs,  or  tuemia. 

In  capsulitis  the  resemblance  of  the  symptoms  to  those  of  stone  in  the 
kidney  is  often  very  striking,  and  has  led  to  the  diagnosis  of  nephrolithiasis 
with  operation  without  discovery  of  a  stone. 

Diagnosis. — The  diagnosis  of  suppturative  nephritis  may  be  easy  or 
difficult.     It  is  easy  when  there  is  the  history  of  a  traumatic  cause  followed 


750  DISEASES  OF  THE  URINARY  ORGANS 

by  hematuria,  and  later  purulent  urine,  with  tenderness  and  pain  over  the 
region  of  the  kidney.  If  the  urine  contain  pus  constantly  or  intermittently, 
and  in  addition  to  this  there  be  pain  or  tenderness  in  the  renal  region, 
suppurative  nephritis  may  be  averred  with  reasonable  certainty.  There  are 
no  distinctive  cellular  elements  from  whose  presence  in  the  urine  it  may  be 
asserted  that  pus  in  a  given  ease  comes  from  the  pelvis  of  the  kidney  or 
ureter,  for  though  the  little  columnar  or  pear-shaped  cells  are  referred  to 
these  sources,  they  also  come  from  the  urethra  and  bladder.  Catheriza- 
tion  of  the  ureters  gives  the  only  actually  positive  means  of  telling  from 
which  kidney  the  pus  comes.  Indeed,  without  lureteral  catherization  it  is 
frequently  impossible  to  tell  even  whether  the  pus  comes  from  the  kidney 
at  all.  In  certain  instances  there  is  a  localized  abscess  which  does  not 
discharge  into  the  urethra.  Under  these  circumstances  a  diagnosis  is 
impossible  except  on  general  principles. 

As  to  differential  diagnosis,  the  only  certain  means  of  recognizing  the 
tuberculous  form  is  by  finding  the  bacillus  in  the  pundent  urine,  at  the  present 
day  greatly  facilitated  by  the  use  of  the  centrifugal  apparatus.  Should 
the  symptoms  described  occur  in  a  case  of  tuberculosis  of  the  lungs,  the 
tubercular  nature  of  the  nephro-pyelitis  becomes  quite  probable. 

Pyelonephritis  is  distinguished  from  paranephritis  by  the  more  circum- 
scribed shape  of  the  tumor,  the  absence  of  edematous  infiltration  of  the 
lumbar  region,  and  by  the  presence  of  purulent  urine,  unless  it  happens,  as 
it  rarely  does,  that  the  paranephric  abscess  breaks  into  the  kidney  and  dis- 
charges by  the  ureter.  Otherwise  there  is  no  pyuria  in  paranephritic  abscess. 
Pain  on  flexing  and  rotating  the  thigh  is  characteristic  because  of  the  involve- 
ment of  the  psoas  muscles.  Pyemic  abscesses  of  the  kidney  may  be  sus- 
pected if  a  pyemic  process  is  present,  and  a  chill  supervene,  followed  by  any  or 
all  of  the  renal  symptoms  described.  By  the  injection  of  colargol  into  the 
kidney  through  the  ureter  and  submitting  the  patient  to  X-ray  examina- 
tion Keene  has  been  able  to  locate  many  cases  of  localized  abscesses  of 
the  kidney. 

Prognosis. — Operation  has  done  much  to  improve  the  prognosis  of  late 
years.  Traumatic  cases  may  recover  if  the  injur\^  is  not  too  extensive, 
while  very  grave  injuries  are  usually  rapidly  fatal.  Recovery,  too,  ensues 
on  cases  succeeding  infectious  fevers  and  pregnancy.  Cases  due  to  obstruc- 
tion of  the  lu-eters  cannot  get  well  so  long  as  the  obstruction  continues 
and  as  their  removal  is  often  impossible,  such  cases  gradually  grow  worse. 
On  the  other  hand,  their  fatal  termination  may  be  delayed  indefinitel\-. 
It  is  often  a  matter  of  astonishment  at  necropsy,  that  the  patient  has  lived 
so  long,  the  barest  remnant  of  secreting  structure  being  sometimes  found. 
Extensive  repair  may  take  place  if  the  cause  can  be  removed.  Conditions 
of  this  kind  occur  when  a  stone  has  been  removed  after  long  presence  either 
in  the  bladder,  in  the  kidney  or  ureter.  It  is  scarcely  necessary  to  say  that 
such  persons  are  in  imminent  danger  from  the  effect  of  exposure,  acute 
disease,  or  other  cause  which  tends  to  suppress  the  action  of  kidneys  already 
crippled  in  function. 

Treatment. — As  operation  offers  the  best  chance  of  cure  in  many  cases,  a 
surgeon  should  be  called  early.  There  is  no  curative  treatment  except  by 
operation  for  suppiu-ative  nephritis.     Necessarily  the  operation  can  be  per- 


PERINEPHRITIC  ABSCESS  751 

formed  only  if  one  kidney  is  affected.  An  operation  on  one  kidney  should 
not  be  performed  miless  both  ureters  have  been  catheterized  and  a  phtha- 
lein  test  performed.  Medicinal  measures  are  mainly  palliative.  One  of 
the  most  frequent  indications  is  the  relief  of  pain,  which  is  often  so  severe 
as  to  call  for  powerful  anodyne  measures — opium  and  its  alkaloids  being 
absolutely  essential.  Hypodermic  injections  of  morphin  in  doses  of  from 
i/8  to  1/3  grain  (0.008  to  0.022  gm.),  repeated,  if  necessary,  are  favorite 
and  effectual  methods  of  relieving  the  intense  pain,  which  is  often  due, 
not  so  much  to  the  inflammation,  as  to  the  impacted  calculus  or  other  cause 
of  obstruction.  Suppositories  of  from  1/2  to  2  grains  (0.03  to  0.13  gm.) 
of  the  extract  of  opium  may  be  substituted.  Hot  fomentations  and 
simple  counterirritants,  svich  as  mustard,  are  also  valuable  adjuvants. 

The  catarrhal  process  in  the  kidney,  its  pelvis,  and  the  ureter,  and  also 
in  the  bladder,  may  be  treated  with  varying  success.  Diluents  are  indicated, 
and  for  this  purpose  any  one  of  the  numerous  negative  mineral  waters  may 
be  used.  The  usual  remedies  are  the  balsams,  benzoic  acid,  hexamethyl- 
enamine  (urotropin)  and  phenylis  salicylas  (salol).  Of  the  first,  sandal- 
wood oil  is  preferable  because  it  is  better  borne  by  the  stomach  than  copaiba. 
Given  in  gelatin  capsules,  each  containing  10  minims  (0.65  c.c),  of  which  one 
or  two  may  be  taken  three  times  a  day,  a  decidedly  beneficial  efl:ect  upon 
the  catarrhal  inflammation  sometimes  ensues,  seen  in  the  diminished  amount 
of  pus.  Benzoic  acid  fiilfills  another  indication,  that  of  seciuring  an  acid 
reaction  of  the  urine,  which  is  very  often  either  alkaline  or  so  faintly  acid 
that  it  rapidly  becomes  alkaline,  and  thus  is  predisposed  to  decomposition. 
The  benzoic  acid  is  best  given  in  the  form  of  capsules.  For  an  adult  5 
grains  (0.33  gm.)  four  times  daily  are  usually  sufficient  to  keep  the  urine  acid. 
Larger  doses  than  these  may  be  given,  or  benzoate  of  sodium  may  be  used 
in  10  grain  (0.6  gm.)  doses,  either  alone  or  in  conjunction  with  the  sandal- 
wood oil,  the  former  before  and  the  latter  after  a  meal.  To  children  smaller 
doses  should  be  given,  i  grain  (0.006  gm.)  three  times  a  day,  increasing  the 
dose.  The  various  vegetable  diuretics,  as  buchu,  pareira  brava,  etc.,  are  of 
little  use  in  suppurative  nephritis  and  pyelitis. 

Urotropin  or  formin  is  the  best  of  the  three  remedies  named.  It  should 
be  given  in  5  grain  doses  (0.33  gm.)  four  times  a  day  preferably  on  an  empty 
stomach,  in  solution  or  in  a  capsule. 

The  constant  and  inevitable  tendency  in  these  cases  to  run  down  in 
general  health,  because  of  the  drain  and  wear  and  tear,  demands  tonics,  such 
as  quinin,  iron,  and  strychnin,  while  milk  and  other  nutritious  articles  of  diet 
are  always  indicated.  The  dangers  to  which  the  patient  is  subject  from  ex- 
posure, cold,  and  dampness  should  be  averted  by  suitable  care  and  woolen 
clothing. 

Many  of  these  cases  are  saved  at  the  present  day  by  a  timely  nephro- 
tomy, by  which  the  pus  is  discharged,  the  kidney  drained,  and  calculi,  if 
present,  removed. 

PARANEPHRITIS     OR  PERINEPHRIC  ABSCESS. 

Definition. — Parenephritis  is  an  inflammation  invading  the  capsule 
and  connective  tissue  about  the  kidney,  terminating  almost  always  in 
suppuration. 


752  DISEASES  OF  THE  URINARY  ORGANS 

Etiology. — A  number  of  causes  may  be  responsible  for  perinephritic 
abscess.  Thus  there  may  be  rupture  of  a  nephritic  abscess  through  the 
capsule  of  the  kidney;  perforation  of  the  bowel,  most  frequently  seen  in 
connection  with  appendicitis;  extension  of  suppurative  disease  from  the 
spine,  as  in  caries  of  the  vertebrae,  or  from  a  bvirrowing  empyema;  finally, 
blows  and  injuries  may  terminate  in  suppuration  about  the  kidney. 

Morbid  Anatomy. — At  autopsy  the  kidney  is  found  surrounded  by 
pus,  which  is  usuall}'  posterior  to  it,  rarely  in  front  between  the  kidney  and 
the  peritoneum.  The  pus  has  often  a  fecal  odor  from  contact  with  the 
large  bowel.  It  may  burrow  in  various  directions,  and  even  burst  into  the 
pleura  and  be  discharged  by  the  lungs ;  or  it  may  work  its  way  to  the  groin 
and  appear  at  Poupart's  ligament.  In  turn  it  may  perforate  the  bowel 
or  rupture  into  the  peritoneum,  bladder,  or  vagina.  Occasionally  the 
fatty  bed  of  the  kidney  is  found  to  be  converted  into  a  fibrous  capsule 
fused  more  or  less  closely  with  that  of  the  true  kidney  capsule.  There  is 
a  milder  degree  of  this  condition  which  I  have  called  capsulitis. 

Symptoms. — Most  cases  are  secondar>^  to  disease  in  the  neighborhood. 
Pain  and  tenderness  in  the  region  of  the  kidney  are  the  most  constant 
symptoms.  In  addition  there  is  a  peculiar  edematous  or  boggy  condition 
in  the  same  locality,  giving  rise  to  pitting  on  pressure.  The  position  as- 
sumed is  often  distinctive,  the  thigh  being  flexed  to  relax  the  psoas  muscle, 
tension  on  which,  especially  in  adduction,  increases  suffering.  The  patient, 
if  able  to  walk,  relies  as  much  as  possible  on  the  opposite  leg,  on  which  he 
leans,  assuming  also  a  stooping  posture  with  the  spine  fixed.  The  whole 
attitude  and  behavior  remind  one  of  hip-joint  disease,  while  the  pain  may 
even  be  referred  to  the  knee,  as  in  this  disease.  These  symptoms  do  not, 
however,  appear  at  once,  and  the  approach  is  often  insidious.  At  other 
times  suppuration  is  ushered  in  by  chills,  fever,  and  sweats.  Various 
directions  of  burrowing  and  seats  of  perforation  were  mentioned  in  treating 
of  the  morbid  anatomy.  The  plastic  form  of  fibroid  paranephritis  is  with- 
out distinctive  symptoms. 

Diagnosis. — The  diagnosis  from  nephric  abscess,  with  which  it  is  most 
likely  to  be  confounded,  has  been  considered.  The  attitude  of  the  patient 
in  lying  or  standing  is  like  that  in  hip-disease,  but  the  histor\'  elicits  that 
in  its  incipiency  the  pain  is  much  higher  up  in  perinephric  abscess,  while 
examination  shows  that  the  swelling  and  tenderness  are  above  the  hip 
and  not  over  the  hip-joint  itself.  As  most  cases  except  those  due  to  injiiry 
are  secondarj^  to  disease  in  the  neighborhood,  it  is  not  necessar\'  to  separate 
the  two  classes.  Secondary  forms  are  more  sudden  in  their  onset,  though 
this  is  not  always  the  case.  Doubtful  cases  may  be  settled  by  the  use  of  the 
X-ray. 

Treatment. — This  is  by  section  and  free  drainage,  for  though  spon- 
taneous rupture  sometimes  takes  place,  it  is  apt  to  be  preceded  by  destruc- 
tive and  dangerous  burro\\'ing,  which  should  be  anticipated  by  operation. 

NEPHROLITPIIASIS  (STONE  IN  THE  KIDNEY). 

Definition. — Nephrolithiasis  means  "stone  in  the  kidney,"  but  the 
term  is  a  general  one,  which  covers  the  presence  in  the  kidney,  its  pelvis. 


STONE  IN  THE  KIDNEY  753 

or  ureter  of  concretions  large  enough  to  justify  the  term  "stone,"  of  smaller 
masses  appropriately  known  as  "gravel,"  and  fine  particles  known  as 
"sand." 

Morbid  Anatomy. — Except  in  the  case  of  "sand"  which  includes 
particles  made  up  either  of  pure  uric  acid  or  oxalate  of  lime,  gravel  and 
stone,  as  found  in  the  kidney  and  its  pelvis,  always  have  an  organic  basis 
through  which  are  distributed  the  mineral  matters  which  go  to  make  up 
their  btdk,  and  which  remains  as  a  framework  after  the  mineral  matters 
are  dissolved  out.  The  matters  thus  precipitated,  in  some  one  of  the  shapes 
named,  in  the  order  of  frequency  are: 

(i)  Uric  acid  and  its  compounds  of  sodium,  ammonium,  and  potassium. 
(2)  Oxalate  of  lime.  (3)  The  phosphates  of  calcium  and  of  ammonium 
and  magnesium. 

Only  in  the  case  of  uric  acid  stones  of  small  size,  and  of  oxalate  of  lime 
stones  likewise  moderate  in  size,  do  we  have  the  btilk  of  the  stone  made 
of  a  single  constituent.  More  frequently  it  is  the  case  that  uric  acid  or 
oxalate  of  lime  stone  forms  the  nucleus,  and  about  this  aggregate  in  concen- 
tric layers,  the  phosphates,  which  make  up  the  great  bulk  of  all  large  stones 
as  well  as  some  stones  in  their  entirety.  More  rarely  a  uric  acid  nucleus  is 
surrounded  by  oxalate  of  lime  or  the  reverse.  Not  only  may  the  sediments 
become  the  nuclei  of  large  stones,  but  foreign  matters,  such  as  a  clot  of  blood 
or  a  fragment  of  any  kind  of  matter  accidentally  reaching  the  urinary  pas- 
sages, may  also  play  a  like  role. 

The  steps  for  determining  the  more  precise  composition  of  stones  will 
be  found  in  appropriate  manuals  on  the  examination  of  urine,  but  the 
three  principal  varieties  present  certain  physical  characters  by  which  they 
can  with  considerable  certainty  be  determined.  Thus,  uric  acid  stones 
are  usually  smooth  or  lobulated,  dark  red  or  reddish-bro-mi  in  color,  hard 
in  consistency,  and  rarely  acquire  a  size  of  acentimeter  (o.4inch)  in  diameter, 
while  many  of  them  are  no  larger  than  a  lentil.  They  may  be  multiple. 
Oxalate  of  lime  stones  are  very  hard  and  Uneven,  so  characteristically  so  that 
they  have  received  the  name  mulberry  calculi,  from  their  resemblance  to 
this  fruit.  Their  hard-pointed  projections  produce  exqmsite  pain  in  transit 
from  the  kidney  through  the  ureter  into  the  bladder.  They  attain  about 
the  same  maximum  size  as  luic  acid  stones,  and  are  also  often  multiple. 
The  phosphatic  stones  are  white  in  color  or  grajdsh-white,  quite  soft,  easUy 
disintegrated,  may  often  be  crushed  between  the  fingers,  though  at  other 
times  they  are  much  harder.  They  attain  the  largest  size,  being  often  as 
large  as  a  hen's  egg.  When  stones  lie  in  the  ureter  rather  than  in  the  pelvis 
of  the  kidney,  they  are  apt  to  be  more  elongated,  or  sometimes,  spindle- 
shaped,  and  present  at  times  a  spiral  marking  which  is  characteristic.  Others 
are  molded  to  the  shape  of  the  pelvis  of  the  kidney  with  a  prolongation  for 
each  calyx,  which  may  be  further  branched — the  dendritic  or  coral  calculi. 
Rarer  forms  of  calculi  are  made  up  of  cystin,  xanthin,  carbonate  of  lime,  and 
iirostealith. 

Etiology. — The  rationale  of  the  precipitation  of  sediments  which  aggre- 
gate to  form  concretions  is  not  always  the  same,  and  is  perhaps  not  thor- 
oughly understood.  In  the  case  of  uric  acid  the  deposit  takes  place  either 
because  of  the  abnormal  acidity  of  the  mine,  because  it  contains  more  than 


754  DISEASES  OF  THE  URINARY  ORGAXS 

the  normal  quantity  of  uric  acid,  or  because,  for  some  reason,  the  amount 
of  water  secreted  is  abnormally  scanty.  In  either  event  the  uric  acid  is 
precipitated  in  the  excretory  tubes  of  the  medullary  substance  or  in  the 
pelvis  of  the  kidney,  forming  minute  concretions  made  up  of  from  five  to 
ten  whetstone-shaped  crystals,  whence  they  descend  in  the  form  of  sand  or 
gravel  to  the  bladder.  At  times  the  sediments  grow  by  successive  addi- 
tions in  the  pelvis  of  the  kidnej^  forming  thus  true  renal  concretions,  whose 
descent  into  the  bladder,  if  at  all  possible,  is  accomplished  with  the  greatest 
difficulty  and  pain.  The  method  in  which  such  concretions  form  in  the 
calices  of  the  kidney  around  a  papilla  is  well  shown  in  Fig.  80.    • 

Oxalate  of  lime  calculi  form  similarly  by  the  precipitation  of  crystals 
of  this  substance  immediately  after  the  urine  is  secreted. 

Phosphatic  concretions  are  rarely  primary.  In  order  that  they  may 
form,  the  proportion  of  phosphates  must  be  largely  increased,  or  the  reaction 
of  the  luine  must  be  permanently  alkaline.  More  frequently  phosphates 
precipitate  around  nuclei  of  uric  acid  or  oxalate  of  lime,  or  foreigh  bodies. 
The  effect  of  these  seems  to  be  to  cause  an  alkalinity  in  the  urine  immediately 
about  them  or,  incases  of  more  general  cj'stitis,  in  all  the  urine  in  the  bladder. 
This  alkalinity  causes  the  precipitation  of  phosphates  about  the  primary 
nucleus  and  formation  of  stone  of  various  sizes.  Rarely  layers  of  phosphates 
and  uric  acid  alternate. 

Symptoms. — It  sometimes  happens  that  a  stone  is  found  postmortem  in 
the  substance  of  the  kidney  or  in  the  pelvis  which  was  not  suspected,  but 
it  is  hardly  likely  that  even  in  these  cases  symptoms  were  not  present. 
They  were  simply  overlooked  or  ascribed  to  some  other  cause.  The  most 
constant  symptom  of  neplirolithiasis  is  pain  in  the  region  of  the  kidney  asso- 
ciated with  more  or  less  tenderness.  Like  the  pain  of  stone  in  the  bladder, 
it  is  aggravated  by  motion,  especially  rough  motion,  and  there  are  certain 
positions  of  the  body  in  which  the  patient  is  made  more  or  less  uncomfortable. 
Sometimes  the  inflammation  caused  by  the  stone  proceeds  to  suppuration, 
and  the  whole  of  the  kidney,  more  or  less,  is  substituted  by  a  pus-sac. 
The  pain  is  often  suddenly  aggravated  when  a  large  stone  so  lodges  as  to 
plug  up  the  ureter  and  interfere  with  the  descent  of  urine,  or  a  small  one 
descends  through  the  vireter  into  the  bladder.  Under  these  circumstances 
comes  the  attacks  of  so-called  nephritic  colic,  characterized  by  pain  which 
may  equal  in  severity  any  to  which  man  is  subject.  It  has  other  distinctive 
features.  It  radiates  downward  into  the  groin  and  the  neighborhood  of  the 
bladder  and  down  the  inside  of  the  thighs  and  into  the  testicle,  which  is  often 
retracted.  Sometimes  it  extends  upward  toward  the  diaphragm,  and  it  is 
not  alwaj's  easy  to  separate  the  pain  of  nephritis  colic  from  that  of  hepatic 
colic  or  appendicitis  when  the  former  is  on  the  right  side.  It  may  happen 
that  both  kidneys  are  the  seat  of  impacted  stone,  though  this  is  a  very 
rare  event.  There  are  often  nausea  and  vomiting,  a  cold  sweat  appears, 
and  the  patient  may  collapse. 

After  the  pain  and  colic  the  changes  presented  by  the  urine  may  be 
highly  distinctive,  aiding  greatly  the  diagnosis;  at  other  times  the  urine  is 
absolutely  negative.  It  very  frequently  contains  blood,  though  the  quan- 
tity is  commonly  small,  and  may  be  demonstrable  only  by  the  microscope. 
Especially  is  there  blood  in  connection  with  fresh  attacks  of  nephritic  colic. 


RENAL  COLIC  755 

Pus  is  almost  always  present  in  small  or  large  amounts.  Cylindroids  or 
mucus-casts  may  be  found,  true  casts  rarely.  In  some  cases,  too,  uric  acid 
crystals  in  the  shape  of  red  or  brickdust-like  particles  either  before  or  during 
an  attack  of  nephritic  colic  point  to  the  uric  acid  nature  of  the  stone.  The 
same  is  true  of  oxalate  of  lime  crystals.  In  the  case  of  the  last  two  sub- 
stances the  urine  is  acid  in  reaction.  Phosphatic  stones  may  be  suspected  if 
the  urine  is  alkaline  in  its  reaction,  as  it  is  only  possible  for  phosphatic  sedi- 
ments to  form  in  the  presence  of  an  alkaline  or  neutral  urine  whUe  uric  acid 
crystals  can  only  remain  permanent  in  an  acid  urine.  Oxalate  of  lime,  the 
most  insoluble  of  all  crystals,  occurs,  however,  in  either  acid  or  alkaline  urine. 
In  cases  of  gravel  or  sand,  as  contrasted  with  stone,  there  are  no  symptoms, 
as  a  rule,  between  attacks,  as  the  stone  must  reach  an  appreciable  size  before 
it  produces  the  constant  or  almost  constant  pain  characteristic  of  it.  In 
some  cases  there  is  complete  suppression  of  urine  ("obstructive  anuria"), 
even  when  the  kidney  on  the  opposite  side  is  normal,  though  more  frequently 
when  it  is  diseased,  and  death  from  uremia  may  occur  in  consequence.  In 
this  form  of  uremia  there  is  often  an  interesting  absence  of  symptoms  of 
uremia  until  coma  closes  the  scene  preceded  by  unclouded  mental  condition. 
There  may  be  minor  degrees  of  convulsive  symptoms,  nausea  and  headache. 
The  duration  of  this  state  may  last  from  four  hours  to  14  days. 

Diagnosis. — Nephritic  colic  may  be  confounded  with  biliary  colic. 
Usually  the  symptoms  of  each  are  sufficiently  distinctive.  Jaundice  in 
biliary  colic  when  present  comes  on  very  soon  after  the  obstruction  begins. 
The  stools  are  without  bile  and  grayish-white  in  color.  Usually  the  pain 
is  more  toward  the  epigastric  regions  as  a  center,  and  thence  through  the 
upper  abdomen  and  perhaps  through  to  the  right  shoulder-blade.  The  urine 
may  be  bile-stained,  and  responds  to  the  tests  for  the  coloring-matter  of 
bile.  Appendicitis  frequently  resembles  renal  colic,  and  renal  colic  may 
be  mistaken  for  appendicitis.  In  appendicitis  fever,  leukoc5i;osis,  local 
tenderness  and  rigidity  over  the  appendix  are  present,  while  in  stone 
there  is  no  fever,  there  are  leukocytes  and  blood  in  the  urine,  there  is 
frequent  tuination,  and,  as  a  rule,  the  pain  radiates  to  the  ureter.  Thus, 
clots  of  blood  may  obstruct  the  ureter  and  give  rise  to  all  the  pain  occasioned 
by  an  impacted  stone,  and  in  the  absence  of  a  history  of  stone  and  of 
hemorrhage  there  are  no  symptoms  by  which  the  two  causes  of  colic  can  be 
separated.  In  the  case  of  hydatid  cysts  of  the  kidney,  fragments  of  these, 
too,  may  be  discharged,  and  in  suppturating  kidney  inspissated  pus  may 
occlude  the  tireter.  Renal  colic  is  also  produced  when  the  ureter  is  com- 
pressed by  any  cause  as  a  twist  in  the  ureter  of  a  floating  kidney,  or  by  com- 
pression of  a  tumor.  The  symptoms  of  stone  in  the  kidney  sometimes 
closely  Teserah\e.thos&oi  stone  in  the  bladder,  but  the  pain  in  the  latter,  though 
it  may  be  felt,  to  the  back,  radiates  toward  both  sides ;  in  stone  in  the  bladder 
the  urine  contains  more  mucus  and  is  alkaline  or  becomes  readily  so,  while 
in  nephrolithiasis  the  pus  is  purer  and  the  urine  acid.  In  all  cases  pointing 
to  the  presence  of  stone  in  the  bladder  the  sound  should  be  promptly  used. 

The  most  invaluable  aid  to  the  diagnosis  of  stone  in  the  kidney  is  the 
X-ray  examination,  and  in  all  cases  of  suspected  stone  this  measure  should 
be  employed.  Almost  without  exception  a  stone,  if  present,  is  disclosed, 
and  many  stones  thus  recognized  have  been  found  at  operation  which  would 


756  DISEASES  OF  THE  URINARY  ORGANS 

have  otherwise  been  less  searchingly  sought.  It  still  happens  occasionally 
that  a  stone  escapes  recognition  even  by  the  aid  of  the  X-ray.  Rarely  it  has 
happened  that  the  X-ray  has  apparently  disclosed  a  stone  when  none  has 
been  found  at  operation.     This  is  due  to  faulty  technique. 

Prognosis. — The  prognosis  of  stone  in  the  kidney  is  very  much  more 
favorable  now  than  it  was  20  years  ago,  in  consequence  of  the  safety  with 
which  operations  can  be  performed.  The  kidney  may  be  exposed,  split  open, 
and  the  parts  reapposed  and  restored  with  perfect  recovery,  and  whenever 
the  diagnosis  of  stone  in  the  kidney  is  made,  an  operation  should  be  done. 
When  many  severe  attacks  occur  without  other  conclusive  evidence,  an 
exploratory^  operation  is  sometimes  justified  for  the  sake  of  diagnosis. 
When  the  sand  or  gravel  is  so  small  as  to  pass  the  ureter,  the  suffering 
terminates  with  its  passage  into  the  bladder. 

Treatment. — There  are  no  medicines  which,  when  administered,  are  cap- 
able of  producing  solution  of  a  stone.  In  cases  in  which  there  is  no  such 
formation  and  we  have  simply  to  contend  with  gravel  or  sand,  therapeutic 
measures  to  prevent  its  further  formation,  may  be  availed  of. 

Treatment  of  the  Renal  Colic. — The  extreme  pain  of  attacks  of  nephritic 
colic  must  be  combated  by  anodynes,  and  for  this  purpose  a  hypodermic  injec- 
tion of  one-fourth  of  a  grain  of  morphin  is  indicated  at  once.  Hot  fomen- 
tations to  the  side  help  to  keep  the  patient  comfortable  while  the  morphin 
is  having  its  effect.  A  whiff  of  chloroform  may  be  given  for  the  same  pur- 
pose. Frequently  the  dose  of  morphin  must  be  repeated.  It  is  rarely  the 
case  that  less  than  1/4  grain  (0.016  gm.)  of  morphin  thus  administered 
is  sufficient,  and  very  frequently  this  dose  must  be  repeated  very  soon. 
Hot  poultices  are  useful  to  a  certain  extent  in  relieving  pain  when  applied 
to  the  lumbar  region  and  to  the  groins,  while  hot  baths  are  of  great  sevice 
in  relaxing  spasm  and  allaying  pain  due  to  it. 

The  escape  of  the  stone  from  the  ureter  into  the  bladder  is  followed  by 
unspeakable  relief,  and  its  discharge  from  the  urethra  usually  follows  sooner 
or  later  with  little  or  no  pain,  although  a  stone  of  considerable  size  may  lodge 
in  the  urethra  and  require  extraction.  When  stones  are  not  discharged  from 
the  bladder  they  are  likely  to  become  the  nuclei  of  larger  stones  in  the 
bladder. 

Repeated  attacks  of  renal  colic  with  pus  and  blood  in  the  urine  can  only 
be  interpreted  as  a  stone  remaining  in  the  kidney  or  ureter.  Such  cases  must 
have  a  diagnosis  completed  by  X-ray  examination  and  catheterization  of  the 
ureter.  If  the  stone  is  found  the  case  must  be  turned  over  at  once  to  the 
surgeon  for  extraction  of  the  stone.  Persons  who  are  subject  to  renal  colic 
should  lead  a  properl}^  regulated  life.  Water  in  abundance,  proper  exercise, 
food  regulated  so  the  strength  is  maintained,  but  digestion  preserved.  Alco- 
holics must  be  avoided.  If  for  any  reason  a  stone  cannot  be  removed,  the 
case  must  be  treated  medicallj^  as  an  ordinary  case  of  pyelitis. 

TUMORS  OF  THE  KIDNEY. 

Definition  and  Application. — The  term  "tumor  of  the  kidney"  is  applied 
to  almost  a.ny  enlargement  of  the  organ  due  to  morbid  growth.  Yet  there 
are  morbid  growths  of  the  kidney  which  are  not  sufficiently  large  to  produce 


TUMORS  OF  THE  KIDNEY  757 

appreciable  change  in  its  size.  Thus,  the  adenoma  does  not  usually  exceed 
4/10  inch  (i  cm.)  in  diameter,  though  it  may  be  two  inches  (5  cm.)  or  more. 
The  same  is  true  of  the  angiomata  and  leukemic  tumors,  of  fibroma  and 
lipoma,  which  sometimes  form  small  white  nodes  in  the  fibrous  tissue  near 
the  bases  of  the  pyramids.  Lymph-adenoma  occurs  in  the  kidney  associated 
with  similar  disease  of  lymph  glands,  liver,  and  intestine.  Villous  papilloma 
sometimes  grows  in  the  pelvis  of  the  kidney.  Syphilitic  gummata  also  belong 
to  the  group  of  moderate-sized  tumors  rarely  producing  symptoms. 

Cysts,  single  and  multilocular,  acquire  larger  size,  producing  appreciable 
enlargement  of  the  kidney.  Hypernephroma  is  a  form  of  tumor  of  the  kid- 
ney ascribed  to  misplaced  suprarenal  tissue.  There  tumors  grow  often  to 
enormous  size.  One  has  recently  been  examined  by  an  exploratory'  operation 
which  reached  from  above  the  edge  of  the  ribs  downward  to  the  pelvis  and 
anteriorly  as  far  as  the  umbilicus.  The  malignant  tumors,  hypernephromata, 
sarcoma  and  carcinoma,  and  cysts,  are,  clinically  speaking,  perhaps  the 
chief  occasion  of  the  term  "tumor  of  the  kidney."  On  the  other  hand, 
renal  abscess,  or  pyonephrosis,  does  not  usually  earn  for  the  kidney  involved 
the  name  "tumor,"  while  hydronephrosis  does. 

Symptoms. — Certain  local  symptoms  are  produced  indifferently  by  any 
one  of  the  tumors  large  enough  to  become  clinically  appreciable.  In  the 
first  place,  renal  tumors  grow  for  the  most  part  forward  rather  than  backward, 
because  of  the  more  yielding  character  of  the  parts  in  front  of  them  than 
behind  them.  Rarely  is  there  produced  posteriorly  more  than  a  prominence 
with  obliteration  of  the  normal  resonance  commonly  present  between  the 
kidney  dullness  and  the  vertebral  spines.  As  a  forward  growth  proceeds,  a 
special  effect  results  from  the  relation  of  the  bowel  to  the  kidney;  as  the 
ascending  colon  on  the  right  side  and  the  descending  colon  on  the  left  lie 
in  front  of  the  corresponding  kidney,  the  effect  of  enlargement  of  this  organ 
is  to  push  the  bowel  in  front  of  it,  the  hollow  viscus  being  recognized  by  the 
tympanitic  percussion  note.  In  this  respect  renal  tumor  differs  from  splenic 
tumor,  and  less  invariably  from  that  of  the  liver,  since  the  bowel  does  not 
intervene  between  these  organs  and  the  abdominal  wall,  though,  Tarely,  the 
small  intestine  may  float  between  the  liver  and  the  parietes.  Commonly, 
too,  the  hand  may  slide  between  the  renal  tumor  and  the  liver  on  one  side 
and  the  renal  tumor  and  the  spleen  on  the  other,  while  it  never  loses  the 
rounded  border  characteristic  of  the  kidney. 

By  bimanual  palpation  with  the  palm  of  one  hand  placed  in  the  lumbar 
region  and  the  other  in  front  below  the  ribs,  pressure  being  made  in  both 
directions,  the  tumor  may  be  recognized.  In  this  examination,  too,  it  will 
be  noticed  that  the  kidney  permits  a  much  more  limited  mobility  during 
breathing  than  does  the  liver,  although  it  is  not  totally  immobile.  The 
renal  tumor,  too,  commonly  resists  lateral  movement. 

Again,  pain  in  the  region  of  the  kidney  is  an  inconstant  symptom.  It 
is  often  totally  absent,  at  other  times  verj^  severe,  especially  if  the  vertebras 
and  spinal  cord  are  encroached  upon.  Because  of  pressure  of  the  kidney 
upon  the  12th  dorsal  nerve  and  branches  of  the  lumbar  plexus  neuralgic 
pains  in  the  abdominal  walls  may  be  present. 

Diagnosis. — As  to  differential  diagnosis,  the  presence  of  tumor  being 
determined  with  either  carcinoma  and  sarcoma,  may  produce  hematuria. 


758  DISEASES  OF  THE  URINARY  ORGANS 

though  it  is  not  frequent  with  them.  The  blood  may  be  fluid  or  clotted, 
and  is  often  molded  in  the  pelvis  of  the  kidney  and  ureter,  which  is  rarely 
the  case  with  blood  poured  into  the  pelvis  under  other  circumstances. 
Hematuria  is  more  frequent  in  carcinoma  than  in  sarcoma.  Both  con- 
ditions are  likely  to  produce  pain.  It  is  sometimes  very  severe  and  de- 
scribed as  boring  in  character,  when  it  is  said  to  indicate  destructive  en- 
croachment on  the  vertebrae.  More  frequently  it  is  dull,  radiating  over  the 
flank  into  the  thighs.  These  tumors  also  produce  cachexia.  Very  rarely 
they  may  be  recognized  by  the  presence  of  distinctive  histological  elements 
in  the  urine.  This  occurred  in  my  experience  in  at  least  two  instances. 
Frequently  the  urine  is  altogether  negative. 

Of  sarcoma  and  carcinoma  of  the  kidney  between  which  no  distinction 
was  made  until  40  years  ago,  the  former  is  now  regarded  as  the  more  com- 
mon. Both  may  be  primary  or  secondary.  Sarcoma  is  a  disease  of  early 
life,  in  fact,  it  is  often  congenital,  when  it  is  represented  by  that  form  known 
as  rhabdomyoma,  which  contains  striated  muscular  fibers.  In  more  than 
half  the  cases  it  affects  children  under  ten.  On  the  other  hand,  renal  cancer 
is  not  confined  to  later  life  as  is  cancer  elsewhere,  and  it  may  even  occur  in 
children.  More  usually  one  kidney  only  is  affected.  Such  organ  is  uneven, 
soft,  even  to  a  sense  of  fluctuation.  Carcinoma  also  selects  one  kidney 
whence  it  may  invade  the  pelvis  and  ureter.  It  affects  the  general  health 
more  rapidly,  hematuria  is  more  frequent  and  copious,  but  intermittent. 
If  there  be  a  superficial  primary  growth  elsewhere  and  a  renal  tumor  is 
present,  the  presumption  is  that  it  is  of  the  same  nature,  but  no  certain 
diagnosis  can  be  made  between  carcinoma  and  sarcoma  unless  the  rare 
opportunity  occur  to  examine  fragments  discharged  with  the  Uiine.  Un- 
fortunately for  diagnosis,  the  urine  is  too  often  quite  free  from  any  sediment, 
even  of  pus.  Carcinoma  of  the  kidney  is  apt  to  invade  the  renal  veins  and 
even  the  vena  cava,  and  as  such  to  cause  metastasis  in  the  lungs  and  in  other 
organs  as  well. 

From  ovarian  tumors  renal  tumors  are  distinguished  by  the  fact  that  in 
the  former  the  intestines  lie  in  the  flanks,  giving  resonance  on  percussion 
in  that  locality,  while  an  enlarging  kidney  pushes  the  bowels  in  front  of  it. 
The  ovarian  tumor  also  grows  from  below  upward  and  drags  -Rath  it  the 
uterus  and  appendages,  as  can  be  recognized  b}'  vaginal  examination  and 
by  rectal  touch. 

Much  more  difficult  is  it  to  distinguish  the  renal  tumor  from  enlargement 
oj  the  retroperitoneal  glands  (retroperitoneal  sarcoma,  Lobenstein's  cancer)  as 
such  enlargement  also  pushes  up  the  intestines  in  front  of  it,  giving  rise  to 
a  tympanitic  percussion  note.  Hematuria  never  occurs  in  retroperitoneal 
tumor,  whUe  it  may  or  may  not  be  present  in  renal  tumor.  The  retro- 
peritoneal tumor  may  press  upon  the  ureter  and  the  renal  vessels  and  thus 
produce  obstruction  to  the  descent  of  the  urine.  The  central  situation  of 
the  enlargement  in  retroperitoneal  tumors  contrasts  wdth  the  lateral  gro^-th 
in  the  renal  tumors. 

From  tumors  oj  the  liver  renal  tumors  differ  in  that  the  former  sooner 
or  later  cause  a  bulging  of  the  right  hypochrondriac  region,  while  the  renal 
tumors  rarely  reach  as  high  as  to  alter  the  configuration  of  the  lower  thorax. 
The  sharper  border  of  the  liver  tumor  as  contrasted  with  the  rounded_edge 


CYSTS  OF  THE  KIDNEY  759 

of  the  kidney  tumor  is  characteristic,  while  the  freer  movements  of  the 
liver  with  the  breathing  is  also  of  value.  Splenic  tumors  are  not  likely  to 
be  confounded  with  tumors  of  the  left  kidney.  Splenic  tumor  protrudes 
from  above  downward  and  toward  the  umbilicus  instead  of  from  the  lumbar 
region  forward.  It  moves  more  with  breathing,  and  its  sharper  edge  and 
indentation  may  be  recognized.  It  is  always  above  or  outside  of  the  colon. 
Treatment. — Renal  tumor  is  beyond  curative  treatment  by  the  physi- 
cian. As  soon  as  the  diagnosis  is  made,  a-surgeon  should  be  called  and  the 
question  of  operation  considered. 

Cysts  of  the  Kidney. 

Reference  is  here  made  only  to  such  cysts  as  produce  clinically  appre- 
ciable enlargement  of  the  organ.     They  include : 

1.  Retention  or  obstruction  cysts,  soUtary  cysts  ranging  in  diameter  from 
a  centimeter  (0.4  in.)  to  ten  centimeters  (4  in.)  and  larger.  They  may  be 
present  in  one  or  both  kidneys.  These  are  probably  primaril}^  the  result  of 
stenosis  of  a  uriniferous  tubule  behind  which  accumulates  first  urine,  which 
is  gradually  substituted  by  an  aqueous  fluid  in  which  may  be  foimd  traces 
of  urinary  constituents.  A  trace  of  albumin  may  also  be  present.  These 
cysts  rarely  give  rise  to  symptoms. 

2.  The  congenital  cystic  kidney,  in  which  both  organs  are  the  seat  of 
numerous  roimd  cysts  varying  in  size  from  1/5  inch  (5  mm.)  to  one  inch 
2 .  s  cm.),  may  produce  tumors  of  large  size,  so  large  in  the  foetus,  that  they 
have  interfered  with  parturition.  They  contain  a  fluid  which  is  at  times 
clear,  at  others  again  turbid,  colloidal  in  consistence,  and  containing 
albumin,  cholesterin,  triple  phosphates,  rarely  urea  and  tuic  acid,  and  some- 
times fat  drops.  Persons  with  these  cysts  may  grow  to  adult  life,  and, 
indeed,  such  cystic  kidneys  have  been  found  postmortem  when  not  sus- 
pected. Commonly,  the  subjects  die  either  before  birth  or  shortly  after. 
The  exact  mode  of  origin  of  these  congenital  cysts  is  not  understood,  but 
they  are  probably  the  consequence  of  a  defect  in  development. 

There  may  be  no  symptoms  beyond  that  of  an  enlarged  organ,  or  they 
may  be  those  of  interstitial  nephritis  with  its  secondary  cardiovascular 
consequences.  There  may  be  a  small  albuminuria.  Blood-disks  may 
be  found,  but  no  casts. 

3.  Dermoid  cysts  are  also  occasionally  met  in  the  kidney,  while  a  general 
cystic  condition  invading  the  liver  and  spleen  as  well  as  the  kidney  is  de- 
scribed. 

4.  Hydronephrosis  is  a  monocystic  degeneration  of  the  kidney  starting 
in  obstruction  of  the  ureter,  succeeded  by  dilatation  of  the  pelvis  and 
gradual  wasting  of  the  kidney  substance,  due  to  pressure  of  the  accumu- 
lating fluid.    . 

The  obstruction  causing  this  condition  may  also  be  congenital.  As 
such  it,  too,  may  be  large  enough  to  impede  labor.  An  oblique  insertion 
of  the  ureter  at  such  angle  as  to  interfere  with  the  easy  discharge  of  the 
secretion  may  be  the  cause  of  its  retention  in  the  pelvis  of  the  organ. 
Among  recognized  causes  during  life  are,  also,  occlusion  of  the  ureter  by 
cicatricial  adhesion,  by  lithiasis,  by  tuberculosis  of  the  ureter,  by  pressure, 


760  DISEASES  OF  THE  URINARY  ORGANS 

by  tumors,  by  a  retroflexed  or  prolapsed  uterus,  by  bands  of  lymph  in 
healed  peritonitis  and  by  twists  in  the  ureter  of  a  movable  kidney.  Finally, 
carcinoma  of  the  bladder  and  even  hypertrophy  of  the  prostate  and 
stricture  of  the  urethra  may  be  causes. 

The  contents  of  the  tumor  may  be  piu-ely  aqueous;  more  frequently 
they  are  slightly  turbid;  they  contain  a  few  pus-cells,  more  numerous  if 
they  are  the  seat  of  inflammation;  also  uric  acid,  tirea,  and  albumin. 

Its  symptoms  consist  of  those  already  described  as  common  to  benign 
renal  tumors  of  sufficient  size.  An  event  which  is  almost  pathognomonic 
is  the  occasionally  sudden  disappearance  of  the  tumor  simultaneously  with 
the  discharge  of  a  large  quantity  of  fluid  from  the  bladder,  followed  by 
gradual  refilling  of  the  sac  and  retirrn  of  the  tumor.  This  intermittent 
discharge  may  be  kept  up  for  years.  Such  an  event  must  be  ascribed  to  a 
valvular  obstruction  in  the  ureter  which  at  times  yields  to  the  pressure  of 
the  accumulated  fluid;  or  it  may  be  due  to  the  undoing  of  a  twist  in  the 
ureter  of  a  floating  kidney. 

As  to  differential  diagnosis  of  hydronephrosis  ovarian  tumor  is  the  con- 
dition with  which  it  is  most  frequently  confounded.  The  relative  immo- 
bility of  the  renal  tumor,  as  contrasted  with  the  mobility  of  the  ovar- 
ian, may  be  mentioned;  also  the  lumbar  origin  of  the  former,  as  con- 
trasted with  the  pehdc  of  the  latter,  as  determined  by  rectal  and  vaginal 
examination.  Should  the  ttrmor  disappear  simultaneously  with  a  copious 
discharge  from  the  bladder,  the  evidence  is,  of  course,  conclusive.  The 
history  in  the  case  of  ovarian  tumor  will  develop  the  events  of  menstrual 
and  sexual  derangement,  which  are  absent  in  hydronephrosis.  Hydrone- 
phrosis is  not  likely  to  be  confomided  with  ascites.  The  changes  in  the 
position  of  the  fluid  wath  that  of  the  patient,  characteristic  of  ascites,  and 
its  bilateral  situation  distinguish  it  at  once  from  hydronephrosis. 

From  a  circtmiscribed  peritoneal  exudate  hydronephrosis  is  distinguished 
by  the  different  history-,  the  greater  tenderness  of  the  former,  and  tympany 
of  the  subjacent  intestine  elicited  by  strong  percussion.  In  renal  abscess 
there  is  fluctuation,  but  there  are  also  fever  and  sometimes  chills.  The 
renal  retention  cyst  is  at  times  indistinguishable  from  hydronephrosis. 
Both  may  be  congenital  or  due  to  congenital  defects,  but  should  there  be 
intermittent  emptying  of  the  sac,  with  refilling,  hydronephrosis  may  be 
suspected.  The  diagnosis  from  hydatid  cyst,  so  far  as  is  possible,  follows 
in  the  next  paragraph. 

5.  Echinococcus  or  Hydatid  Cyst. — Hydatid  disease  of  the  kidney  is  a 
rare  affection,  and  when  the  enlargement  caused  by  it  is  sufficient  to  produce 
physical  signs,  they  do  not  differ  essentially  from  those  of  hydronephrosis 
and  cystic  kidney.  Onlj^  in  the  event  that  the  microscope  recognizes 
hooldets  or  scolices,  or  fragments  of  the  cyst-wall  in  the  urine  or  in  the  fluid 
obtained  by  tapping  or  in  the  discharge  into  other  localities,  such  as  the 
stomach,  intestines,  or  bronchi,  can  a  diagnosis  be  made  with  certainty. 
Such  discharge  into  the  pelvis  of  the  kidney,  if  it  produce  obstruction,  may 
also  cause  acute  hydronephrosis.  The  presence  of  hydatids  elsewhere, 
and  of  the  hydatid  fremitus,  is  .presvimptive  evidence.  The  .chemical  and 
physical  characters  of  the  fluid  from  hydatid  cysts  are  given  vinder  hydatid 
disease  of  the  liver  (p.  474).     Like  hydronephrosis  and  cystic  tumor,   the 


ANOMALIES  OF  THE  KIDNEY  761 

hydatid  kidney  differs  from  ovarian  tumor  by  its  immobility,  unless  the 
disease  should  perchance  invade  a  movable  kidney. 

Treatment  of  Renal  Cysts. — The  treatment  of  the  whole  list  of  affec- 
tions included  under  cysts  of  the  kidneys  lies  in  the  province  of  the  surgeon, 
the  chief  office  of  the  physician  in  these  cases  being  one  of  diagnosis  and 
relief  of  pain. 

ANOMALIES  OF  FORM  AND  POSITION  OF  THE  KIDNEY. 

Normal  Situation  of  the  Kidney. — The  normal  situation  of  the 
kidney  is  on  the  quadratus  lumborum  and  psoas  muscles,  the  inferior  end 
of  the  left  kidney  extending  a  variable  distance  below  the  edge  of  the 
12th  rib,  while  the  right  extends  about  3/4  inch  (20  mm.)  lower  down, 
the  whole  right  organ  being  lowered  by  the  position  of  the  liver.  The 
outer  edge  of  the  kidney  is  often  in  a  line  drawn  vertically  through  the 
end  of  the  12th  rib.  Both  kidneys  descend  about  1/2  inch  (12.5  mm.) 
during  deep  inspiration.  The  kidney,  if  in  its  normal  situation,  is  accessible 
to  pressure  just  below  the  last  rib  at  the  outer  edge  of  the  erector  spinae 
muscle.  Sometimes  one  or  the  other,  more  frequently  the  left,  lies  on  the 
lumbar  vertebrae  on  the  sacrum,  or  in  the  inguinal  canal. 

Congenital  Absence  of  the  Kidney. — The  total  absence  of  both 
kidneys  is  possible  in  connection  with  extreme  abnormalities  and  defect  of 
development,  but  is  incompatible  with  life. 

Congenital  absence  of  one  kidney  is  not  vary  rare,  the  absent  one  being 
usually  the  left.  Such  absence  may  be  suspected  when  over  the  normal 
situation  of  the  organ  a  tympanitic  note  only  can  be  elicited  by  percussion. 
In  such  event,  the  remaining  kidney  supplements  the  work  of  the  absent 
one,  and  serious  consequences  only  follow  in  the  event  of  disease  of  the 
remaining  organ.  The  ureter  and  pelvis  of  the  absent  kidney  are  absent 
also,  but  sometimes  the  remaining  organ  has  two  pelves  and  two  ureters. 
Occasionally  the  rudiment  of  a  ureter  is  present.  Congenital  atrophy  of 
one  kidney  is  even  more  common,  but  is  discoverable  only  at  autopsy. 

Lobulated  Kidney. — The  lobulated  kidney  is  the  most  frequent 
anomaly  of  form.  It  consists  essentially  in  the  persistence  of  the  lobulation 
natural  to  the  organ  in  the  fetal  state.  This  is  acquired  by  the  end  of  the 
eighth  week  of  fetal  life,  after  which  it  gradually  disappears  in  normal 
development,  but  is  still  maintained  with  more  or  less  distinctness  through- 
out the  first  year  after  birth.  The  abnormal  lobulation  is  variously  distinct. 
Usually  partial  and  superficial,  the  fissures  are  sometimes  so  deep  as  to 
divide  the  organ  into  separate  reniculi,  of  which  there  may  be  from  seven 
to  20.  This  lobulation,  a  rare  event  in  man,  is  clearly  seen  in  the  kidneys 
of  the  lower  animals,  especially  in  the  sheep  and  ox. 

Horse-shoe  Kidney. — The  most  striking  of  the  anomalies  of  form  is 
the  horse-shoe  kidney,  in  which  usually  the  lower  ends  of  the  two  organs 
are  united  either  by  true  renal  tissue  or  by  a  band  of  fibrous  tissue.  More 
rarely  it  is  the  middle  segments  which  are  united,  and  more  rarely  still 
the  upper  ends.  In  either  event,  this  coalescence  is  usually  associated 
with  displacement  of  the  organ,  which  is  then  lower  down  than  in  the 
normal  condition,  usually  just  above  the  promontory  of  the  sacrum,  more 


762  DISEASES  OF  THE  URINARY  ORGANS 

rarely  in  the  pelvis,  and  at  times  on  one  side  or  the  other  of  the  spinal 
column.  In  the  fused  kidney  there  are  usually  two  pelves,  with  from  two 
to  four  ureters.  More  rarely  there  is  but  one  pelvis.  The  ureters  pass 
over  the  front  of  the  kidney.  The  renal  arteries  spring  from  the  aorta  at 
points  corresponding  to  the  situation  in  which  the  organ  is  found.  Thus, 
when  above  the  sacnxm,  the  arteries  spring  from  the  back  of  the  aorta 
near  its  bifurcation  or  from  one  of  the  common  iUacs,  while  the  veins  en- 
ter the  corresponding  parts  of  the  vena  cava  or  iliac  veins. 

The  horse-shoe  kidney  is  generally  first  recognized  at  autopsy,  or  at 
operation,  but  rarely  it  may  be  recognized  in  its  abnormal  position  above 
the  sacrum,  especially  in  thin  persons. 

The  Movable  or  Floating  Kidney. 

Synonyms. — Ren  mohilis;  Floating  Kidney;  Palpable  Kidney;  Nephroptosis. 

Description. — The  normal  kidney  is  commonly  quite  firmly  retained 
in  position  by  its  capsule  of  fat  and  by  a  covering  of  peritoneum.  The 
movable  or  floating  organ  exhibits  a  very  different  degree  of  mobility  in 
different  instances.  The  mobility  may  be  so  slight  that  it  can  be  recognized 
only  by  the  expert  manipulator,  or  so  great  that  the  organ  may  be  easily 
grasped  by  the  hand  through  the  abdominal  walls.  In  the  latter  condition 
there  is  a  mesonephron  or  peritoneal  fold  looselj^  attaching  the  kidney  to 
the  spine. 

Etiology. — The  movable  kidney  is  more  common  in  thin  persons  than 
in  the  obese,  in  women  than  in  men.  Indeed,  it  has  been  said  that  one 
woman  out  of  every  four  has  a  movable  kidney.  It  is  six  times  as  frequent 
in  the  working-classes.  The  right  kidney  is  far  more  frequently  movable 
than  the  left.  Repeated  pregnancies  are  assigned  causes,  as  is  also  me- 
chanical violence,  as  a  fall  or  tight  lacing.  It  is  most  likely,  however, 
that  the  majority  of  floating  kidneys  are  congenitally  loose,  and  that  this 
looseness  may  be  increased  by  the  conditions  named.  Frequently  a  float- 
ing kidney  is  only  a  part  of  a  general  enteroptosis. 

Symptoms. — The  floating  kidney  often  occasions  no  symptoms.  At 
other  times  it  is  responsible  for  a  remarkable  train  of  nervous  symptoms, 
mainly  reflex  in  character.  These  include  obstinate  indigestion  of  every 
grade,  flatulence,  palpitation  of  the  heart,  cardialgia,  neuralgic  pain  almost 
anywhere  in  the  body,  but  especially  in  the  abdomen  and  cardiac  region. 
Gastric  crises  identical  with  those  characteristic  of  locomotor  ataxia  have 
been  ascribed  to  floating  kidney.  Irritable  bladder  and  dysmenorrhea  are 
also  consequences.  It  is  an  interesting  fact  that  where  the  degree  of  dis- 
placement and  the  mobility  are  most  marked,  the  reflex  symptoms  are  least 
so.  This  is  not  without  a  parallel  in  other  diseases,  and  in  illustration  may 
be  cited  the  well-known  fact  that  prolapsus  uteri  of  moderate  degree  often 
causes  decided  reflex  symptoms,  while  a  complete  procidentia  produces 
often  trifling  local  annoyance.  The  direct  result  of  the  displacement,  so 
far  as  appreciable,  is  a  sense  of  dragging  or  weight,  which  especiallj'  mani- 
fests itself  while  standing,  wallring,  riding,  or  dancing,  to  which  may  be 
added  a  variable  amovmt  of  pain.  More  serious  s}-mptoms  sometimes 
manifest  themselves  as  the  result  of  torsion  of  the  ureter,  occasioned  by 


FLOATING  KIDNEY  763 

complete  rotation  of  the  kidney,  in  which  the  renal  vessels  and  nerves 
are  also  involved.  These  are  agonizing  pain,  associated  with  symptoms 
of  collapse,  such  as  nausea,  and  anxious  expression,  and  scanty  urination. 
They  are  caused  in  part  by  obstruction  to  the  ureter  and  the  backing  of 
the  urine  on  the  kidney.  These  are  known  as  Dietl's  crises.  Acute 
hydronephrosis  may  also  be  the  restdt  of  such  strangulation,  which  may  be 
caused,  too,  by  inflammatory  bands.  This  condition  ends  sometimes  as 
suddenly  as  it  begins.  Both  hemorrhage  and  albuminuria  are  reported  as 
results.  Both  are  certainly  rare.  There  may  be  other  effects  of  displace- 
ment due  to  the  location  of  the  organ  at  times,  of  which  irritation  due  to 
pressure  upon  the  bladder  may  be  mentioned  as  one.  It  is  often  very 
imcomfortable  for  the  patient  to  lie  on  the  one  side  opposite  that  on  which 
the  displaced  organ  belongs. 

Diagnosis. — This  is  variously  difficult.  The  kidney  exhibits  some 
mobility  in  health,  descending  also  always  1/2  inch  (1.3  cm.)  with  each  deep 
inspiration.  Movable  kidneys  are  sometimes  so  loose  and  movable  that 
they  may  be  felt  with  ease  through  the  abdominal  walls.  Between  this 
ready  recognition  and  that  which  requires  the  highest  manipulative  skill 
of  the  examiner  there  is  every  degree.  At  the  present  day,  movable  kidney 
is  regarded  as  a  much  more  frequent  condition  than  was  formerly  believed. 
So  frequently  has  the  set  of  reflex  nervous  symptoms  described  been  fotmd 
associated  with  movable  kidney  that  their  presence  should  always  suggest 
an  examination  for  the  presence  of  such  an  organ.  The  examination  may 
be  made  with  the  patient  in  the  standing  posture,  or  when  lying  on  the 
back.  In  the  first  he  bends  slightly  forward,  the  hands  being  placed  on  a 
table,  and  the  clothing  thoroughly  loosened.  The  right  hand  of  the  exam- 
iner is  then  placed  in  front  immediately  next  the  skin,  below  the  hypochon- 
drium,  while  the  left  is  placed  over  the  lumbar  region.  The  patient  is 
directed  to  respire  deeply  and  regularly,  and  to  relax  during  expiration. 
The  region  between  the  two  hands  is  carefully  palpated,  when,  if  there 
is  any  marked  degree  of  displacement,  or  rather  of  lowered  position,  the 
organ  can  be  felt  as  a  firm,  smooth,  oval  body,  somewhat  sensitive  to  pres- 
sure, which  produces  a  sickening  pain  quite  characteristic.  Most  rarely 
the  pxJsation  of  the  renal  artery  can  be  felt.  The  right  kidney  naturally 
moves  with  breathing  more  than  the  left,  being  pushed  down  by  the  liver. 
Sometimes  the  maniptdation  will  be  more  successful  in  the  knee-elbow 
position.  When  in  this  position,  the  movable  kidney  having  fallen  forward, 
a  resonant  note  may  be  obtained  by  percussing  over  the  normal  situation 
of  the  organ;  or  the  patient  may  be  placed  on  the  back  with  the  side  to  be 
examined  toward  the  edge,  of  the  bed,  on  which  the  physician  may  sit. 
The  hands  are  applied  as  in  the  standing  position,  and  manipulation  is 
practised  as  described. 

The  displaced  organ  is  hardly  likely  to  be  confounded  with  anything 
else.  The  spleen,  which  corresponds  nearly  in  size,  is  also  sometimes 
movable.  Its  shape  is,  however,  different.  Its  anterior  border  is  sharp 
and  often  notched.  Sometimes  both  the  left  kidney  and  the  spleen  are 
floating.  A  movable  pyloric  tumor  has  been  mistaken  for  a  movable  kidney. 
The  passage  of  a  stomach  tube  in  case  of  doubt  would  clear  it  up. 

Treatment. — As  may  be  inferred,  many  cases. of  movable  kidney  re- 


764  DISEASES  OF  THE  URINARY  ORGANS 

quire  no  treatment.  In  a  few  instances  the  symptoms  are- relieved  by 
improving  the  general  health ;  in  others  the  patient  is  comfortable  while 
lying  on  the  back,  and  such  comfort  may  continue  for  a  time  after  rising. 
When  decided  symptoms  attributable  to  the  kidney  are  present,  surgical 
treatment  for  fixing  the  kidney — nephroiThaphy — is  the  most  satisfactory- 
treatment,  and  this  sometimes  fails.  We  have  known  an  operation  for 
removal  of  the  kidney — nephrectomy — to  be  necessary  after  nephrorrhaphy 
had  been  attempted  twice  imsuccessfully.  The  use  of  pads  and  supports 
has  been  only  partly  successful.  On  the  other  hand,  Charles  D.  Aaron 
had  recently  published  a  paper  on  the  successful  treatment  of  442  cases 
without  surgical  intervention. '  Progress  has  certainly  been  made  in  the 
success  obtained  by  bandages  made  by  skillful  persons,  and  it  is  advisable 
to  make  an  effort  with  a  bandage  before  operation  is  tried. 

IDIOPATHIC  HEMATURIA.^ 

Definition. — So-called  idiopathic  hematviria  is  a  hematuria  the  origin  of 
which  is  unknown.  In  addition  to  the  various  causes  of  bloody  urine  already 
referred  to  in  treating  diseases  of  the  urinary  organs,  and,  in  addition  to 
malarial  hematuria,  there  remains  a  form  of  renal  hematiuia  of  not  very 
infrequent  occurrence,  for  which  none  of  the  causes  named  wiil  account. 
To  this  the  term  idiopathic  hematuria  is  appropriate. 

Symptoms. — The  characteristics  of  the  urine  in  this  form  of  hematuria 
are  in  no  way  different  from  those  of  renal  hematuria  from  other  causes. 
The  blood  is  intimatel}'  admixed  with  the  urine,  and  is  not,  as  a  rule,  found 
in  the  shape  of  coagula,  as  is  so  often  the  case  when  it  comes  from  the 
bladder  or  pelvis  of  the  kidney  or  in  malignant  disease  of  the  organ.  There 
is  the  usual  smoky  hue  characteristic  of  acid  urine  containing  a  small  amount 
of  blood,  becoming  brighter  red  as  the  luine  becomes  aUvaline,  and  darker 
red  as  the  quantit}'  of  blood  is  increased.  The  microscope  reveals  numerous 
blood-disks  recognizable  by  their  usual  characters,  and  often  blood-casts 
and  casts  filled  with  the  debris  of  red  disks,  or  red  disks  so  closely  packed 
as  to  malve  it  impossible  to  distinguish  their  outline.  The  urine  is,  of  course, 
albimiinous. 

Next  to  the  change  in  the  urine,  the  most  striking  featixre  is  the  absence 
of  other  symptoms.  The  subject  is  not  ill,  is  not  weak,  and  complains  of 
nothing.  Occasionally  a  dull  ache  in  the  back  is  felt  or  supposed  to  be  felt, 
perhaps  because  the  patient  thinks  that  since  there  is  bloody  urine,  there 
ought  to  be  pain  in  the  back.  The  same  may  be  said  of  weakness,  but  these 
symptoms  are  not  usually  complained  of,  though  they  may  be  present. 
Sir  William  Gull  spoke  of  such  hematiuia  as  a  "renal  epistaxis."  With 
the  lapse  of  time,  however,  and  the  continuance  of  the  symptom,  positive 
weakness  gradually  supervenes. 

Treatment. — Rest  is  an  important  and  essential  condition  in  the  suc- 
cessftal  management  of  idiopathic  hematuria.  Calcium  lactate  is  perhaps 
the  most  valuable  remedy  we  have.  Hexamethylenamine  should  be  tried  on 
general  principles.     The  usual  astringents,  mineral  and  vegetable,  known 

1  Jour.  Am.  Med.  Assoc."     Dec.  s.  1903. 

'  We  realize  that  the  subjects  hematuria,  hemoglobinuria,  and  chyluria,  next  to  be  considered,  are  not 
strictly  renal  affections,  but  it  is  difficult  to  classify  them  otherwise. 


HEMOGLOBINURIA  765 

to  be  efficient  in  the  treatment  of  hemorrhagic  conditions  elsewhere,  are 
often  without  effect  here,  though  these  substances,  including  adrenalin, 
gallic  acid,  the  persulphate  of  iron,  and  acetate  of  lead,  alum,  catechu, 
and  kino,  may  be  tried. 

Recent  studies  by  Weil,  Moss'  and  others  on  the  serum  treatment  of 
hemorrhagic  diseases  have  shown  the  efficiency  of  daily  intravenous  or 
subcutaneous  injections  of  fresh  human  or  animal  sertun.  It  is  reasonable 
to  suppose  the  same  treatment  would  be  efficient  in  hematuria.  Under 
ordinary  circumstances  15  c.c.  may  be  injected  intravenously  and  30  c.c. 
subcutaneously.     See  Treatment  of  hemophelia. 


HEMOGLOBINURIA. 

Definition. — In  this  interesting  condition,  the  coloring-matter  only 
of  the  blood  is  found  in  the  urine ;  very  rarely  a  few  blood-disks  or  their 
fragments.  In  their  absence,  other  criteria  of  the  presence  of  blood  coloring- 
matter  must  be  sought.  To  do  this,  one  may  make  Teichmann's  hemin 
crystals,  or  if  the  spectroscope  be  available,  the  filtered  and  diluted  urine 
produces  the  absorption  bands  of  oxyhemoglobin  between  Fraunhofer's  line 
D  and  E,  or  more  frequently  the  three  bands  of  methemoglobin,  of  which 
that  in  the  red  near  C  is  distinctive.  Sometimes  both  are  present.  The 
urine  thus  stained  with  hemoglobin  or  methemoglobin  is  dark  brownish- 
red,  and  even  black  in  color.  It  is  also  albuminous,  and  in  lieu  of  the 
blood-disks  are  sometimes  found  yeUowish-brown,  irregular,  and  granular 
flakes,  and  sometimes  cylindrical  masses  of  hemoglobin. 

Hemoglobinuria  is  always  associated  with  hemoglobinemia,  which  is, 
however,  less  easy  of  demonstration.  The  hemoglobin  is  set  free  from 
the  corpuscles  and  imparts  a  reddish  hue  to  the  blood-plasma.  The  disks 
themselves  are  paler,  and  yellowish-brown  particles  of  hemoglobin  may 
be  demonstrated  between  the  corpuscles.  The  number  of  corpuscles  them- 
selves may  be  reduced,  falling  to  4,000,000  and  less. 

Hemoglobinemia  and  hemoglobinuria  may  easily  be  separated  into 
two  divisions,  toxic  and  simple  paroxysmal. 

Toxic  Hemoglobinuria. — This  is  produced  by  toxic  substances, 
which  dissolve  out  the  hemoglobin  from  the  corpuscles.  Such  are  sulphu- 
reted  hydrogen,  arseniixreted  hydrogen,  carbon  mo  noxid,  carbolic  acid, 
pyrogallic  acid,  naphthol,  nitrobenzole ;  potassium  chlorate  in  large  doses, 
and  the  poison  of  certain  mushrooms;  also  sometimes  the  poison  of  the 
infectious  diseases,  including  scarlet  fever,  diphtheria,  pyemia,  yellow  fever, 
typhoid  fever,  malaria,  and  even  syphilis.  The  last  has  sometimes  seemed 
to  act  as  a  predisposing  cause,  subsequently  to  which  so  trifling  a  thing 
as  exposure  to  cold  has  caused  it.  I  have  seen  it  associated  with  pregnane}^ 
as  a  probable  cause.  Hemoglobinemia  and  hemoglobinuria  sometimes 
succeed  on  extensive  burns  when  the  poison  is  probably  the  retained 
excretions  of  the  skin.  Both  high  and  low  temperature  alone  is  said  to 
have  caused  it.  In  malarial  poisoning  the  hemoglobinemia  may  be  the 
direct  result  of  the  action  of  the  malarial  plasmodium.     The  blood  of  one 

1  Moss,  "Johns  Hopkins  Hospital  Bulletin,"  July,  1911. 


766  DISEASES  OF  THE  URINARY  ORGANS 

animal  transfused  into  the  vessels  of  another,  must  be  added  to  this  group, 
since  it  results  in  disintegration  of  red  cells  and  hemoglobinuria.  Then 
there  is  Epidemic  hemoglobinuria  of  the  new  born  with  jaundice,  cyanosis 
and  nervous  symptoms. 

Prognosis. — This  depends  upon  the  dose  of  the  toxin  causing  it  and 
the  other  symptoms  produced.  Recovery  is  usual,  but  some  cases  are 
rapidly  fatal. 

Treatment. — This  is  that  of  the  disease  occasioning  it.  The  same 
astringent  measures  may  be  tried  as  in  hematuria,  and  restorative  medicines 
may  be  given  to  rebuild  the  blood.     Of  these,  iron  is  the  most  important. 

Paroxysmal  Hemoglobinuria. 

In  this,  intermittent  attacks  occur.  They  come  on  suddenly,  preceded 
by  chills  and  fever,  headache,  and  pain  in  the  limbs,  the  temperature 
often  reaching  104°  F.  (40°  C).  The  bloody  iirine  follows  in  an  hour 
or  less,  and  may  last  four  or  five  hours,  or  there  may  be  two  or  three  par- 
oxysms in  a  day.  At  other  times  there  is  no  fever  or  the  temperature  is 
even  subnormal.  Jaundice  is  associated  with  some  cases,  especially 
toward  the  end.  At  times,  instead  of  the  expected  hemoglobinuria,  there 
is  only  albuminuria.  Ralfe  explains  this  by  supposing  that  the  toxic  agent 
has  destroyed  only  a  small  number  of  corpuscles,  the  coloring  matter  from 
which  is  used  up  in  the  spleen  and  liver,  while  the  globulin  goes  off  in  the 
urine.  Von  Leube  especially  calls  attention  to  a  swelling  and  tenderness 
of  the  liver  and  spleen,  and  says  he  has  met  these  symptoms  in  lieu  of 
the  expected  hemoglobinuria — in  Ueu  even  of  albuminuria. 

The  occasional  association  of  hemoglobinuria  with  Raynaud's  disease 
is  very  interesting.  The  probability  is  that  in  most  cases  where  the  two 
conditions  are  associated,  the  preliminary  hemoglobinemia  is  due  to  a  sepa- 
ration of  the  hemoglobin  from  the  red  disks  in  the  peripheral  asphyxiated 
part  of  the  nose,  ears,  fingers,  or  other  parts. 

As  to  other  causes  of  paroxysmal  form,  malaria  is  imdoubtedly  one, 
though  perhaps  not  so  often  as  was  once  supposed.  Another  cause  is  ex- 
cessive muscular  exertion,  especially  when  associated  with  cold,  while 
cold  itself  is  perhaps  the  most  frequent  of  all  causes.  Mental  emotion  is 
sometimes  a  cause.  It  must  be  admitted  that  for  the  cases  not  explained 
by  toxic  agency  no  satisfactory  solution  has  been  presented.' 

Prognosis. — The  prognosis  of  the  paroxysmal  form  is  commonly  favor- 
able, though  it  may  continue  to  recur  for  a  long  time. 

Treatment. — This  depends  upon  the  cause.  If  it  be  malaria,  the  con- 
dition is  easily  ctuable  by  quinin.  To  seek  the  causes  in  many  cases  is 
to  seek  the  unattainable,  and  the  cases  must  be  treated  on  general  prin- 
ciples. Rest  and  warmth  are  essentials.  After  this,  the  same  astringent 
remedies  as  those  recommended  under  hematuria  may  be  tried.  Adrenalin 
is  one  of  these.  As  cold  seasons  and  cold  weather  favor  it,  a  residence  in  a 
warm  cHmate  should  be  recommended  when  the  condition  persists.  Nitrite 
of  amyl  is  said  to  have  cut  short  and  to  have  prevented  an  attack. 


*  It  is  well  known  that  horses  are  subject  to  hemoglobinuria,  and  that  it  occurs  in  them  after  exposure 
to  cold,  especially  after  having  been  stabled  for  several  days. 


CIIYLURIA  767 

NON-PARASITIC  CHYLURIA. 

Definition  and  Description. — A  state  of  the  urine  in  which  the  secre- 
tion is  admixed  with  fat  in  a  minute  state  of  division,  whereby  the  urine 
acquires  a  milky  or  chylous  appearance. 

The  proportion  of  fat  varies  greatly,  being  at  times  only  enough  to 
impart  a  mere  opalescence,  while  at  other  times  the  urine  is  scarcely  distin- 
guishable from  miUc,  even  the  characteristic  odor  and  taste  of  urine  being 
wanting.  The  fat,  on  standing,  often  rises  to  the  surface,  Uke  cream.  By 
the  microscope,  in  addition  to  this  molecular  fat  and  a  few  oil  drops,  numer- 
ous blood-disks  are  also  found.  These  are  sometimes  so  numerous  as  to 
impart  a  pinkish  tinge  to  the  fluid,  and  at  times  a  spontaneous  coagulation 
takes  place,  with  the  formation  of  a  slight  reddish  clot,  showing  the  presence 
also,  of  fibrin — hematochyluria. 

Etiology. — To  produce  chyluria  there  must  be  brought  about  in  some 
way  a  leakage  from  chyle  vessels  into  the  urinary  passages  somewhere 
between  the  kidney  and  the  neck  of  the  bladder.  Yet  no  such  communi- 
cation has  ever  been  found,  so  far  as  we  know,  though  W.  H.  Mastin  noticed 
the  patulous  mouths  of  several  chyle  vessels  opening  into  the  serous  sac 
of  a  testicle  which  he  laid  open  for  the  cure  of  a  chylous  hydrocele  or  lymph 
scrotum.  Having  ligated  them,  no  recurrence  of  the  hydrocele  happened. 
Supposing  such  a  communication  to  exist,  how  is  it  brought  about  ? 

Symptoms. — Few  symptoms  other  than  those  of  the  chylous  urine 
are  present.  It  is  usually  intermittent,  but  may  be  persistent.  There  is 
sometimes  a  loss  of  strength  from  the  draining  off  of  fluid  which  is  un- 
doubtedly nutrient;  at  other  times  there  is  some  pain  in  the  back,  and  at 
others  again  painful  urination  due  to  obstruction  of  the  urethra  by  coagula 
of  fibrin,  but  in  most  cases  the  patient  feels  well  and  would  not  know  there 
was  anything  the  matter  with  him  had  not  his  attention  been  called  to  the 
urine. 

Treatment. — No  means  have  been  discovered  to  check  the  leakage  in 
the  idiopathic  form,  which  often  persist  for  years  and  then  subsides 
spontaneously. 

See  also  article  on  Filariasis  in  section  on  Parasites. 

Renal  Infarct  the  Result  of  Heart  Disease. — This  form  of  kidney  in- 
volvement, secondary  to  disease  of  the  vascular  apparatus,  commonly 
heart  disease,  is  more  frequently  seen  on  the  postmortem  table  than  recog- 
nized in  the  living  subject.  It  is  embolic  infarction,  produced  by  the  lodg- 
ment in  some  branches  of  the  renal  artery  of  an  embolus  derived  from  the 
heart  or  a  blood-vessel.  Its  most  frequent  source  is  a  fragment  of  vege- 
tation or  clot  from  a  diseased  heart-valve,  commonly  the  aortic.  An 
embolus  may  also  arise  from  a  thrombus  in  a  vein.  If  from  the  latter, 
it  must  be  carried  first  to  the  right  heart,  and  thence  through  the  lungs 
into  the  left  heart,  and  thence  by  the  aorta  to  the  kidney,  and  must,  of 
course,  be  small. 

The  effect  of  the  lodgment  of  an  embolus  in  the  kidney  is  a  wedge- 
shaped  hemorrhagic  infarct  which  at  first  is  dark  red  in  color,  standing 
out  above  the  surface,  but  which  in  time  whitens,  contracts,  and  is  ulti- 
mately absorbed,  leaving  a  mere  cicatricial  mark. 


768  DISEASES  OF  THE  URINARY  ORGANS 

Most  frequently  a  renal  infarct  occurs  without  noticeable  symptoms. 
Its  occurrence,  if  looked  for  by  reason  of  the  presence  of  valvular  heart 
disease,  may  be  suspected  if  there  is  the  sudden  appearance  of  blood  in 
the  urine.  A  sudden  pain  in  the  region  of  the  kidney  occurring  at  the  same 
time  with  hematuria  would  go  to  confirm  the  diagnosis.  No  treatment, 
except  rest,  is  indicated,  even  if  the  event  is  recognized. 


DISEASES  OF  THE  BLADDER. 

CYSTITIS. 

Synonyms. — Catarrh  of  the  Bladder;  Vesical  Catarrh. 

Definition. — Cystitis  is  an  infectious  inflammation  of  the  bladder 
excited  usually  by  different  varieties  of  pathogenic  bacteria. 

Etiology. — Among  these  are  the  bacillus  coli  communis,  the  gonococcus, 
staphylococcus  pyogenes,  bacillus  tuberculosus  and  the  typhoid  bacillus.  ^  The 
causes  formerly  assigned  to  such  inflammation,  though  relegated  by  the  above 
definition  to  favoring  causes,  are  still  very  important.  They  include 
foreign  bodies,  such  as  stone,  trauma,  obstruction  to  the  outflow  of  urine 
by  enlarged  prostate  or  stricture  of  the  urethra.  A  frequent  medium  of 
introduction  of  bacteria  was  formerly  catheters.  The  number  of  cases 
caused  by  catheterization  has  diminished  because  of  the  greater  precaution 
taken  of  late  in  the  care  of  instruments.  Of  acknowledged  bacterial  origin 
is  also  gonorrheal  cystitis,  which,  succeeding  an  attack  of  gonorrheal 
lu-ethritis,  invades  the  bladder  by  extension. 

Cystitis  succeeds  upon  the  introduction  of  substances  in  the  blood, 
as  cantharides  and  capsicxim.  Even  the  ingestion  of  certain  articles  of 
food  has  been  followed  by  it.  While  traumatic  agencies  are  often  predis- 
posing causes  furnishing  the  conditions  favorable  to  the  operation  of 
bacteria,  they  may  also  be  exciting  causes  as  may  any  mechanical  irritants, 
independent  of  bacteria,  if  sufficiently  irritating. 

Morbid  Anatomy. — The  bladder  of  cystitis  is  a  varied  picture.  There 
may  be  degrees  so  slight  as  to  produce  scarcely  appreciable  change  in  its 
appearance.  At  other  times  the  mucous  membrane  is  hyperemic  and 
bathed  with  a  mucoid  or  mucopyoid  secretion  of  dirtj'-gray  color.  In  many 
cases  only  the  neck  of  the  bladder  and  the  part  of  the  urethra  passing  through 
the  prostate  are  involved.  Again,  the  bladder  is  "ribbed,"  a  result  of 
straining.  During  this  act  the  mucous  membrane  between  the  muscular 
trabecule  yields,  producing  depressions  bounded  by  the  more  impelding 
muscular  bands.  On  the  other  hand,  in  chronic  cases  permanent  thicken- 
ing of  the  bladder-walls  may  result.  Finally,  in  the  severest  forms  of 
inflammation  due  to  pathogenic  organisms,  such  as  those  associated  with 
putrid  urine,  the  mucous  membrane  may  be  covered  with  patches  of  false 
membrane,  or  the  wall  of  the  bladder  may  be  infiltrated  and  undermined 
vAth.  pus,  constituting  the  so-called  phlegmonous  or  diphtheritic  cj-stitis, 
from  which  there  may  result  urethral  and  perineal  infiltration.     A  further 


*  See  an  admirable  paper  by  Thomas  R.  Brown  on  "  The  Bacteriology  of  Cystitis,  Pyelitis,"  etc.,  "Johns 
Hopkins  Hospital  Reports,"  vol.  x.,  looi. 


CYSTITIS  769 

extension  of  the  cystitis  into  the  pelvic  connective  tissue  about  the  bladder 
is  known  as  paracystitis;  this  belongs  to  the  province  of  the  surgeon. 

Symptoms. — While  a  division  of  cystitis  into  acute  and  chronic  is 
justified  by  the  suddenness  and  severity  of  symptoms  in  certain  cases  as 
contrasted  with  their  slow  development  in  others,  yet  the  conditions  so 
constantly  verge  into  each  other  that  a  separate  consideration  of  the  two 
forms  is  not  necessary.  The  first  symptom  is  usually  a  frequent  desire  to 
void  urine.  Such  frequency  varies  greatly  in  intensit3^  It  may  be  every 
few  minutes  or  almost  incessant,  several  times  an  hour  or  once  in  two  hours. 
After  the  primary  frequency  of  disturbance  it  usually  diminishes  somewhat. 
Such '  frequency  is  often  attended  bj^  painful  straining.  In  severe  cases 
there  is  always  tenderness  over  the  region  of  the  bladder  above  the  pubes, 
and  in  some  cases  there  is  constant  pain.  In  these  tenderness  can  also  be 
elicited  by  pressure  from  the  vagina  and  rectum,  whUe  catheterization  is 
especially  painful.  In  calculous  cystitis  pain  is  excited  or  aggravated  bj' 
motion,  especially  such  as  is  communicated  to  one  riding  in  a  wagon  over 
a  rough  road. 

As  commonly  met,  there  is  rarelj^  fever  with  cystitis,  but  the  severe 
forms  are  attended  with  moderate  fever  and  sometimes,  in  the  diphtheritic 
variety,  with  high  fever.  Even  when  there  is  fever,  the  temperature  does 
not  exceed  ioo°  to  102°  F.  (37.8°  to  38.9°  C),  though  it  may  be  higher. 
In  certain  acute  diphtheritic  cases  of  great  virulence  there  are  chills,  sweats, 
and  high  fever.  In  advanced  stages  there  may  be  sepsis,  due  to  absorption 
of  retained  putrid  matter  from  the  bladder. 

The  iirine  presents  striking  changes,  by  which  alone  the  diagnosis  can 
be  made.  First,  it  contains  pus  in  varying  quantities,  but  it  is  especially 
characteristic  of  the  pus  of  cystitis  that  it  it  associated  with  mucus,  which 
imparts  a  glairy,  stringy  character  to  the  urine,  that  increases  the  difficulty 
of  its  discharge  from  the  bladder.  The  reaction  of  the  urine  when  passed 
is  commonly  either  alkaline  or  faintly  acid,  and  if  acid,  it  promptty  becomes 
alkaline.  This  is  due  to  the  formation  of  ammonium  carbonate  out  of  the 
normal  urea,  the  result  of  the  operation  of  bacteria.  The  greater  alkalinity 
thus  resulting  reacts  upon  the  pus  and  converts  it  into  a  glain^  matter 
resembling  mucus,  thus  further  increasing  the  difficulty  of  passing  it. 
Under  the  circumstances  the  pus  is  loaded  with  amorphous  phosphates  of 
lime  and  glistening  crj'Stals  of  ammonio-magnesium  phosphate.  It  is  so 
viscid  that  it  will  not  rise  in  the  pipet,  and  must  be  cut  with  scissors  to  be 
manipulated  for  microscopic  study.  Blood  is  an  almost  constant  constitu- 
ent of  the  urine  in  calculous  cystitis,  and  in  the  grave  diphtheritic  forms 
shreds  of  gangrenous  bladder  tissue  may  be  discharged. 

The  question  as  to  whether  there  is  pyelitis,  separate  or  associated  with 
cystitis,  is  still  more  difficult.  It  is  true  that  the  pus  in  pyelitis  is  very 
much  less  glairy  and  viscid  than  that  of  cystitis  piure  and  simple.  How- 
ever, there  are  no  distinctive  cellular  -elements  which  settle  this  ques- 
tion, though  some  assert  there  are.-  Even  spasm  of  the  bladder,  com- 
monly regarded  as  peculiar  to  cystitis,  may  be  present  in  pyelitis.  Rather 
must  we  rely  upon  tenderness  in  the  neighborhood  of  the  kidney  on  the 
one  hand  and  in  that  of  the  bladder  on  the  other.  Marked  intermission 
in  the  purulent  discharge,  especially  if  associated  with  attacks  of  nephritic 


770  DISEASES  OF  THE  URINARY  ORGAXS 

colic,  which  imply  an  obstructed  ureter,  point  to  pelvic  involvement.  Pro- 
longed cases  of  cystitis  should  alwaj^s  be  sent  to  a  surgeon  for  cystoscopic 
examination  to  be  followed  by  catheterization  of  the  ureters  or  one  of  the 
elimination  tests  if  circumstances  make  it  necessary.  Catheterization  of 
the  tireters  may  aid  in  the  diagnosis,  pus  from  the  pelvis  of  the  kidney 
being  thus  separated  from  the  bladder  contents. 

Calculous  cystitis  may  be  suspected  when  pain  in  the  region  of  the 
bladder  is  excited  by  motion,  as  in  riding  over  a  rough  road,  or  at  the  end 
of  the  penis  after  micturition;  also  when  there  is  blood  in  the  urine  or  when 
the  stream  of  urine  is  suddenly  interrupted.  These  symptoms  should 
immediately  suggest  the  use  of  the  sound,  negative  results  with  which  must 
not,  however,  be  accepted  without  qualification,  as  the  stone  may  be 
concealed  in  a  diverticulum.  '  The  X-ray  is  also  an  indispensable  aid  to 
diagnosis  in  calculous  cystitis. 

Prognosis. — The  medical  treatment  of  cystitis  does  not  furnish  a  very 
satisfactory  chapter  in  therapeutics.  It  includes  such  treatment  as  the 
physician  is  called  upon  to  use,  supposing  the  exciting  cause,  such  as  a 
stone  in  the  bladder  or  obstruction  in  the  iirethra,  to  have  been  removed, 
whenever  possible.  Thanks  to  modem  surgery;  the  enlarged  prostate 
which  is  responsible  for  so  many  cases  of  cystitis  is,  in  the  vast  majority 
of  cases,  removable  without  accident  even  in  the  old.  Many  cases  due  to 
other  causes  get  well;  others  are  only  partiallj- reUeved. 

Treatment. — Acute  Cystitis. — Of  this  form  the  treatment  is  far  more 
satisfactory,  at  least  so  far  as  the  removal  of  the  symptoms  is  concerned, 
than  that  of  the  chronic  form.  Rest  in  bed  is  a  primary  and  essential 
condition.  Leeches  to  the  perineum  should  be  applied  more  frequently 
than  they  are.  A  poultice  to  this  same  region  and  over  the  lower  abdomi- 
nal region  is  always  useful,  while  a  brisk  saline  cathartic  should  never  be 
omitted. 

As  the  feverish  state  which  always  accompanies  cystitis  is  more  or 
less  constantly  associated  with  scanty  urine,  concentrated  and  irritating 
to  the  inflamed  mucous  membrane,  it  is  desirable  at  once  to  increase  the 
secretion  and  thus  dilute  it.  Copious  libations  of  pure  water,  to  which 
the  citrate  or  acetate  of  potassium  is  added,  in  15  to  20  grain  (i  to  1.3 
gm.)  doses  for  an  adult,  should  be  allowed.  The  ordinars^  spirit  of  nitrous 
ether  in  dram  (3.4  c.c.)  doses  every  two  hours  is  an  admirable  adjuvant, 
and  may  be  combined  with  the  official  liquor  potassii  citratis,  which  con- 
tains about  20  grains  (1.3  gm.)  of  citrate  of  potassium  to  1/2  ounce  (15 
c.c).  Formerl}',  the  mucilage  of  flaxseed  or  flaxseed  tea  was  much  used 
as  a  diluent  menstruum  for  the  diuretic  alkalies  indicated,  but  it  is  doubt- 
ful whether  it  is  an}-  more  efficient  than  a  like  quantity  of  water.  When 
there  are  much  pain  and  straining,  as  is  often  the  case,  opium  is  indispen- 
sable, always  in  the  form  of  a  suppository,  1/2  grain  (0.03  gm.)  to  i  grain 
(0.065  gm.)  of  the  extract,  or  a  corresponding  amount  of  morphin.  Iced- 
water  injections  into  the  rectum,  or  pieces  of  ice  similarly  applied,  are  very 
efficient  in  allajdng  the  pain  and  irritation  when  additional  measures  are 
needed.  Injections  of  cocain  into  the  bladder  are  useful  in  aUajdng  the 
intense  irritation.  Not  more  than  2  grains  (o.  13  gm.)  of  cocain  should  be 
introduced  iiito  the  bladder  at  one  time. 


CHRONIC  CYSTITIS  771 

Chronic  Cystitis. — The  successful  treatment  of  chronic  cystitis  is  a 
much  more  difficult  task,  for  three  evident  reasons :  Though  the  case  is 
frequently  a  purely  surgical  condition  and  the  usefulness  of  drugs  by  the 
mouth  is  decidedly  questionable  we  will  consider  it  here. 

1.  The  constant  presence  in  the  bladder  of  the  urine  with  its  irritating 
qualities,  especially  so  to  an  inflamed  mucous  membrane. 

2.  The  difficulty  in  getting  remedies  to  reach  the  inflamed  surfaces. 

3.  The  pent-up  inflammatory  products,  which  in  their  decomposi- 
tion often  make  the  urine  still  more  irritating  by  exciting  in  it  ammoniacal 
changes. 

There  is  no  doubt  that,  if  the  urine  could  be  kept  from  entering  the  blad- 
der during  the  existence  of  an  inflammation,  the  latter  would  rapidly  heal; 
that  cure  would  be  facilitated  by  obtaining  ready  escape  for  the  pus  and 
mucus;  while  happier  resvdts  might  also  be  reasonably  expected  if  we 
could  secure  readier  access  for  remedies  to  the  inflamed  areas.  None  of 
these  indications  can  be  met  entirely.  They  remain,  however,  the  conditions 
to  be  fulfilled,  and  while  none  can  be  thoroughly  fulfilled,  they  may  be 
variously  approximated. 

First,  the  irritating  qualities  of  the  urine  may  be  diminished  by  the 
use  of  diluents,  already  recommended  in  the  treatment  of  acute  cystitis. 
Almost  any  of  the  negative  mineral  waters,  so  highly  recommended  by 
their  owners,  are  useful  for  this  purpose.  Pure  spring  water  is  just  as  good 
and  distilled  water  is  even  better.  From  one  to  two  quarts  should  be 
taken  daily.  If  the  kidneys  are  equal  to  their  office,  a  large  quantity  of 
light-hued  urine  of  low  specific  gravity  and  relatively  weak  in  solids  will 
be  secreted. 

When  it  is  purposed  to  go  further  and  add  to  the  efficiency  of  diluents, 
mistakes  are  often  made.  While  one  can  scarcely  go  astray  in  adding 
alkalies  to  the  fluid  ingested  in  acute  cystitis,  it  is  very  different  with  the 
chronic  form.  In  this  the  urine  is  often  alkaline,  or  ready  to  become  so  on 
the  slightest  addition  of  alkali  to  the  blood.  Such  alkalinity  of  urine  in  turn 
favors  decomposition,  the  effect  of  which  is  to  convert  the  pus,  if  present, 
into  a  tenacious,  glairy  fluid  which  the  bladder  cannot  evacuate.  Notwith- 
standing this  tendency,  liquor  potassii  and  other  alkaHes  are  sometimes 
administered  under  precisely  these  conditions — adding  "fuel  to  the  flame." 
The  indication  under  these  circumstances  is  to  render  the  tirine  acid,  if 
possible,  although  the  means  to  this  end  are  unsatisfactory.  Benzoic  acid 
has  the  reputation  of  doing  this,  and  it  is  probably  true  of  it  when  adminis- 
tered in  siifficient  doses.  It  may  be  given  in  the  shape  of  a  5  grain  (0.32 
gm.)  capsule,  of  which  at  least  six  must  be  given  in  a  day  to  produce  any 
effect.  Benzoate  of  sodium  may  be  given  in  10  grain  doses  (0.6  gm.) 
every  two  hours.  The  same  property  has  been  assigned  to  citric  acid,  but 
this  is  a  mistake,  as  all  of  the  vegetable  acids,  when  ingested,  are  eliminated 
as  alkaline  carbonates. 

The  second  indication  is  to  medicate  the  inflamed  surface.  Two  ways 
suggest  themselves: 

1.  By  the  internal  administration  of  drugs. 

2.  By  the  injection  of  medicated  liquids  into  the  bladder. 

To  carry  out  the  first  method,  an  anormous  number  of  infusions,  decoc- 


772  DISEASES  OF  THE  URINARY  ORG  ASS 

tions,  and  fluid  extracts  of  vegetable  substances  have  been  suggested,  the 
vast  majority  of  which  are  absolutely  useless,  except  as  they  serve  by  their 
quantity  to  act  as  diluents.  Among  the  best  known  of  these  are  buchu, 
pareira  brava,  uva  ursi,  and  triticum  repens. 

The  remedies  heretofore  most  efficient  in  cystitis  through  their  internal 
administration  are  the  balsams.  Sandalwood  oil  is  easily  borne,  and 
is  also  an  efficient  remedy.  It  is  best  administered  in  capsvdes  containing 
lo  minims  (0.6  gm.).  They  can  be  given  on  an  empty  stomach  before 
meals.  It  is  desirable  to  impregnate  the  blood  and  to  impart  a  balsamic 
odor  to  the  tunne.  This  is  scarcely  possible  wdth  less  than  eight  capsules  a 
day — two  before  each  meal  and  two  at  bedtime.  They  should  be  followed 
by  a  little  milk  rather  than  water. 

A  valuable  addition  to  drugs  usefiil  in  the  treatment  of  cystitis  is 
hexamethylenamin,  and  it  is  most  efficient.  It  is  most  indicated  in  subacute 
and  chronic  stages.  The  dose  is  5  to  7  1/2  grains  (0.33  to  0.5  gm.)  in  a 
capsule  three  to  five  times  a  day.  It  is  not  always  superior  to  sandalwood. 
Occasionally  this  balsam  is  more  efficient. 

Both  boric  acid  and  benzoic  acid  are  useful  adjuvants  to  the  treatment 
of  chronic  cystitis  through  their  antiseptic  effect  on  the  urine,  each  in  5 
grain  (0.32  gm.)  doses,  rapidly  increased  to  10  grains  (0.65  gm.).  They 
may  be  given  jointly,  as  in  the  following  prescription: 

R     Sodii  biborat.,    1  1    i^,         \ 

Ac.  benzoic,       /  gr.  x  (0.65  gm.) 

Infus.  buchu,  f  S  ij  (60  c.c). 
Three  times  a  day. 

Resorcin  in  3  to  5  grain  (0.198  to  0.33  gm.)  doses  and  naphthalin  in  2 
grain  (0.13  gm.)  doses  are  recommended  for  the  same  purpose.  Salol  is 
a  popular  remedy,  very  large  doses  being  ad\'ised — from  15  to  30  grains 
(i  to  2  gm.)  every  three  hours. 

The  apph cation  of  remedies  to  the  bladder  by  injections  is  best  con- 
sidered in  connection  with  the  third  indication — the  getting  rid  of  inflam- 
matory products,  the  pus  and  mucus,  and  the  matters  resulting  from  their 
decomposition.  The  latter  are  not  alwaj's  present,  but  all  who  have  had 
much  experience  wdth  cystitis  are  familiar  with  the  tenacious,  glair>', 
mucoid  matter,  which  will  not  drop  or  rise  up  in  a  pipet,  gHstening  with 
large  crj'stals  of  triple  phosphate,  and  exhaling  a  stinking,  ammoniacal 
odor  which  quickly  contaminates  an  entire  apartment.  There  is  only 
one  way  to  get  rid  of  this,  and  that  is  to  wash  out  the  bladder,  and  often 
this  is  too  long  deferred.  Tepid  water  should  be  used  first,  and  the  injection 
made  through  the  soft,  flexible  catheter.  Four  ounces  vaax  be  used  vnth. 
entire  safety.  After  the  capacity  of  the  bladder  has  been  determined, 
even  more  may  be  thrown  in,  because  it  is  sometimes  useful  to  distend 
the  viscus  a  little,  in  order  to  reach  the  depressions  and  inequalities 
always  present  in  advanced  inflammations.  These  simple  injections, 
]:)ractised  once  a  day,  or  in  severe  cases  twice  a  day,  often  result  most 
happily.  After  a  few  injections  with  plain  water  some  medications  may 
be  added.  Salicylate  of  sodium,  in  the  proportion  of  a  dram  (4  gm.)  to 
the  pint  (1/2  liter),  is  one  of  the  best.  Its  disinfecting  qualities  are  ^XD.- 
doubted.     Boric  acid,  in  the  proportion  of  a  dram  (4  gm.)  to  the  pint  (1/2 


CHRONIC  CYSTITIS  773 

liter),  is  also  very  satisfactory.  Sir  Henry  Thompson's  soothing  lotion — 
of  biborate  of  sodium  an  ounce  (30  gm.),  glycerin  2  ounces  (60  c.c), 
water  2  ounces  (60  c.c.)  and  of  this  mixture  1/2  ounce  (15  c.c.)  to  4  ounces 
(120  c.c.)  of  tepid  water — may  also  be  used. 

At  the  University  Hospital  to-day  the  emulsion  of  silver  iodide  has 
largely  replaced  the  nitrate  of  silver.  The  bladder  is  first  irrigated  by  a  five 
per  cent,  boric  acid  solution.  Two  ounces  (60  c.c.)  of  five  per  cent,  emulsion 
of  iodid  of  silver  are  then  introduced  into  the  bladder  by  a  glass  catheter 
and  allowed  to  remain  as  long  as  the  patient  can  hold  it.  The  injection  is 
made  at  first  twice  daily.  If  the  patient  is  made  more  comfortable  it  is 
applied  daily;  later  as  improvement  progresses  every  other  day  followed 
by  increasing  interval.  Salt  solutions  may  be  used  on  intervening  days. 
The  bladder,  if  previously  washed  out  by  boric  acid  solution,  should  be 
irrigated  with  plain  warm  sterilized  water  in  order  to  avoid  chemical 
reaction  between  the  iodide  of  silver  and  the  boric  acid. 

Alum  is  an  astringent  which  has  been  too  often  overlooked  of  late  in 
suppurating  processes  in  mucous  membranes,  and  may  be  substituted  for 
the  salicylate  vnXh.  advantage  when  the  pus  does  not  disappear  so  rapidly 
as  is  desired.  It  should  be  more  cautiously  used  than  the  salicylate  of 
sodium.  Sufificient  of  the  powdered  alum  should  be  first  added  to  a  pint  of 
water  to  give  it  a  distinctly  astringent  taste,  when  the  bladder  should  be 
washed  out  as  described,  while  a  small  quantity  may  be  allowed  to  remain 
after  the  last  injection. 

When  there  is  a  foul  odor  present,  the  bichlorid  of  mercury  may  be  used 
in  exceedingly  dilute -solution — not  more  than  i  to  25,000  at  first — gradually 
increasing  the  strength  if  it  is  well  borne.  Carbolic  acid  may  also  be  used 
in  weak  solution — 1/4  to  1/2  per  cent. — also  peroxid  of  hydrogen,  one  part 
to  four  or  five  of  water.  Among  other  remedies  recommended  for  use  in 
the  same  way  are  acetate  of  lead,  i  grain  (0.06  gm.)  to  4  ounces  (120  c.c); 
dilute  nitric  acid,  i  or  2  minims  (0.06  or  0.12  c.c.)  to  the  ounce  (30  c.c). 

Anodj'nes  are  indispensable  in  many  cases  of  cystitis  to  relieve  the 
patient  of  extreme  pain  and  of  the  frequent  desire  to  pass  water,  which  are 
the  result  of  the  same  cause.  Opium  and  its  alkaloids  are  the  most  efficient, 
and  they  are  best  introduced  by  the  rectum.  There  appears  to  be  no 
absorbing  power  in  the  bladder  for  opium;  and  there  is  no  use  in  attempting 
to  administer  anodynes  by  that  channel.  Cocain,  from  which  so  much 
might  reasonably  be  expected,  is  disappointing,  its  effects  are  fleeting 
though  it  should  not  be  overlooked,  that  it  may  produce  some  of  the  symp- 
toms of  cocain  poisoning.  To  avoid  this  not  more  than  2  grains  (0.13 
gm.)  of  cocain  should  be  put  into  the  bladder  at  one  time. 

The  urethra  can  be  cocainized.  For  catheterizing,  a  four  per  cent, 
solution  may  be  injected  into  the  urethra,  allowing  two  or  three  minutes  to 
elapse  before  the  catheter  is  introduced.  ■  Then,  through  the  soft  catheter 
itself,  a  few  drops  of  this  solution  may  be  injected  in  advance  of  the  catheter, 
which  is  again  pushed  a  little  further;  then  a  few  more  drops  are  instilled, 
the  catheter  is  introduced  a  little  further,  and  so  on  until  the  instrument 
enters  the  bladder.  This  is  not  always  a  safe  procedure.  Serious  s^'mp- 
toms  of  cocaine  poisoning  can  occur. 

When  there  is  greatly  enlarged  prostate,  catheterization  is  indispensable, 


774  DISEASES  OF  THE  URINARY  ORCAXS 

and  is  often  attended  with  the  most  happy  results.  It  is  often  too  long 
deferred  because  of  the  natural  repugnance  to  the  use  of  the  instrument. 
The  greatest  precautions  should  be  taken  to  cleanse  the  catheter  after  its 
use,  in  order  to  avoid  sepsis.  The  catheter  should  be  thoroughly  boiled 
after  and  before  its  use. 

A  surgeon  should  be  consulted  in  all  cases  of  severitj-.  Catheter  life 
is  distressing  and  short.  In  proper  cases,  prostatectomy  is  the  only  proper 
course  to  follow. 

vSTONE  IN  THE  BLADDER. 

All  that  has  been  said  in  a  general  way  of  stone  formation  and  the  treat- 
ment of  its  tendency  when  treating  of  nephrohthiasis  ma}-  be  applied  to 
stone  in  the  bladder. 

Symptoms. — The  symptoms  of  stone  in  the  bladder  are  practically 
those  of  cystitis,  already  described,  aggravated  by  motion,  especially  riding 
over  rough  roads.  As  further  distinctive  of  stone  in  the  bladder  may  be 
mentioned  pain  at  the  end  of  the  penis  immediately  after  micturition.  The 
only  proof,  however,  of  the  presence  of  stone  is  its  recognition  by  the  soimd 
or  X-raj'  which  sould  be  uSed  in  ever>'  case  of  cystitis. 

Treatment. — For  removal  of  stone  in  the  bladder  medicinal  treatment 
is  valueless,  and  operative  treatment  is  imperative. 

NEUROSES  OF  THE  BLADDER. 
Paralysis  of  Bladder. 

If  the  spinal  cord  is  cut  above  the  lumbar  enlargement,  volimtary  power 
to  aid  or  suspend  the  action  of  the  sphincter  is  lost,  the  bladder  is  given 
over  to  the  lumbar  cord  as  a  pure  reflex  center.  The  urine  accumulates  as 
long  as  the  action  of  the  sphincter  prevails,  but  as  soon  as  a  sufficient 
amount  accumulates  to  stimulate  the  extrusor,  the  bladder  is  emptied  more 
or  less  completely.  Thus  is  produced  one  of  the  forms  of  incontinence,  as 
when  there  is  extensive  lesion  of  the  cord  above  the  lumbar  region. 

If,  on  the  other  hand,  there  is  paralysis  of  the  detrusor  muscle  and  the 
sphincter  remain  intact,  there  wiU  be  retention  of  urine.  If,  however, 
commimication  with  the  brain  remains  intact,  by  an  act  of  the  ■will  the  reflex 
contraction  of  the  sphincter  may  be  suspended  and  the  bladder  partially 
emptied  by  a  straining  effort,  at  least  so  far  as  pressure  can  be  exerted 
by  the  abdominal  rmiscles.  Should  the  afferent  or  sensorj-  nerves  of 
the  reflex  arc  be  paralyzed  either  alone  or  in  conjunction  ^ath  the  efferent 
to  the  detrusor,  the  bladder  will  become  enormously  distended;  but  if  the 
distention  continue,  a  point  is  reached  when  the  sphincter  is  paralyzed  by 
overstretching,  when  incontinence  occurs  and  the  tuine  dribbles  away. 
There  is  the  same  effect  if  there  be  destruction  of  the  cord  at  its  lumbar 
enlargement.  So  long  as  the  cord  is  intact  the  patient  may  partially 
empty  the  bladder  by  abdominal  pressiue.  Again,  if  paralysis  of  the  sphinc- 
ter vesicce  occurs,  incontinence  succeeds  as  soon  as  urine  has  accumvilated 
sufficiently  to  overcome  the  elastic  closure  of  the  bladder  orifice.  It  may 
also  be  slightly  dela>-ed  by  voluntan-  innervation  of  the  sphincter,  but  is 


CYSTOSPHASM  775 

unrestrained  during  sleep.  Hence  at  such  time  the  patient  wets  the  bed. 
Such  incontinence  is  also  manifested  when  the  patient  coughs  or  when  in 
any  way  sudden  pressure  is  brought  to  bear  on  the  bladder.  It  is  often  seen 
in  women  who  are  said  to  have  "weak"  bladders.  Combined  detnisor 
and  sphincter  paralysis  is  followed  by  dribbling  away  of  urine  as  soon  as 
enough  accumulates  to  overcome  the  elastic  closure  of  the  urethra,  because 
there  is  no  contraction  of  the  bladder,  and  the  outflow  is  a  mere  overflow. 

Muscular  Spasm  of  the  Bladder— Cystospasm. 

Symptoms. — In  detrusor  spasm  sudden  evacuation  of  the  bladder  takes 
place.  This  occurs  in  hyperirritabiUty  of  the  mucous  membrane  of  the 
bladder  or  of  the  reflex  center  in  the  cord  as  soon  as  a  small  amount  of  urine 
accumulates  in  the  bladder.  It  may  be  controlled  to  a  degree  by  a  voluntarj^ 
impulse  to  the  sphincter,  but  at  other  times  it  is  irresistible,  and  is  especially 
prone  to  occur  during  sleep.  To  this  class  of  cases  belong  many  of  the 
instances  of  incontinence  in  children. 

In  spasm  of  the  sphincter,  on  the  other  hand,  the  orifice  is  kept  forcibly 
closed,  though  this  clostrre,  too,  may  be  intermitted  by  action  of  the  will, 
permitting  thus  a  smaU  quantity  of  urine  to  be  discharged  at  a  time.  As 
the  tirine  accumulates  the  discomfort  increases  still  further,  when  an 
attempt  is  often  made  to  empty  the  bladder  by  straining  efforts.  This 
sometimes  reacts  on  the  sphincter,  producing  further  contraction,  which 
may  extend  to  the  bulbo--urethral  and  sphincter  ani  muscles,  causing  pain- 
ful spasm.  Such  spasm,  too,  forcibly  resists  the  introduction  of  a  catheter. 
It  may  be  due  to  hyperexcitabilit}^  of  the  sensory  reflex  center  or  to  irri- 
tation directly  in  the  neighborhood  of  the  sphincter,  such  as  intense 
inflammation. 

A  combination  of  spasm  of  the  detrusor  and  sphincter  muscles  may  exist, 
giving  rise  in  high  degrees  to  intense  suffering.  It  may  be  caused  by  a 
simultaneous  irritation  of  the  two  reflex  centers  in  the  cord  or  by  intense 
irritation  of  the  mucous  membrane  of  the  bladder  reflected  to  both  sets  of 
muscles. 

In  addition  to  the  nervous  affections,  chiefly  of  the  cord,  which  may 
occasion  these  symptoms,  modifications  in  the  sensibility  of  the  mucous 
membrane  of  the  bladder,  of  the  deeper  urethra  and  prostate  may  also 
occasion  them.  These  changes  may  be  purely  neurotic.  R.  Ulzmann  has 
refined  the  subject  of  neuroses  of  the  genito-urinary  system  to  a  high  degree, 
referring  many  symptoms  of  the  kind  described  to  an  "exalted  reflex  excit- 
ability" caused  by  "overstrained  physical,  but  especially  by  exciting  mental 
activity,"  long  kept  up.  Among  these  he  mentions  fright,  pain,  grief,  loss 
of  property,  and  the  like,  as  well  as  the  "gonorrheal  process,"  excess  in 
venery,  and  masturbation,  apart  from  the  organic  processes  of  hyperemia, 
and  even  inflammation,  which  may  be  due  to  gonorrhea.  The  pure  neurotic 
representatives  of  this  class  are  imattended  with  changes  in  the  urine,  which 
is  normal  in  every  particular.  These  are  not  very  uncommon,  and  they  are 
often  extremely  difficult  to  treat  successfully. 

A  comparatively  frequent  representative  of  this  class  is  due  to  a  hyper- 
esthesia of  the  vesical  mucous  membrane,  as  the  result  of  which  the  presence 


776  DISEASES  OF  TUE  URIXARY  ORGANS 

of  the  smallest  quantity  of  urine  gives  rise  to  a  pressing  desire  to  empty  the 
bladder,  which  is  accomplished  with  spasm,  pain,  or  other  discomfort. 
As  the  result  of  this  the  patient  must  empty  his  bladder  often — several  times 
an  hour,  but  much  less  frequently,  if  at  all,  at  night.  The  urine  is,  as  a  rule, 
normal,  and  though  sometimes  concentrated,  with  a  proportionate  specific 
gravity,  is  still  no  more  so  than  that  which  is  commonly  retained  with  per- 
fect comfort.     This  occurs  also  sometimes  in  women. 

Occasionally  there  is  absolute  loss  of  sensation  in  the  vesical  mucous 
membrane,  apparently  also  functional,  in  consequence  of  which  the  tirine 
accumulates  without  exciting  the  attention  of  the  patient,  and  the  bladder 
becomes  thus  overdistended. 

Treatment. — Of  Incontinence  or  Enuresis. — Previous  to  instituting 
treatment  for  these  conditions  the  most  careful  inquiry  must  be  made  as  to 
the  cause,  and  its  removal  sought.  This  is  often  impossible,  and  treatment 
must  then  be  empirical. 

Incontinence  most  frequently  calls  for  treatment.  If  due  to  disease 
of  the  cord,  it  is  amenable  to  treatment  so  far  as  such  disease  is,  and  in  the 
meantime  the  patient  must  be  protected  by  catheterization  from  the  over- 
distention  which  is  so  apt  to  precede  incontinence.  Incontinence  due  to 
weak  sphincters  demands  that  this  weakness  should  be  treated  by  fuU  doses 
of  strychnin,  which  may  be  advantageously  given  in  gradually  ascending 
doses.  Tincture  of  nux  vomica  may  be  substituted  in  ascending  doses  tmtil 
IS  minim  (i  c.c.)  doses  or  more  are  attained.  Electricity  has  been  highly 
commended  for  this  form  of  incontinence,  in  the  shape  of  faradization,  one 
pole  being  applied  to  the  lumbar  part  of  the  spine  and  the  other  in  the  ure- 
thra, in  the  vagina,  or  to  the  perineum,  the  sittings  being  continued  for  a 
few  minutes  each  day  or  every  other  day.  Cold  douches  to  the  perineum 
are  also  useful. 

If  incontinence  is  due  to  hyperesthesia  of  the  mucous  membrane  or  to 
irritability  of  the  bladder,  belladonna  is  the  accepted  remedy.  It  should 
be  given  in  ascending  doses,  and  toward  evening  if  it  be  nocturnal  incon- 
tinence, so  common  in  children.  The  physiological  effect  of  the  belladonna 
shoidd  be  produced.  The  bromids  may  be  combined  with  it  or  used  sepa- 
rately. If  there  is  irritabiUty  of  the  lumbar  cord,  ergot  commends  itself 
through  its  effect  of  diminishing  congestion  of  the  cord.  The  virine  should 
receive  attention,  since  a  high  degree  of  acidity  or  the  presence  of  sediments 
of  wric  acid  and  of  oxalate  of  lime  may  become  the  exciting  causes  of 
incontinence. 

Incontinence  in  children  (which  is  the  most  frequent  variety  met  in 
practice)  is  a  source  of  great  annoyance,  but  in  the  majority  of  cases  it 
subsides  spontaneously  not  later  than  the  12th  year.  In  its  treatment  in 
addition  to  the  measures  suggested,  close  investigation  should  be  made  for 
causes  which  should  be  removed.  Masturbation  especially  in  asylums  and 
institutions  is  apt  to  be  a  cause  of  incontinence  and  should  be  carefully 
inquired  after. 

Habit  is  sometimes  a  cause  of  incontinence  in  children,  and  encourage- 
ment of  a  cautious  ]3ractice  of  holding  the  water  may  gradually  correct  the 
evil.  Children  should  not  be  punished  for  incontinence,  as  the  ner^^ous 
apprehension  excited  only  serv'es  to  make  matters  worse.     General  ill- 


HEMORRHOIDAL  OF  THE  BLADDER  111 

health  and  irregular  habits  are  sometimes  responsible,  and  when  these  are 
corrected  the  patient  recovers.  Phimosis  is  sometimes  a  cause,  and  should 
be  corrected  if  present.  Indeed  circumcision  is  sometimes  a  cure  even  when 
phimosis  is  not  present. 

Of  Hetention. — An  overfull  bladder  should  alwaj's  be  relieved  by  the 
catheter,  and  catheterization  should  be  repeated  as  often  as  necessarj'  to 
prevent  recurring  distention  while  the  cause  is  being  treated.  When  the 
retention  is  due  to  weakness  of  the  detrusor  muscle,  strj'chnin  wiU  be  of 
service.  Electricity  may  also  be  used — one  pole  being  placed  behind  the 
pubes  and  the  other  applied  to  the  lumbar  region. 

If  retention  is  due  to  spasm,  the  cause  should  be  carefully  sought.  The 
same  irritations  referred  to  as  causes  of  incontinence  may  produce  spasm, 
and  some  of  the  same  remedies  are  useful  to  relieve  it,  as  belladonna  and  the 
bromids.  Warm  sitz-baths  and  full  baths  and  enemas  of  warm  water  mav 
be  used  at  a  temperature  of  95°  F.  (35°  C.)  two  or  three  times  a  day.  In  the 
event  of  failure  with  these  measures,  more  powerful  anodj^nes  may  be  used, 
including  opium  and  morphin.  These  are  best  administered  in  the  shape  of 
a  suppository  containing  from  1/2  grain  to  i  grain  (0.033  to  0.0066  gm.)  of 
extract  of  opium,  and  1/4  grain  (0.0165  g™-)  of  morphin.  Ultzmann 
recommends,  in  cases  of"  frequent  micturition  due  to  hyperesthesia  of  the 
prostate,  injections  through  the  prostatic  urethra  by  a  catheter  which  just 
reaches  the  membranous  portion  of  the  urethra.  The  solutions  used  are  a 
1/4  to  1/2  per  cent  of  carbolic  acid  and  a  1/2  per  cent,  solution  of  sulphate 
of  zinc,  increasing  the  strength  as  it  is  borne  to  three,  four,  and  five  per 
cent.  These  should  be  used  once  a  day  with  a  syringe  holding  4  ounces 
(100  gm.),  and  the  whole  quantity  should  be  thrown  into  the  bladder  in  the 
manner  prescribed. 

Other  forms  of  spasm  must  also  be  treated  by  sedatives,  and,  strange  as 
it  may  seem,  the  passage  of  a  sound  will  sometimes  reHeve  such  spasms. 

Unfortunately,  the  causes  of  either  of  these  conditions  cannot  always 
be  ascertained,  and  a  cure  must  be  secured  by  passing  from  one  remedy  to 
another  until  the  correct  one  is  arrived  at. 

HEMORRHOIDAL  VEINS  OF  THE  BLADDER. 

Excluding  all  other  causes  of  hemorrhage  of  the  bladder  heretofore 
considered,  such  as  villous  cancer,  stone,  and  tuberculosis,  there  remains 
a  cause  of  hemorrhage  which,  by  exclusion,  resolves  itself  into  a  hemor- 
rhoidal state  of  the  veins.  Its  subjects  are  only  older  persons,  rarely  under 
60;  it  is  rather  copious  and  yet  rarely  fatal — in  our  experience  never  so — 
though  fatal  cases  are  reported. 

Great  care  should  be  taken  in  the  study  of  cases  of  this  kind  in  order  to 
make  sure  that  the  hemorrhage  is  not  due  to  the  more  serious  causes  aheadv 
considered,  otherwise  a  grave  mistake  in  prognosis,  as  well  as  in  diagnosis, 
may  occur.  The  bladder  should  be  carefully  explored  by  the  sound,  and 
if  necessary,  by  the  endoscope. 

Treatment. — Hemorrhages  from  this  source  may  occur  and  not  be 
repeated,  and  it  is  this  favorable  termination,  in  the  absence  of  stone  or 
maUgnant  disease,  on  which  we  are  sometimes  unfortunately  compelled  to 


778  DISEASES  OF  THE  URINARY  ORGANS 

rely  for  the  diagnosis.  Should  the  hemorrhage  continue,  astringent  solu- 
tions— 1/2  per  cent,  and  upward  of  aliun  and  sulphate  of  zinc — may  be 
injected  into  the  bladder,  always  using  the  soft  catheter.  Absolute  rest  in 
bed  should  be  insisted  upon..  At  the  same  time,  the  astringent  drugs  and 
mineral  waters  recommended  under  the  treatment  of  hematuria  may  be 
tried,  but  it  is  hardly  to  be  expected  that  astringent  effects  can  be  produced 
in  the  bladder  through  the  route  of  the  circulation  by  medicines  administered 
by  the  mouth.  Turpentine  in  emulsion  thus  administered  has  appeared  to 
me  to  be  decidedly  efficient  in  controlling  these  hemorrhages. 

MORBID  GROWTHS  OF  THE  BLADDER. 

The  bladder  is  subject  to  myoma,  myxoma,  sarcoma,  and  carcinoma, 
especially  the  variety  known  as  villous  or  papilloma;  also  to  tuberculosis. 
Carcinoma  may  be  primary,  but  is  commonly'  secondary-.  The  simplest 
histoid  tumors  are  not  clinically  recognizable,  one  from  the  other. 

Symptoms. — Carcinoma  of  the  bladder  may  be  suspected  if,  in  addition 
to  the  usual  symptoms  of  cystitis,  hemorrhage  is  copious  and  persistent,  if 
there  is  carcinoma  elsewhere,  and  if  there  is  rapidly-developed  cachexia,  and 
especially  if  there  are  other  signs  of  secondary  cancer  in  the  vicinity.  Occa- 
sionally villi  of  the  papillomatous  growth  are  passed  in  urine  and  easity 
recognized.  The  only  certain  means  of  diagnosis  is  in  the  cystoscope  which, 
in  the  hands  of  a  skillful  manipulator,  affords  valuable  assistance. 

The  symptoms  of  tuberculosis  of  the  bladder  are  those  of  cystitis,  and 
the  recognition  of  the  bacillus  of  tuberculosis,  or  better,  a  guinea-pig  test, 
affords  the  only  sure  means  of  differential  diagnosis  between  it  and  other 
forms  of  inflammation  of  the  bladder. 

Treatment. — If  the  diagnosis  of  villous  cancer  can  be  made  early,  the 
life  of  the  patient  may  be  prolonged  by  surgical  procedures.  The  pallia- 
tive treatment  is  that  of  cystitis.  At  the  same  time  the  counsel  of  a  surgeon 
should  be  promptly  sought. 

The  local  treatment  of  tuberculosis  of  the  bladder  is  that  of  cystitis. 
It  demands  the  same  general  treatment  as  tuberculosis  occurring  elsewhere. 


SECTION  VIII. 

DISEASES  OF  DERANGED  METABOLISM 
(CONSTITUTIONAL  DISEASES). 

MYALGIA. 

Synonyms . — Myositis;  Fibrositis. 

Definition. — A  painful  condition  of  voluntary  muscles  and  their  ap- 
oneurotic coverings,  especially  aggravated  by  motion  and  pressure.  It 
affects  especially  large  muscles,  such  as  those  of  the  neck,  the  shoulders,  the 
arms,  the  back,  the  thighs,  and  the  calves  of  the  legs,  and  the  intercostal 
muscles. 

Etiology  and  Pathology. — Exposure  to  cold,  damp  and  wet,  and  espe- 
cially to  drafts  of  cool  air,  as  from  an  open  door  or  window,  is  the  most 
frequent  cause.  Any  one  of  a  number  of  poisons  is  capable  of  acting  as  an 
irritant  to  peripheral  nerves  whose  irritation  constitutes  muscular  rheuma- 
tism or  myalgia.  Such  are  the  metallic  poisons  as  lead  and  arsenic,  alcohol, 
certain  drugs,  the  poisons  of  the  infectious  diseases  and  of  other  diseases 
associated  with  deranged  metabolism  as  diabetes  and  gout.  Barometric 
changes  with  or  without  the  approach  of  rain  may  increase  the  severity  of 
the  pain,  more  particularly  in  the  chronic  variety. 

Its  true  nature  is  uiiknown,  and  whether  it  is  an  affection  of  muscular 
substance  or  of  the  intermuscular  connective  tissue  is  also  unknown.  From 
the  supposed  r61e  played  by  the  latter,  the  term  "fibrositis"  has  been 
suggested.^  Certain  forms  of  myalgia,  especially  that  of  the  back,  are 
ascribed  to  gout.  An  infectious  origin  has  been  suggested.  It  is  sometimes 
associated  with  articular  rheumatism.  Similar  pain  often  succeeds  muscular 
strain. 

The  division  of  myalgia  into  acute  and  chronic  is  not  based  on  any  essen- 
tial difference  but  rather  upon  the  duration  of  the  pain  and  upon  its  disposi- 
tion to  recurrence.  The  term  chronic  is  justified  by  those  forms  which 
recur  with  changes  in  the  weather,  and  are  either  excited  or  reUeved  by  them. 
It,  too,  is  less  localized  than  the  acute.  On  the  other  hand,  it  is  not  inaptly 
at  times  called  wandering.  It  is  more  common  in  men  than  in  women, 
because  of  their  more  frequent  exposure  to  its  causes. 

Symptoms. — The  only  invariable  symptom  is  pain,  aggravated  by  motion 
or  pressure.  Sometimes  there  is  swelling.  It  is  usually  rather  sudden  in  its 
onset,  requiring  at  most  but  a  few  hours,  and  often  less,  to  develop  it.  It 
is  never  accompanied  by  marked  constitutional  disturbance.  The  pulse 
may  be  somewhat  accelerated,  and  the  temperature  may  approach  ioo°  F. 
(37.8°  C),  but  more  often  there  is  no  fever  at  all. 

1  For  an  excellent  paper  by  Arthur  P.  Luff,  enlarging  these  views,  see  "Clinical  Journal,"  Oct,  11,  1905. 
'Forms  of  The  Diagnosis  and  Treatment  of  Some  of  the  So-called  Rheumatism." 

779 


780  CONSTirUTIOXAL  DISEASES 

Myalgia  is  especially  named  according  as  it  involves  S])ecial  muscles. 
Thus,  lumbago  is  a  painful  affection  of  the  lumbar  muscles  and  their  tendin- 
ous attachments.     The  attacks  come  on  under  the  conditions  already  named. 

Rheumatic  sti^  neck  or  torticollis  (as  contrasted  vnth  congenital  and 
spasmodic  torticollis)  is  an  affection  of  the  side  and  back  of  the  neck, 
forcing  the  patient  to  hold  his  neck  to  one  side  as  the  situation  of  least 
discomfort,  and  when  he  desires  to  turn  his  head  he  is  forced  to  turn 
the  whole  body.  If  the  spasm  is  in  the  trapezius  the  back  of  the  head 
is  drawn  down  toward  the  affected  side.  If  the  sterno-mastoid  is  affected, 
the  chin  is  tilted  and  drawn  away  from  the  affected  side.  It  is  more  fre- 
quently met  in  children  and  young  adults. 

Omalgia  is  a  similar  condition  of  the  muscles  of  the  shoulder  and  upper 
arm,  making  motion  exquisitely  painfid.  Ankylosis  of  the  shoulder  joint 
may.  be  caused  by  delayed  motion.  Pleurodynia  affects  the  intercostal 
muscles  and  makes  breathing  and  coughing  ven.'  painful,  while  a  deep  breath 
becomes  impossible  and  sneezing  an  agony.  The  pectoral  and  serratus 
muscles  may  also  be  involved  when  the  pain  is  higher  up.  It  occurs  more 
frequently  on  the  left  side. 

Cephalodynia,  or  myalgia  of  the  muscles  of  the  scalp,  scapulodynia,  and 
dorsodynia  are  all  forms  of  muscular  rheumatism  which  explain  themselves. 
It  also  affects  the  abdominal  muscles,  and  a  most  intestesing  instance  of  this 
form  simulating  peritonitis  was  published  by  myself  in  the  "Philadelphia 
Medical  Times,"  volume  x.,  1880. 

The  duration  of  the  acute  form  is  brief,  seldom  lasting  for  more  than  a 
few  days,  though  there  may  be  a  tendency  to  relapse.  The  chronic  forms 
are  indefinite  in  duration. 

Diagnosis. — This  is  easy  for  the  coarser  acute  forms  of  omalgia,  stiff" 
neck,  and  lumbago.  Myalgia  may,  however,  be  confounded  vinth  neuritis. 
In  netiritis  there  is  pain  with  tenderness  more  localized  and  along  the 
course  of  large  nerve  trunks.  Myalgia  and  neuritis  are  distinctly  worse 
on  motion ;  neuralgia  less  so.  Myalgia  is  commonly'  relieved  by  the  warmth 
of  the  bed;  neuritis  may  be  aggravated  while  neui-algia  is  uninfluenced  by 
this  cause  and  increased  by  cold  winds.  Pleurodynia  is  sometimes  difficult 
to  distinguish  from  intercostal  neuralgia  but  attention  to  the  points  named 
will  prevent  mistakes.  Brachial  neuritis  resembles  omalgia,  but  the  for- 
mer is  early  followed  by  atrophy,  while  myalgia  is  not.  From  pleurisy, 
pleurodynia  is  easily  distinguished  by  the  absence  of  fever  and  of  physical 
signs.  The  lancinating  pains  of  Iccomotor  ataxia  and  the  pains  of  incipient 
disease  of  the  vertebra  resemble  at  first  those  of  lumbago,  but  the  special 
symptoms  of  these  diseases  are  soon  superadded.  Attacks  of  iliosacral 
luxation  are  constantly  mistaken  for  lumbago,  and  can  be  dift"erentiated 
by  the  sudden  onset  of  pain  while  performing  some  indift'erent  motion  like 
stooping.  The  pain  is  freuqently  so  severe  that  the  patient  is  unable  to 
move  about  and  almost  immediate  relief  is  given  by  strapping  or  bandaging 
the  Uiosacral  joint. 

Treatment. — The  acute  form  of  myalgia  is  occasionally  amenable  to 
treatment  by  the  salicylates  and  salicin.  Some  phenomenallj'  good  results 
sometimes  foUow  the  use  of  these  remedies.  They  are,  however,  incon- 
staiit,  and  if,  after  a  fair  trial,  such  residts  are  not  promptly  attained,  the 


PULMONARY  ARTHROPATHY  781 

drugs  should  be  omitted.  If  efficient,  the  same  rules  as  to  their  continued 
use  in  reduced  doses  after  relief  has  been  obtained  apply  as  in  acute  ar- 
ticular rheumatism.  The  group  of  muscles  treated  must  be  placed  at 
absolute  rest,  and  in  the  case  of  the  thorax  this  is  best  accomplished  by  strap- 
ping the  side  with  adhesive  plaster.  Rest  may,  however,  be  everdone,  in 
case  of  muscles  Hke  those  of  the  shovilder  in  which  atrophy  may  result  from 
too  prolonged  a  rest.  Another  measure  of  great  value  is  dry  heat,  applied 
by  means  of  a  hot-water  bag  covered  with  flannel,  or  by  a  warm  flat-iron. 
To  use  a  popular  expression,  a  myalgia  may  thus  be  sometimes  "ironed 
out."  A  flannel  cloth  should  be  interposed.  With  these  measures  may  also 
be  associated  massage.  Sometimes  a  single  efficient  treatment  by  massage 
is  enough  to  "rub  out"  such  a  myalgia.  Of  less  permanent  utihty  are  hot 
poultices,  although  they  allay  pain,  at  least.  The  same  effect  is  accom- 
plished by  moist  hot-air  or  vapor  (steam)  baths,  which,  by  special  appli- 
ances, can  be  localized. 

The  chronic  form  is  also  treated  by  massage,  passive  motion,  and 
electricity,  either  the  induced  or  direct  current.  Counterirritation  by 
liniments,  such  as  those  made  with  chloroform,  ammonia  hydrate,  or 
turpentine,  have  long  enjoyed  a  reputation,  but  at  the  present  day  it  is 
beginning  to  be  questioned  as  to  whether,  after  aU,  it  is  not  the  friction, 
rather  than  the  liniment  itself,  which  produces  the  good  effect.  Some 
efficiency  in  the  liniment  itself,  must  still  be  admitted,  and  I  would  advise 
its  use  as  determined  by  circumstances.  Hydrotherapy  is  more  likely  to 
be  useful,  and  here  the  warm  or  cold  pack  is  the  better  method  of  applica- 
tion. Dry-cupping  is  also  often  of  service.  SmaU  blisters  should  not  be 
forgotten. 

General  treatment  should  not  be  neglected:  cod-Hver  oil,  iron,  strych- 
nin, quinin,  and  good  food  are  necessarj^  measures  when  the  patient  is 
run  down.  Among  diseases  which  need  nutritious  food,  chronic  muscular 
rheumatism  is  preeminent. 

Joint  Affections  Simulating  Rheumatism. 

These  include  numerous  joint  inflammations  of  septic  origin,  such 
as  occur  in  septicemia,  scarlet  fever,  diphtheria,  and  the  like.  Excepting 
hypertrophic  pulmonary  arthropathy  and  arthritis  deformans,  they  have 
aU  been  appropriately  referred  to  when  treating  of  the  infectious  diseases. 

HYPERTROPHIC  PULMONARY  ARTHROPATHY. 

The  club  fingers  and  toes  of  chronic  pulmonary  and  cardiac  disease  were 
known  to  Hippocrates  from  whom  the  fingers  received  the  name  Hippocratic 
fingers;  but  it  was  not  until  1889  that  this  category  of  arthropathies  was 
enlarged  by  Bamberger  to  include  thickening  of  the  long  bones.  It  was 
fixrther  enlarged  the  next  year  by  Marie  whence  the  term  Marie's  syndrome- 
There  are  many  subvarieties  and  modifications  but  usually  there  is  symmet. 
trical  involvement  of  the  lower  ends  of  the  radius,  tdna  and  metacarpals, 
more  rarely  the  lower  end  of  the  humerus  and  of  the  tibia  and  fibula.  The 
fingers  are  often  involved  and  sometimes  the  fingers  of  one  hand  only. 


782  CONSTITUTIONAL  DISEASES 

There  is  no  actual  bone  change  fibroid  thickening  of  the  periosteum  and 
surrounding  capsular  tissue  in  which  also  the  blood-vessels  are  distended. 
The  iiltimate  cause  is  unknown.  It  has  been  ascribed  to  the  turgidity  of 
the  blood-vessels  mentioned  above;  again  to  toxins  causing  periostitis. 
Marie  favored  the  latter  cause. 

Symptoms. — Among  the  associated  conditions  are  tuberculosis,  bron- 
chiectasis empyema,  congenital  heart  disease,  hepatic  disease,  chronic 
nephritis  and  diarrhea.  The  symptoms  therefore  include  those  of  these 
diseases.  There  may  be  none  except  the  enlargement  which  may  be  so 
gradual  as  to  escape  notice.     Frequently  there  is  pain  and  tenderness. 

The  fully  developed  condition  is  easily  recognized,  and  typical  club 
fingers  once  seen  are  never  forgotten. 

There  is  no  efficient  treatment  and  the  condition  slowly  increases  but 
probably  does  not  shorten  life. 

ARTHRITIS  DEFORMANS. 

Synonyms. — Rheumatoid  Arthritis;  Osteoarthritis. 

Definition. — A  deforming  disease  of  the  joints,  distinct  from  gout  and 
rheumatism,  and  characterized  by  destructive  changes  in  the  synovial 
membranes,  cartilages,  and  bone,  periarticular  inflammations,  also  at  times 
by  atrophic  changes  in  the  bones. 

Etiology. — Although  in  the  clinical  features  of  its  incipiency  arthritis 
deformans  sometimes  closely  resembles  the  mild  form  of  acute  rheumatism, 
they  have  no  caiisal  relation.  Heredity,  however,  plays  a  likely,  if  not  an 
important,  r61e.  Females  are  much  more  Hable  to  the  disease  than  males, 
especially  sterile  women  and  those  who  have  had  uterine  or  ovarian  disease. 
A.  E.  Garrod  collected  500  cases,  of  which  411  were  females  and  only  89 
males.  It  is  a  disease  said  to  be  as  common  in  the  rich  as  in  the  poor. 
It  usually  begins  between  the  ages  of  20  and  30,  but  it  may  occur  in  children 
under  12  and  as  late  as  50.  In  Garrod's  500  cases  there  were  only  25  under 
20.  It  is  comparati^'ely  rare  in  negroes.  The  ending  of  the  menstrual 
period  m  women  is  a  favorite  time  for  its  incipiency.  The  disease  is 
probably  infectious  in  origin. 

Traumatism,  often  assigned,  by  the  subjects  of  the  disease  as  a  cause, 
has  commonly  no  weU-sustained  relation,  but  must  be  allowed  as  a  factor 
in  monarthritic  cases.  Exposure  and  cold  are  ruled  out  at  the  present  daj- 
as  exciting  causes,  yet  sometimes  it  seems  impossible  to  exclude  them. 
On  the  other  hand  autogenetic  toxic  agencies  such  as  arise  not  only  from 
errors  in  diet  but  also  from  ptosis  or  other  displacements  of  the  abdominal 
viscera  resvdting  in  the  undue  detention  of  food  and  consequent  fennentation 
and  putrefaction,  are  allowed  increasing  importance.  Gonorrheal  and 
tuberculous  microbes  are  among  those  causing  the  infection  types.  Cer- 
tainly, insufficient  food  seems  to  favor  the  disease.  Shock,  worr\% 
care,  and  grief  are  alleged  causes.  Most  cases  of  'chronic  rheimaatism" 
are  forms  of  this  disease. 

As  the  result  of  the  various  findings  in  etiology  and  morbid  anatomy 
there  has  arisen  a  disposition  to  make  two  or  three  different  types  of  the 


ARTHRITIS  DEFORMANS  783 

affection.  HofEa,  R.  L.  Jones  and  others  make  three  types  (i),  rheumatoid 
or  atrophic  arthritis  in  which  the  synovial  membranes  and  per'articular 
tissues  are  especially  involved;  (2),  osteo-arthritis  or  hypertrophic  arth- 
ritis in  which  the  cartilages  and  bones  are  the  primary  seats  of  invasion. 
The  third  type  is  based  on  etiological  distinctions  rather  than  anatomic 
and  is  scarcely  justified;  (3)  infective  arthritis.  Others  omit  the  third 
variety  or  type. 

Morbid  Anatomy. — All  three  of  the  structures  which  enter  into  the 
formation  of  the  joint  share  in  the  process,  the  changes  beginning  now  in 
the  synovial  and  periarticvilar  tissues  and  now  in  the  cartilages  and  bones 
probably.  The  active  changes  in  the  cartilages  consist  in  a  proliferation 
of  the  cartilage  cells,  succeeded  by  fibrillation  of  the  intercellular 
substance,  which  subsequently  undergoes  mucous  degeneration,  hque- 
faction,  and  absorption.  Thus,  the  bone  ends  are  laid  bare.  These  sub- 
sequently become  atrophied,  smooth,  and  ebumated.  The  bone  ends 
and  joint  cavities  are  aUke  distorted;  concavities  may  become  convexities, 
and  convexities  concavities.  The  edges  of  the  cartilages  where  overlapped 
by  synovial  membranes,  thicken  and  form  (hypertrophic)  outgrowths, 
which  subsequently  ossify  and  become  the  osteophytes  which  contribute 
to  the  deformity  of  the  bone,  sometimes  also  forming  rims  or  Ups.  The 
effect  of  the  latter  is  to  impair  motion  without  producing  actual  ankylosis, 
except  in  very  rare  instances,  which  may  include  even  vertebrae.  The 
synovial  membranes  also  become  thickened  and  the  fringes  hypertrophied. 
Effusion  is  sometimes  present  in  the  joints  and  in  the  bursas.  Fragments 
of  cartilage  may  be  attached  to  the  tufts,  or,  becoming  detached,  they  ma}^ 
lie  loose  in  the  joint.  Muscular  atrophy  also  makes  a  conspicuous  part 
of  the  morbid  changes. 

Symptoms. — If  the  joint  lesions  be  made  the  criterion  of  the  presence 
of  arthritis  deformans,  any  remaining  difference  in  symptoms  depends 
mainly  upon  the  grouping  and  extent  of  these  lesions.  Hence  it  is  more 
convenient  to  subdivide  them  into  clinical  varieties.  Two  such  are  easily 
made: 

1.  Multiple  arthritis  deformans  corresponding  to  the  rheumatoid  or 
atrophic  form  of  the  newer  classification  including  (a)  Heberden's  nodosities 
on  the  small  joints  and  (6)  the  progressive  form,  in  which  large  joints  are 
successively  invaded  in  an  acute  or  a  chronic  manner. 

2.  The  monarthritic  or  partial  form,  in  which  one  or  two  joints  are 
alone  attacked,  corresponding  to  the  osteo-arthritic  or  hypertrophic 
type  of  the  newer  classification. 

I.  Multiple  Arthritis  Deformans.     Rheumatic  or  Atrophic  Arthritis. 

(a)  Heberden's  Nodosities. — These  are  prominences  or  nodules 
which  develop  gradually  on  the  sides  and  ends  of  the  distal  phalanges, 
especially  of  the  fingers  and  sometimes  also  of  the  toes.  Women  are  the 
most  frequent  subjects,  and  the  development  begins  usually  between 
the  30th  and  40th  years,  and  gradually  increases  with  age,  but  varies  also 
at  times  and  seasons  independently  of  this  gradual  increase.  The  pain  and 
tenderness  also  vary,  being  usually  worse  when  the  hands  become  cold, 


784 


COXS  TI  r  U  TIONA  L  DISEA  SES 


and  especially  when  accidentally  struck.  At  other  times  they  are  insen- 
sitive. These  nodosities  have  no  relation  to  gout  and  are  especially 
contributed  by  the  laity  to  gout,  but  this  is  an  error.  They  are 
quite  independent  of  the  tophaceous  deposits  of  gout,  which  are  alto- 
gether absent  in  arthritis  deformans.  Persons  in  whom  they  are  per- 
manently present  rarely  have  the  large  joints  invaded,  and,  indeed,  are 
said  to  have  promise  of  long  life.  Subcutaneous  nodules,  are  also  found 
in  arthritis  deformans. 

(6)  The  Progressive  Form. — This  may  be  acute  or  chronic.  The 
acute  form  simulates  in  its  beginning  rheumatic  fever.  Among  children 
boys  are  more  frequently  attacked  than  girls.  There  are  swelUng  of  the 
joints,  tenderness,  and  fever.  These  may  continue  without  material 
change  for  weeks,  or  may  abate  to  recur  with  increased  severity;  on  the 
whole,  however,  growing  worse,  until  the  permanently  enlarged  and  distorted 
state  to  be  described  is  established. 


Fig.  130. — HcbcnlLii's  X'Mlo>ii !«.■>. 
From  a  photograph  of  the  hand  of  a  patient  of  the  author. 


In  the  chronic  form  the  same  changes  develop  more  slowly  and  with- 
out fever,  maintaining  with  remarkable  constancy  a  symmetrical  order 
of  development,  the  order  of  frequency  being  the  hands,  knees,  feet,  ankles, 
wrists,  elbows,  shotilders,  jaws,  cervical  spine,  hips,  and  dorsal  spine.  Strik- 
ing changes  are  seen  in  the  knees,  which  become  enlarged  and  so  fixed  that 
the  legs  are  constantly  flexed  on  the  thighs,  and  the  thighs  on  the  trunk. 
These  flexions  may  be  contributed  to  by  contractures,  which  may,  however, 
arise  secondarily,  subsequent  to  the  flexion,  or  form  pari  passu  with  it. 
They  are  seen  in  the  upper  extremity  as  well  as  in  the  lower,  producing  the 
' '  seal-fin ' '  deflection  at  the  wTist  and  a  rectangtilar  bend  at  the  elbow.  The 
actual  enlargement  is  exaggerated  in  appearance  because  of  wasting  of  the 
adjacent  muscles  and  thickening  of  the  capsular  ligament.  Its  stirface 
becomes  hard  and  shining.  There  may  also  be  some  effusion  in  the  joint, 
though  the  condition  has  been  called  by  the  French  arthrite  sbche.  Motion 
grows  more  and  more  difficult,  tmtil  the  joint  is  almost  locked,  and^ grating 


ARTERITIS  DEFORMANS  785 

and  crackling  attend  attempt  at  motion.  Pain  varies  greatly:  at  times  it 
is  very  severe,  at  others  it  is  quiescent,  but  it  is  always  excited  by  attempt 
at  motion.  Tingling,  numbness  of  the  hands  and  feet,  and  local  sweating 
and  skin  pigmentations  are  not  uncommon  among  the  early  symptoms, 
and  are  regarded  as  trophic  in  origin.  Day  by  day  the  patient  becomes 
more  helpless  and,  in  the  absence  of  fresh  air,  wan,  weary,  and  anemic. 
Fortunately,  in  many  cases  the  fingers  are  unencumbered,  and  the  patient 
may  be  able  to  occupy  himself  or  herself  in  some  handiwork,  such  occupation 
serving  to  make  more  bearable  a  life  of  virtual  imprisonment.  Weather 
has  its  influences;  diet  rarely.  The  condition  is  singularly  free  from  com- 
plications of  all  kinds. 

Spondylitis. — The  vertebral  form  is  usually  accompanied  by  changes  in 
other  joints.  It  is  constantly  mistaken  for  rheumatism,  sometimes  for 
tuberculosis,  the  entire  spinal  column  is  often  fixed  and  inflexible,  or  some- 
times only  two  or  three  if  the  intravertebral  joints  are  involved. 

Diagnosis. — This  is  rarely  difficult.  Arthritis  deformans  differs  wideh- 
from  gout  in  the  total  absence  of  tophaceous  deposits,  and  from  acute 
rheumatism  in  the  absence  of  fever,  though  in  the  incipiency  of  the  progres- 
sive multi-articular  form  there  is  a  certain  resemblance  to  acute  rheumatism. 
But  rheumatism  does  not  leave  behind  a  partly  injured  joint.  Gonorrheal 
arthritis  of  polyarticular  form  may  closely  resemble  the  disease,  but  the 
causative  factor  is  the  one  point  to  be  depended  upon. 

X-ray  examination  of  the  joints  showing  rarefaction  is  valuable.  Tuber- 
culosis of  the  joints  is  another  condition  constantly  mistaken  for  the  con- 
dition. The  atrophied  shoulder  of  omoneuritis  also  somewhat  resembles 
the  monarticular  form,  but  the  greater  tenderness  and  painfulness,  as  well 
as  acuteness,  of  this  affection  distinguish  it.  The  arthropathies  attending 
locomotor  ataxia  and  syringomyelia  are  distinguished  by  the  symptoms 
peculiar  to  them  and  by  the  absence  of  osteophytes. 

Treatment. — The  most  important  part  of  the  treatment  is  early  diag- 
nosis search  for  some  focus  of  infection;  in  the  sinus,  bladder,  urethra, 
intestine,  tonsils,  the  removal  of  obvious  foci  will  often  clear  up  a  case. 
The  usual  remedies  for  rheimiatism  are  of  little  avail.  Yet  treatment  is 
by  no  means  unavailing,  especially  if  instituted  early,  and  we  may  always 
hold  out  to  the  patient  the  hope  of  arrest  at  some  stage.  The  principle 
of  treatment  consists  in  efforts  to  improve  nutrition  by  means  of  good  food 
and  tonics,  of  which  cod-liver  oil,  iron,  iodin,  and  arsenic  are  the  most 
efficient.  A  systematic  course  of  these  remedies,  continuous,  except  so 
far  as  judicious  intermission  may  be  necessary,  will  sometimes  accomplish 
surprising  results  if  instituted  early  and  continued  perseveringly.  The 
iodid,  either  in  the  form  of  the  pill  or  syrup,  is  the  best  preparation  of  iron. 
A  grain  (0.066  gm.)  of  the  former  and  15  minims  (i  c.c.)  of  the  latter  are 
suitable  doses  three  times  a  day.  Massage  is,  perhaps,  the  single  measure 
calculated  to  be  of  most  use,  in  certain  cases  where  the  condition  is  confined 
to  free  contraction  tissues.  When  there  is  an  acute  condition  massage  is 
often  harmful.  Disappointing  as  the  treatment  often  isr  in  a  few  cases 
surprising  resvdts  may  be  obtained.  One  of  the  most  serious  drawbacks 
in  certain  cases  is  the  difficulty  in  securing  outdoor  life  and  the  advantage 
of  exercise.     One  of  the  objects  of  massage  must  be  to  substitute  the  latter. 


786  CONSTITUTIONAL  DISEASES 

while  every  possible  effort  should  be  made  to  have  the  patient  in  the  open 
air  as  much  as  possible,  and  when  his  means  will  permit  it,  to  take  advantage 
of  residence  in  warm  but  dry  climates.  It  is  verj'  important  to  avoid  the 
use  of  anodynes  altogether,  if  possible.  The  relief  afforded  by  them  is 
but  temporary,  they  militate  against  the  effort  at  securing  an  improved 
nutrition,  and,  above  all,  there  is  danger  of  forming  the  morphin  habit. 
Simple  support  by  splints  is  sometimes  a  comfort  to  patients.  The  treat- 
ment by  hydrotherapy,  as  carried  out  at  Aix-les-Bains  and  Aix-la-Chapelle 
in  Europe  undoubtedly  affords  temporary'  relief.  The  same  may  be  said 
of  the  treatment  at  the  Hot  Springs  of  Arkansas,  Virginia,  and  North 
Carolina  in  this  country,  and  at  St.  Catharine's  in  Canada.  While  gen- 
eral steam  baths  are  contraindicated  by  reason  of  their  debilitating  effect, 
local  vapor  baths  applied  to  separate  limbs  or  portions  of  limbs  by  a 
specially  constructed  apparatus  are  sometimes  useful. 

Much  was  expected  first  from  the  hot  dr>'-air  or  Tallerman-Shefiield 
treatment  of  this  disease.  Temporarily  it  does  produce  relief  of  pain, 
and  certain  writers  claim  permanent  benefits  have  been  secured. 

The  bowels  should  receive  close  attention,  the  body  should  be  fre- 
quently bathed,  preferably  in  warm  water,  and  all  measures  desirable 
to  secure  the  most  perfect  personal  hygiene  should  be  practised.  This 
is  another  of  the  few  diseases  where  an  abundance  of  good,  nourishing 
food  is  necessary.  This  is  the  more  important  when  we  remember  that 
many  cases  originate  among  the  poor  and  badly  fed.  These  persons 
may  take  meat  with  great  benefit.  Much  harm  is  occasionally  done  by 
putting  the  patients  on  a  limited  diet. 


OSTEITIS  DEFORMANS. 

Synonym. — Paget's  Disease. 

Definition. — A  chronic  nonsymmetrical  overgrowth  of  bones  resulting 
in  an  enlarged  head,  dorso-cer\'ical  kyphosis,  enlargement  of  the  clavicles, 
flaring  of  the  base  of  the  chest  and  outward  and  forward  bowing  of  the 
legs.  The  condition  was  first  described  by  Sir  James  Paget  in  1877,  whence 
the  name  Paget's  disease.  Packard  and  Steele'  collected  100  cases  up  to 
the  date  of  their  paper  in  1891  but  they  cut  out  34  as  lacking  essential 
conditions,  reducing  the  number  of  typical  cases  to  67.'  J.  Chalmers  Da  Costa 
has  added  two  not  yet  published  of  which  one  was  for  a  time  at  the  Hospital 
of  the  University  of  Pennsylvania.  Higbee  and  Ellis  estimate  the  total 
number  up  to  the  date  of  their  paper,  1911,  to  be  158  of  which  23  were  found 
in  this  country. - 

Its  etiology  is  unlvnown.  A  mother  and  daughter  are  known  to  have 
had  it.  Also  two  brothers.  It  is  more  common  in  males.  The  average 
age  of  the  cases  coming  under  the  obser\^ation  of  Packard  and  Steele  was 
61  but  it  may  start  at  21.  Its  subjects  are  generally  past  middle  Ufe.  Some 
have  ascribed  the  disease  to  syphilis,  others  to  arterio-sclerosis  or  per\'erted 
internal  secretion. 


OSTEOPSA  Til  VROSIS  787 

Symptoms — The  disease  may  begin  with  rheumatoid  symj^toms  in- 
cluding extreme  pain  worse  at  night  but  this  is  not  essential.  The  symp- 
toms are  chiefly  objective.  Attention  may  be  attracted  to  the  enlarged 
head  by  the  fact  that  the  hat  has  become  too  small,  or  the  patient's  friends 
remark  that  he  is  growing  shorter  and  that  his  legs  are  becoming  bowed. 
A  patient  of  Osier's  lost  13  inches  in  height.  Headache,  bronchitis  and 
pigmentation  of  the  skin  may  be  present.  The  skull,  spine  and  long 
bones  are  most  affected,  the  face,  hands  and  feet  less.  It  may  be  confined 
to  the  femurs.  In  one  variety  the  tibiae  and  fibuljE  were  alone  involved. 
The  process  is  a  thickening  by  new  formation  subperiosteal  and  myelogenous 
producing  a  fibro-osteoid  tissue  which  does  not  calcify.  The  shafts  of  the 
bones  are  thickened  and  heavj',  often  twice  as  heavy  as  the  normal  bone. 
The  skull  may  be  3/4  inch  (rg  mm.)  thick  and  71  cm.  (28.4  inches)  in 
circumference.  In  one  variety  the  bones  are^  deformed  by  multiple  hyper- 
ostoses whence  this  variety  is  called  "tumor  forming."  The  dorso- 
cervical  kj'phosis  as  well  as  bowing  of  the  long  bones  contributes  to  reduce 
the  stature. 

Diagnosis. — This  is  easy  when  the  disease  is  established.  The  coarser 
changes  in  acromegaly  are  similar,  but  in  osteitis  the  face  is  triangular 
with  the  base  upward;  in  acromegaly  the  face  is  egg  shaped  with  the  large 
end  down.  It  is  allied  to  osteomalacia  and  the  two  conditions  merge  but 
in  osteitis  deformans  regeneration  takes  place  synchronously  with  absorp- 
tion.    Fractures  do  not  occur  in  osteitis. 

Treatment  is  unavailing. 


OSTEOGENESIS  IMPERFECTA. 

Synonym. — Fragilitas  Ossium. 

A  condition  of  the  fetus  in  which  its  bones  fail  to  develop  normally, 
reaching  at  birth  a  stage  of  great  fragility  wherein  fractures  are  so  easily 
produced  that  they  may  have  occurred  in  utero.  The  defective  develop- 
ment extends  to  the  cranium  and  the  fragiUty  to  aU  bones.  At  other 
times  the  extremities  are  bent  and  deformed.  Though  the  disease  is  com- 
monly fatal  the  bones  sometimes  repair  and  as  the  child  grows  older  a 
natural  firmness  is  acquired. 


OSTEOPSATHYROSIS. 

Synonyms. — Fragilitas  Ossium;  Lobesteins  Disease. 

Definition. — A  condition  characterized  by  great  brittleness  of  bones 
and  frequent  fractures  in  consequence. 

It  is  further  characterized  by  the  fact  that  the  general  health  of  the 
patient  is  otherwise  good  though  the  fractures  may  number  as  many  as 
a  hundred  or  more  in  a  single  case.  They  are  generally  painless  and 
heal  rapidly.  They  cannot  be  said  to  be  spontaneous  because  they  result 
from  trifling  causes  such  as  turning  over  in  bed,  a  sUght  blow,  or  even  so 
trifling  a  cause  as  the  act  of  chewing  which  may  fracture  the  jaw.     It 


788  CONS  TI T  U  TTONA  L  DISEA  SES 

contrasts  further  with  fractures  of  the  more  usual  kind  in  that  it  occurs 
in  the  young  rather  than  the  old. 

OXYCEPHALY. 

Synonyms. — Tower  or  steeple  head. 

Definition. — A  deformity  of  the  cranial  vault  resulting  in  abnormal 
vertical  dimension  associated  with  exophthalmos  and  defective  vision 
without  mental  derangement.  It  is  further  characterized  b}'  feebly  marked 
supraorbital  ridges.  The  forehead  slopes  to  a  pointed  vertex  and  the  scalp 
rising  also  abnormally  gives  the  appearance  of  being  set  on  the  top  of  a 
comb.     Usually  present  at  birth  it  may  appear  as  late  as  the  sixth  year. 

The  deformity  is  ascribed  to  premature  synostosis  of  certain  sutures 
especially  the  coronal.  The  brain  thus  restricted  grows  vertically  instead 
of  laterally  and  anteroposteriorly.  The  closure  of  the  anterior  fontanelle 
is  delayed,  its  site  displaced,  but  closure  ultimately  takes  place,  the  original 
site  being  covered  by  thin  and  prominent  bone. 

The  visual  defect  is  du,e  to  optic  neuritis  and  atrophy  caused  by  the 
internal  brain  pressure  as  in  tiunor  of  the  brain;  whence  too,  the  exophthal- 
mos and  headache  and  it  may  be  the  occasional  loss  of  the  sense  of  smell. 

Decompressing  operation  has  been  done  in  the  way  of  treatment. 

Leontiasis  Ossia. — -Is  a  condition  which  is  characterized  by  bony 
outgrowths  upon  the  cranium  and  face.  A  case  at  present  under  the  care 
of  one  of  us  has  great  protuberances  upon  the  temporal  bones  and  upon 
the  vault.  She  has  at  the  same  time  a  steadily  increasing  general  arthritis. 
The  entire  head  is  distorted. 

GOUT. 

Synonym. — Podagra. 

Definition. — An  acute  and  chronic  constitutional  affection,  due  to  an 
abnormal  accumulation  of  uric  acid  and  other  purin  bodies  in  the  blood 
and  tissues,  causing  \^arious  symptoms,  of  which  arthritis  is  the  most  dis- 
tinctive and  significant.. 

Etiology. — The  tendencj^  to  gout  is  more  frequently  inherited,  than 
acquired.  Between  50  and  60  per  cent,  of  all  cases  of  gout  can  be  traced 
to  ancestry,  parents  or  grandparents.  More  men  are  gouty  than  women, 
and  it  is  the  male  line  through  which  the  tendency  is  most  frequently 
transmitted.  It  is  not  usually  manifested  until  after  40  years  of  age, 
sometimes  later,  but  the  signs  which  are  almost  sure  to  eventuate  in  gout 
may  show  themselves  before  the  12th  yeas.  While  overeating,  especially 
of  meats,  and  intemperate  drinking,  associated  with  the  luxurious  habits 
which  grow  out  of  the  possession  of  wealth,  are  the  most  frequent  causes 
of  acquired  gout,  these  last  are  by  no  means  essential.  Sir  Dyce  Duck- 
worth's studies  of  gout  in  what  is  probably  the  richest  field  in  the  world, 
London,  go  to  show  that  man}'  of  the  peasantry-  of  Ireland,  among  whom 
gout  is  vmknown,  became  gouty  after  having  lived  for  a  time  in  London. 
This  ma}"  be  due  to  free  indulgence  in  malt  liquors.     Such  gout  is  often 


GOVT  789 

spoken  of  as  poor  man's  gout.  Not  ever>'  person  who  inherits  a  tendencj- 
to  gout  becomes  gouty,  since  the  fostering  causes  previously  mentioned 
may  be  wanting.  In  others  this  tendency  is  so  great  as  not  even  to  require 
the  favoring  condition.  Negroes  are  not  exempt,  and  Osier  reports  three 
out  of  59  cases  admitted  to  Johns  Hopkins  Hospital,  up  to  April  i,  1905. 

While  alcohol  is  an  acknowledged  cause  of  gout,  it  has  been  observed 
that  something  depends  on  the  shape  in  which  it  is  presented.  Malt 
liquors,  especially  the  "heavy"  English  ales  and  beers,  strong  in  alcohol, 
are  more  active  in  the  production  of  gout  than  the  lighter  beers  consumed 
in  German}^  and  this  country  where  gout  is  less  common.  Striimpell  beUeves, 
however,  that  gout  is  more  common  in  Germany  and  especially  in  Bavaria 
than  is  commonly  supposed.  The  strong  and  sweet  wines,  of  which 
port  and  sherr\^  are  the  type,  are  strongly  predisposing,  while  pure  whisky 
is  less  harmful.  According  to  Futcher  "It  is  quite  probable  that  the 
increase  of  uric  acid  in  the  blood  and  urine,  after  the  ingestion  of  alcohol 
and  pvirin  containing  food,  is  due  to  the  inhibitory-  action  of  alcohol  on 
the  "oxidase"  which  normally  oxidizes  uric  acid  into  urea." 

An  interesting  cause  of  gout  is  lead-poisoning.  This  is  seen  partic- 
ularly in  England  and  especially  in  London,  as  pointed  out  by  Sir  Alfred 
Garrod  in  1854.  It  is,  however,  rare  in  other  parts  of  Great  Britian  and 
Ireland,  and  is  gro-nnng  more  infrequent  in  London;  for  in  1870,  accord- 
ing to  Garrod,  33  per  cent,  of  people  who  suffered  from  gout  had  been 
poisoned  by  lead,  whUe  Sir  Dyce  Duckworth,  up  to  1890,  found  only 
18  per  cent,  in  hospital  cases.  It  is  a  rare  cause  also  in  France  and  Ger- 
naany.  It  may  be,  as  suggested  by  Alexander  Haig,  that  the  effect  of 
plumbism  is  to  diminish  the  alkalinitj^  of  the  blood  and  thus  its  solvent 
power  for  uric  acid  which  is  consequently  precipitated.  In  this  countn,' 
the  combination  is  comparatively  rare. 

Food  and  Exercise. — The  relation  of  food  taken  to  exercise  indulged  in 
is  important.  Improper  amounts  of  food  difScult  to  digest,  especiably  if 
much  alcohol  is  used  and  little  exercise  taken,  unquestionably  predisposes 
to  gout. 

Injuries  and  blows  on  susceptible  parts,  and  so  slight  a  cause  as  pres- 
sure b}^  a  boot,  are  often  predisposing  causes.  On  the  other  hand,  worr\- 
or  shock  maj^  be  exciting  causes. 

Pathogenesis. — Mam^  theories  have  been  proposed  as  to  the  metabolism 
in  gout.  For  the  exposition  of  those  theories,  the  reader  is  referred  to  the 
various  systems  of  medicine.  The  following  statements  seem  to  be  well  es- 
tablished. Gout  is  caused  by  faulty  metabolism,  which  eventuates  in 
the  accumulation  of  an  excess  of  uric  acid  in  the  blood  and  tissues.  It 
has  been  estabUshed  that  there  is  a  specific  intracellular  enzyme  called 
nuclease,  which  has  the  power  of  liberating  the  purin  bases,  adenin, 
guanin,  hj^poxanthin  and  xanthin  from  the  nucleo  proteids  of  the  tissue 
or  of  the  food.  These  bases  having  been  Hberated  are  acted  upon  by  the 
ferments,  adinase,  guanase,  and  xanthin  oxidase  which  are  present  in 
the  thymus,  adrenals,  pancreas,  lungs  and  liver,  and  step  by  step  the 
uric  acid  is  built  up.  Schittenhelm  has  further  shown  that  there  is  another 
specific  tissue  oxidase  present  in  the  kidneys,  and  muscle,  which  has  the 
power  of  oxidizing  the  uric  acid,  and  thus  destroying  it.     The  chief  fault 


790  CONSTITUTIONAL  DISEASES 

in  the  metabolism  would  appear  to  be  the  lack  of  power  to  destroy  the 
uric  acid  formed.  It  would  therefore  appear  that  persons  who  have  dif- 
ficulty in  getting  rid  of  the  purin  bases  thus  formed  and  destroyed,  have 
gout  in  one  form  or  another,  whether  it  be  in  an  acute  attack  or  in  the 
deposit  of  the  biurate  about  the  joints  or  in  the  tissues. 

Morbid  Anatomy. — As  will  be  further  evident  in  treating  the  sj-mp- 
tomatology  of  gout,  there  is  scarcel}^  a  tissue  which  may  not  be  affected 
by  it,  but  the  morbid  conditions  which  are  more  distinctive  are,  first,  the 
characteristic  inflamed  great  toe  of  acute  gout — the  true  podagra.  The 
angr}-,  swollen,  dark-red  or  mottled  appearance  of  such  a  toe  once  seen 
is  not  forgotten.  Similar  though  less  striking  changes  are  sometimes  seen 
in  the  metacarpophalangeal  articulation  of  the  thumb. 

The  superficial  changes  in  chronic  gout  are  less  distinctive,  and  are 
often  not  different  from  chronic  arthritis  due  to  other  causes.  But  where- 
ever  uratic  deposits  are  present  in  the  tissues,  there,  by  vmiversal  consent, 
is  gout.  Thejr  are  found  most  often  in  joints  and  in  the  parts  around  them: 
first,  the  cartilages  of  the  movable  joints,  then  the  ligaments,  tendons, 
biirsse,  and,  finally,  the  connective  tissue  and  skin,  this  being  the  order 
of  feebleness  in  vasctdarity  and  nutritive  activity.  Frequent  situations 
are  the  digital  joints  and  cartilages  of  the  ear;  more  rarely  the  cartilages 
of  the  nose,  the  vocal  cords,  the  cornea,  kidneys,  marrow  of  bone,  and  ex- 
pectoration. Cartilages  impregnated  with  urates  present  the  appear- 
ance of  being  smeared  with  whitewash  or  white  paint,  and  when  preserved 
in  pure  alcohol,  maintain  it  for  a  long  time.  Minutely  examined,  cartil- 
ages are  infiltrated  on  the  peripheral  siirface,  more  rarely  beneath,  with 
acicular  crystals  of  sodium  urate.  Rarely  they  are  found  in  the  bone  under 
the  cartilage.  The  cartilage  cells  are  for  the  most  part  free,  and  after  the 
urates  are  dissolved  out,  the  tissue  appears  natural  or  slightly  granular. 
The  tophaceous  deposits  are  the  best  known  and  most  characteristic 
lesion  of  gout.  About  the  digital  joints,  especially  the  knuckles  of  the 
hands,  they  sometimes  ulcerate  through  the  skin.  The  deposits  are  often 
associated  with  deflection  of  the  fingers  to  the  vdnar  side — "seal-fin"  type 
of  hands — and  of  the  toes  outward,  a  late  symptom  not  confined  to  gout — 
in  fact,  more  common  in  rheumatoid  arthritis.  It  is  due  to  stronger  action 
of  the  abductor  muscles. 

Deposits  of  biurate  of  soda  called  tophi  appear  on  the  helix  and  antiheUx 
of  the  ear,  in  the  subcutaneous  tissue  of  various  subcutaneous  tissue  of 
the  forearms,  tendo  achillis,  etc.  The  gouty  tophi  occurring  about 
the  phalangeal  joints,  must  not  be  confoxmded  with  Heberden's  nodosities, 
which  are  characteristic  of  rheumatoid  arthritis.  Their  significance  must 
be  determined  b}-  other  sj'mptoms  more  essential  to  gout.  They  vax}'-  in 
prominence  and  tenderness  at  different  times,  being  worse  in  gout,  es- 
pecially after  errors  of  diet,  but  on  the  whole  the}-  slowly  increase  with 
the  age  of  the  patient  and  the  persistence  of  other  symptoms. 

Of  xmdoubted  gouty  natiu^e  are  the  Uttle  vesicles  over  the  nodosities, 
called  "crab's-eye"  cj-sts.  To  these  are  to  be  added  certain  exostoses 
and  ecchondroses,  or  "lippings,"  beneath  the  synovial  membrane,  at 
the  edges  of  the  cartilages,  and  round  the  heads  of  the  phalanges,  and  even 
of  larger  bones  like  the  femur,  patella,  and  tibia. 


GOUT  791 

Changes  in  the  internal  organs  are  most  often  confined  to  the  kidneys 
and  vascular  system.  Deposits  of  urates  have  been  referred  to.  They  are 
not  constant,  and  are  found  usually  in  the  interlobular  tissue  toward  the 
apices,  but  also  more  rarely  in  the  tubules.  Ultimately  the  gouty  sub- 
ject acquires  an  interstitial  nephritis,  the  well-known  gout\-  kidnej' ;  though 
the  term  "gouty  kidney"  has  also  been  applied  to  kidneys  the  straight 
tubules  of  which  are  found  filled  with  uratic  sediments,  as  is  the  case  some- 
times at  necropsy.  Arterio-sclerosis  is  almost  always  present,  and  must 
now  be  ascribed  to  the  irritative  effect  of  the  purin  bodies,  which  include 
xanthin  bases  on  the  one  hand  and  uric  acid  on  the  other.  The  heart 
is  hypertrophied  in  its  left  ventricle.  There  may  be  deposits  of  urate 
of  sodium  on  its  valves.  Changes  in  the  lungs  are  mainly  confined  to 
emphysema,  which  is  found  in  many  cases  of  long  standing. 

Symptoms. — Of  Typical  Acute  Gout. — Persons  subject  to  attacks  of 
gout  sometimes  have  premonitory  symptoms  suggesting  the  approach  of 
an  attack.  These  vary  with  the  individual  and  are  significant  only  in 
each  case.  They  may  be  headache,  neuralgia,  any  one  of  the  nvunerous 
manifestations  of  deranged  digestion,  irregularity  of  the  heart's  action, 
palpitation,  high  tension  of  the  pulse,  depression  of  spirits,  drowsiness, 
a  disposition  to  yawn,  a  tired  feeling — in  fact,  any  symptom  which  the 
patient  learns  to  associate  -nath  the  attack.  Attacks  are  apparently  also 
invited  or  determined  by  anything  which  lowers  the  ^-itaUty  of  the  patient. 
On  the  other  hand,  a  supper  with  wine  or  a  single  glass  of  champagne  will 
often  produce  an  attack. 

The  first  actual  symptom  of  the  typical  attack  is  articular  pain,  com- 
monly in  the  great  toe,  at  the  metatarsophalangeal  joint,  and  with  its  ap- 
pearance the  premonitory  symptoms  usually  pass  awaj^.  The  pain  is 
extremely  severe,  sharp,  shooting,  and  sudden,  often  arousing  in  the  middle 
of  the  night  a  patient  who  has  gone  to  bed  apparently  well  and  least  ex- 
pecting an  attack.  With  this  pain  are  the  swelling,  heat,  and  discoloration 
already  described  under  morbid  anatomy.  Rarely,  the  attack  begins  with 
a  slight  chill.  On  the  other  hand,  there  may  be  pain  without  heat,  redness, 
or  swelling,  and  all  the  typical  local  anatomical  features  of  an  attack  with- 
out pain.  In  some  instances  the  attack  develops  more  slowly.  At  times 
the  first  attack  is  so  Httle  distinctive  that  it  is  assumed  to  be  something 
much  more  trifling,  such  as  rheumatism  or  some  sUght  injurj^  while  the 
personal  pecuHarities,  natural  or  acquired,  always  more  or  less  influence  the 
sj'mptoms.  After  the  outburst  at  night  the  extreme  pain  diminishes  as 
morning  advances,  but  it  may  recur  the  next  night,  and  this  goes  on  for 
four,  five,  or  six  days,  when  the  attack  terminates. 

Some  fever  usually  accompanies  the  onset  of  acute  gout.  The  tem- 
perature promptly  rises  to  ioo°  F.  (37.8°  C.)  and  even  higher,  but  does 
not  far  exceed  it,  102°  F.  (38.9°  C.)  being  the  usual  maximum  attained. 
As  in  other  acute  diseases,  the  temperature  is  higher  in  the  evening.  The 
local  temperature,  notwithstanding  the  sensation  of  heat,  is  five  or  six 
tenths  of  a  degree  below  that  of  the  axtUa  at  the  same  time.  The  attack 
terminates  with  desquamation  of  the  epidermis  over  the  inflamed  joint. 
During  the  acute  attack  a  leucocytosis  develops. 

Changes  in  the  Urine. — It  is  scanty,  acid,  highly  colored,  and  of  high 


792  CONSTITUTIONAL  DISEASES 

specific  gravit}^  It  deposits  uric  acid  and  urates  on  standing  and  cooling 
but  this  deposit  is  not  an  index  as  to  the  quantity  of  uric  acid  excreted. 
It  often  contains  a  small  quantity  of  albumin. 

Futcher  has  made  some  interesting  studies  as  to  the  relations  of  uric 
acid  and  phosphoric  acid  excretion  to  the  acute  attacks.  Both  increased 
nearly  pari  passu  after  a  low  output  before  the  attack  and  in  its  early  part, 
but  rose  to  normal  limit  shortly  after  the  onset.  Hematiuia  and  oxaluria 
may  occur. 

A  recognized  symptom  of  acute  gout,  and  sometimes  the  only  one, 
is  pharyngitis,  and  now  the  term  "gouty  sore  throat"  is  one  in  common 
use,  though  it  is  doubtless  also  often  used  carelessly,  many  cases  of  in- 
fectious sore  throat  being  maltreated  on  the  ground  that  they  are  gouty  in 
character.  There  seems  no  way  of  distinguishing  it  locally  from  other 
forms  of  sore  throat  in  which  there  is  no  decided  swelling. 

Gout  is  said  to  be  retrocedent  or  metastatic  when  it  disappears  suddenly 
from  its  external  site  and  there  are  substituted  for  the  outward  symptoms 
derangements  of  some  internal  organ,  especially  the  heart  or  stomach  or 
brain  or  ttrinary  bladder.  In  the  first  there  appear  cardiac  symptoms  of 
varying  severity,  including  pain,  shortness  of  breath,  and  irregularit}'  in 
the  heart's  action;  in  the  second,  gastrointestinal  pain,  a  sinking  sensation, 
vomiting  or  diarrhea,  often  associated  with  intense  mental  excitement  or 
depression;  in  the  third,  meningeal  symptoms;  and  in  the  fourth,  cystitis 
and  prostatitis.  More  rare  events  are  gouty  orchitis,  parotitis,  and  urti- 
caria or  other  fugitive  skin  affections.  Metastasis  is  more  prone  to  occur 
in  atonic  cases.  Sudden  death  has  supervened  in  some  instances,  but 
postmortem  lesions  of  a  definite  kind  seem  to  be  wanting,  at  least  lesions 
which  can  be  held  responsible  for  the  symptoms. 

Of  Irregular  or  Atypical  Gout. — This  includes  a  set  of  symptoms  not 
so  distinctive  in  themselves  as  peculiar  in  this,  that  they  occur  in  persons 
who  have  had  gout  or  who  have  a  decided  hereditary  tendencj^  thereto. 
These  conditions  being  fulfilled,  there  is  scarcely  an\^  superficial  or  vis- 
ceral symptom  which  may  not  be  of  gouty  origin,  but  among  them  may 
be  named  cutaneous  eruptions,  gastrointestinal  disorders,  various  forms 
of  headache  and  neuralgia,  hot  and  itching  palms  and  soles,  especially 
at  night,  a  similar  condition  of  the  eyeballs,  lumbago  and  other  muscular 
pains,  cramps  in  the  legs,  arterio-capillarj'  fibrosis  and  its  consequences, 
iritis,  bronchitis,  pericarditis,  cystitis  with  hemorrhage  into  the  bladder, 
and  others. 

Some  affections  of  the  teeth  occurring  under  the  same  conditions  may 
be  regarded  as  gouty.  On  the  other  hand,  an  easy  method  of  satisfying  a 
patient  and  liiding  one's  ignorance  under  a  name  is  to  make  a  diagnosis  of 
"uric  acid  diathesis"  or  "uric  acid  in  the  blood"  without  the  least  founda- 
tion.    Such  terms  should  be  banished  from  medical  literature. 

Among  other  organs  the  eye  in  its  blood-vessels,  retina  and  optic  nerve 
falls  heir  to  changes  which  are  ascribable  to  gout,  but  the  same  law  as  to 
their  necessary  relation  holds,  bj'  which  we  mean  that  identical  conditions 
occur  which  are  not  due  to  gout,  and  the  conclusion  that  they  are  thus 
related  depends  upon  a  definite  knowledge  of  the  previous  existence  of  gout 
in  the  patient.     An  exception  to  this  exists  in  the  rare  cases  of  actual 


GOUT  793 

deposits  of  urates  in  certain  situations,  as  the  cornea,  the  crystaUine  lens, 
vitreous  humor,  and  even  the  retina. 

Of  Chronic  Gout. — As  repeated  attacks  of  gout  occiu"  and  the  patient 
grows  older,  there  gradually  accumulate  the  morbid  changes  described 
under  morbid  anatomy  as  more  or  less  characteristic — the  joints  deformed 
by  tophaceous  and  ether  deposits,  the  lipping,  the  seal-fin  hand,  the  renal 
and  arterio-vascular  changes,  interstitial  nephritis,  etc.  The  urine  now 
is  increased,  lighter  hued,  and  contains  albumin  and  a  few  hyaUne  and 
granular  casts. 

Some  further  allusion  should  be  made  to  the  deformities  thus  resulting 
as  symptoms  of  chronic  gout.     They  appear  especially  in  connection  with 


Fig.  131. — Tophaceous  Gout. 
Both  hands  were  symmetrically  affected,  man  aged  sixty — {after  Duckworth). 

the  toes  and  fingers,  causing  swellings,  deflections,  and  torsions  which 
produce  the  most  fantastic  shapes.  Among  these  are  deflected  and  ab- 
ducted toes.  The  seal-fin  hand,  and  the  deformities  caused  by  tophaceous 
deposits.  It  is  important  to  remember  that  any  of  these  except  the 
tophaceous  deposits  may  be  due  to  rherunatoid  arthritis  as  well  as  gout. 
The  appended  cut  from  Duckworth  illustrates  the  appearance  of  enormous 
tophaceous  deposits  undoubtedly  of  gouty  origin  as  contrasted  with 
Heberden's  nodosities. 

Diagnosis. — Only  two  events  point  unmistakably  to  gout  in  an  in- 
dividual, viz.,  podagra  or  tophi  in  some  portion  of  the  body,  ears,  forearms 
or  joints.  Gout  prefers  the  distal,  smaller  joints,  and  one  of  these  rather 
than  many.  Frequent  recurrence  in  the  same  joint  is  characteristic  of 
gout  rather  than  articular  rheumatism.  The  gastrointestinal  sj'mptoms 
of  gout  are  in  no  way  distinctive.  Nor  are  the  skin  affections  or  interstitial 
nephritis  or  cardiovascular  changes,  as  the  same  may  arise  from  other 
causes.  Yet  if  they  occtu-  in  a  person  who  has  had  podagra  or  tophaceous 
deposits  they  are  probably  due  to  gout.  Gout  and  cardiovascular  changes 
may  result  from  the  same  cause.  The  presence  of  lead-poisoning,  on  the 
other  hand,  lends  support  to  a  diagnosis  of  gout.  The  continued  presence 
of  tiric  acid  sediments  in  the  urine  also  lend  a  support  to  the  diagnosis  of 


794  CONSTITUTIONAL  DISEASES 

gout.  On  the  other  hand,  after  interstitial  nephritis  has  set  in  the  urine 
may  be  increased  in  quantity,  of  low  specific  gravity  and  light  colored. 
Nodosities  occur  in  gout  or  in  rheumatoid  arthritis  alike,  but  the  presence 
of  crab's  eye  vesicles  on  them  points  to  gout.  A  certain  unexplained 
relation  exists  between  gout,  diabetes  and  obesity.  All  cf  these  or  any 
two  of  them  occur  rather  frequently  in  the  same  individual;  or  they  may 
alternate. 

Treatment. — The  treatment  easily  divides  itself  into  two  parts:  first, 
that  of  the  inherited  tendency;  second,  treatment  of  the  paroxj-sm  or  of 
the  acute  attack. 

Treatment  of  the  Inherited  Tendency. — It  is  plain  that  those  who  inherit  a 
tendency  to  gout  should  be  taught  from  the  earliest  possible  moment  that, 
food  and  exercise  shoiild  have  an  intimate  relation.  Food  of  moderate 
quantit)^  and  exercise  in  fresh  air  that  keeps  the  strength  up  to  par  and  the 
appetite  good  are  essentials.  The  patient  should  be  protected  from  sudden 
changes  of  temperature  by  proper  clothing.  Malt  liquors  and  sweet  "n-ines 
should  be  especially  excluded.  Those  who  work  hard  and  have  insufficient 
food  must  be  taught  that  malt  liquors  are  to  them  a  poison,  that  fresh  air 
is  essential,  that  milk  and  eggs  should  be  the  main  sta^-  of  their  diet 
rather  than  meats  and  pastr3.^ 

I.  The  Dietetic  Treatment. — This  is  by  far  the  most  efficient  of  the 
treatment  of  gout,  without  which  all  else  is  only  palliation.  It  consists 
in  the  proper  combination  of  food  taken,  of  the  regulation  of  the  amount, 
and  of  the  practical  exclusion  of  alcohol,  especiallj-  malt  liquors  and  light 
wines. 

^4  Modified  Nitrogenous  Diet. — It  is  perhaps  well  pro^■en,  that  the 
foods  rich  in  nucleoprotein  should  be  avoided,  therefore,  sweet-breads, 
liver,  kidneys  and  brain  should  be  debarred.  Beef  extracts  are  injurious. 
White  meat  on  the  whole  is  preferable  to  red  meats  because  the  latter  contains 
more  extractives  though,  boiled  or  stewed  red  meats  may  be  allowed  in 
moderate  quantities,  when  broiled  or  roasted  can  be  taken  in  small  quan- 
tities. Meat  soups  and  beef  extracts  shotdd  not  be  used.  Fish  may  be 
taken  in  moderation.  Eggs  and  milk  are  the  safest  forms  of  protein  diet. 
Cheese  is  permissible.  Vegetables  and  carbohydrates  may  be  taken  in  any 
rational  amount.  Fruits  maj-  be  eaten,  although  certain  individuals  have 
idios5'ncrasies  toward  certain  ones.  Fats  may  be  used  but  should  be  iised  in 
quantities  which  wall  not  upset  the  digestion.  Alcohol  should  not  be  used 
in  any  form,  it  certainly  inhibits  the  ftmction  of  the  liver  in  destroj-ing 
uric  acid.  If  alcohols  are  insisted  upon  by  the  patients  they  should  take 
whisk}-  and  brandy  and  not  malt  liquors.  Tea  and  coffee  can  be  used  in 
moderation,  never  in  excess,  they  are  better  than  alcohol.  The  amount 
of  the  food  is  important,  never  excessive.  Any  amount  which  leaves  a 
feeling  of  fuUness  or  causes  joint  pains,  afterward  is  too  great. 

An  abimdance  of  any  good  drinking  water.  So-called  mineral  waters, 
are  still  extensively  used.  They  are  probably  not  a  whit  better  than  any 
potable  water. 

Residence  at  Spas  is  desirable  for  those  who  can  afford  it,  not  so  much 
became  of  the  efficiency  of  the  water,  but  because  of  the  proper  diet,  the 
amount  of  water  and  amount  of  exercise  taken  as  a  part  of  the  treatment. 


GOUT  795 

If  alkaline  waters  are  demanded  by  the  patients,  Vichy,  Baden  Baden,  Kis- 
singen  and  Saratoga  waters  ma_v  be  allowed. 

The  bowels  should  be  kept  moving  daily.  A  habit  can  be  established 
of  daily  evacuation.  Salines  such  as  magnesium  sulphate,  Rochelle  Salts 
are  best,  this  may  be  given  in  the  form  of  Hunyadi  water. 

II.  The  Medicinal  Treatment  and  the  Treatment  of  the  Acute  Attack. 
— As  a  rule,  the  use  of  medicines  is  reserved  for  the  acute  attack.  From 
the  earliest  histor\^  of  the  disease  practice  has  recognized  two  classes  of 
remedies  in  the  treatment  of  gout — alkaUes  and  purgatives — the  object 
of  both  being  to  eliminate  the  offender,  the  first  by  producing  soluble 
combinations  which  pass  off  readily  by  the  kidneys,  and  the  secQnd  to 
carry  it  off  b}^  the  bowels.  It  is  plain  that  a  combination  of  the  two  prin- 
ciples might  be  expected  to  be  more  efficient  than  either  one  alone. 

First  as  to  alkalies  and  allcaline  combinations.  Salicylate  of  sodirun  is 
easily  at  the  top,  and  while  it  is  not  so  rapid  in  its  effect  in  relieving  the 
pain  of  an  acute  attack  of  gout  as  it  is  in  rheumatism,  it  is  nevertheless 
an  invaluable  remedy,  excelling  all  others.  During  an  attack  it  should  be 
given  in  doses  as  large  as  can  be  borne.  As  a  rule,  adult  men  easilj'  bear 
IS  grains  (i  gm.)  four  times  a  day,  or  lo  grains  (0.65  gm.)  may  be  admin- 
istered every  two  hours.  Even  larger  doses  may  be  given  with  advantage, 
if  borne  by  the  stomach.  With  relief  to  the  acute  sj-miptoms  the  dose 
should  be  reduced ;  but,  as  in  rheumatism,  the  remedy  should  not  be  dis- 
continued, and  between  attacks  smaller  doses  should  be  kept  up  for  some 
time.  These,  however,  may  be  substituted  by  the  natural  mineral  waters 
to  be  presently  alluded  to. 

After  the  salic3'lates,  the  alkaline  carbonates  have  alwa^^s  held  a 
high  position  in  the  treatment  of  gout.  Half  an  ounce  (15  gm.)  of  potas- 
sium bicarbonate  a  day  in  divided  doses  should  be  the  initial  treatment, 
continued,  in  smaller  doses,  when  rehef  comes  to  the  acute  symptoms. 
It  may  be  combined  with  a  little  lemon-juice  to  improve  the  flavor,  or 
the  citrate  of  potassium  may  be  given  in  the  same  doses. 

Among  the  eliminating  remedies  is  the  time-honored  colchicum,  a  drug 
which  is  of  undoubted  value  in  gout,  but  which,  in  Tyson's  experience, 
must  3'ield  the  palm  to  salicjdate  of  sodium.  For  a  long  time  its  action 
was  inexplicable,  and  it  came  to  be  known  as  a  specific  in  gout  as  quinin 
is  in  chills  and  mercury  in  sj^philis.  Modem  studies  have,  apparently, 
solved  this  problem.  Professor  Rutherford  has  shown  that  it  is  one  of 
the  most  powerful  cholagogues  known.  This,  taken  in  connection  with 
what  we  now  know  of  the  office  of  the  liver  in  urea  formation,  simplifies 
Yery  much  the  solution  of  the  problem.  It  explains,  too,  why  colchicum 
produces  its  sedative  and  anesthetic  effect  without  necessarily  causing 
piirgation.  Indeed,  some,  as  Sir  Alfred  Garrod,  consider  that  its  effects 
are  best  attained  without  purgation,  and  Garrod  says  that  if  cathartic 
action  is  required,  it  is  better  to  combine  some  aperient  with  the  colchi- 
cum, as  when  much  ptirging  and  vomiting  results  from  colchicum,  nervous 
and  vascvdar  depression  follows.  It  is  not  necessary  to  produce  either 
violent  purging  ot  vomiting.  Whatever  its  mode  of  action,  it  sometimes 
operates  in  the  most  magical  manner  in  relieving  pain.  The  preparation 
commonly  used  is  the  wine.     In  this  country  the  wine  of  the  seeds  is  no 


796  CONSTITUTIONAL  DISEASES 

longer  official,  so  that  if  the  wine  is  ordered,  that  of  the  root  is  dispensed. 
This  is  more  powerfi.il  than  the  wine  of  the  seeds. 

Colchicin,  the  active  principle  of  colchicum,  is  also  employed.  Its 
dose  is  i/so  grain  (0.0013  gm.).  The  same  dose  may  be  employed  hypo- 
dermically.  A  favorite  modern  remedy  is  the  salicylate  of  colchicin  in 
doses  of  5  minims  (0.31  c.c),  given  in  pearls  or  capsules.  The  other 
aperients  commonly  used  in  gout  are  the  sulphates,  of  which  magnesium 
sulphate  is  the  favorite.  Sodium  sulphate  is  also  used,  and  it  is  the  con- 
stituent of  the  most  actively  purgative  mineral  waters  already  mentioned, 
viz.,  the  Hunyadi  Jdnos,  Rakoczy,  and  Friedrichshalle,  now  largely 
used  instead  of  the  pure  salt.  It  is  also  the  largest  constituent  of  the 
Carlsbad  waters. 

Colocynth  is  also  emploj-ed  as  an  aperient  in  gout,  and  advantage 
has  been  taken  of  this  fact  in  the  preparation  of  the  secret  remedj'  known 
as  Laville's  tincture,  which  is  very  largely  used  by  the  laity,  and  which 
undoubtedly  has  a  very  prompt  effect  in  many  cases  of  acute  gout.  The 
following  has  been  published'  as  the  composition  of  Laville's  remedy,  as 
determined  by  analysis: 

Quinin 5      parts. 

Cinchonin 5 .     parts. 

Colocynthin 2.5  parts. 

Lime  salts 5 .     parts. 

Water 82 . 5  parts. 

Alcohol 100      parts. 

Port  wine 800      parts. 

The  lithium  compounds — the  carbonate  and  citrate — have  not  proved 
so  usefrd  as  to  cause  us  to  prefer  them  to  salicylic  acid.  Indeed,  the  early 
results  of  Garrod  mth  them  cannot  be  said  to  have  been  realized  in  modern 
therapeutics.  Sir  Dyce  Duckworth  says  of  lithia  that  it  is  a  remedy  better 
adapted  to  the  chronic  than  to  the  acute  phases  of  gout,  and  so  we  have 
been  using  it.  Five  grains  (0.3  gm.)  four  times  a  day,  freely  diluted,  is 
the  dose  usually  administered,  and  with  this  the  potassium  salts  are  some- 
times combined. 

Local  Applications. — For  the  relief  of  the  acute  attack  of  gout,  leeches, 
blisters,  and  cold  have  all  been  discontinued,  not  only  because  they  are 
useless,  but  also  because  their  use  has  been  followed  by  fatal  attacks  of 
the  so-called  internal  gout.  Warmth  and  moisture  do.  however,  have  a 
mollifying  effect,  which  is  increased  if  the  liquid  preparations  of  opitim 
be  associated. 

It  often  happens  that  the  pain  in  a  paroxysm  of  gout  is  so  severe 
that  it  is  impossible  to  wait  until  the  effect  of  the  foregoing  remedies  is 
seciu-ed,  and  a  hi'podermic  injection  of  morpliin  is  absolutely  necessarj' 
to  relieve  the  sirfferings  of  the  patient. 

All  pressure  by  boots  on  joints  disposed  to  gout  should  be  carefully 
avoided,  as  well  as  injuries,  as  such  influences  undoubtedly  act  as  predis- 
posing causes.  Muscular  and  mental  fatigue  are  exciting  causes  of  acute 
attacks,  and  should  be  avoided  by  the  gouty. 

Treatment  of  Retrocedent  Gout. — The  true  nature  of  a  metastatic  at- 
tack having  been  determined,  it  must  be  relieved  symptomatically,  while 

•"Druggist's  Circular."  October,  1889. 


DIABETES  MELLITUS  797 

efforts  to  stimulate  a  true  external  attack  may  be  made  by  the  hot  mustard 
foot-baths,  sinapisms,  and  the  like.  It  has  even  been  suggested  that  a 
pint  of  champagne  may  be  advised,  this  being  the  wine  most  frequently 
responsible  for  acute  attacks. 

DIABETES  MELLITUS. 

Definition. — A  condition  of  deranged  metabolism  characterized  by 
a  constant  copious  secretion  of  a  urine  charged  with  glucose  and  due  to  some 
as  yet  imperfectly  understood  derangement  of  the  glycogenic  and  glyco- 
destructive  functions  of  the  organism. 

Geographical  and  Racial  Distribution. — Diabetes  is  not  a  common 
disease  anywhere,  and  it  is  variously  frequent  in  different  countries  and 
races.  The  latest  census  report  (igio)  shows  the  death  rate  from  diabetes 
in  the  United  States  to  be  14.9  to  100,000  population,  somewhat  greater 
than  the  rate  found  in  European  countries.  According  to  Dickinson, 
disease  is  more  widely  prevalent  in  the  agricultural  countries  of  England 
than  in  the  cities.  It  is  common  in  Sweden,  on  the  one  hand,  and  in  south- 
em  Italy  and  India,  especially  in  Ceylon,  on  the  other,  while  especially 
rare  statistically  in  Holland,  Russia,  and  Brazil. 

It  is  much  more  frequent  among  Hebrews  than  among  Chrirtians  in 
the  experience  of  almost  everyone.  It  is  rare  in  the  negro  race.  It  is  a 
disease  especially  frequent  among  the  rich  and  well-to-do,  though  the  poor 
are  not  exempt.  It  is  also  a  disease  of  adults,  yet  it  has  occiured  in  infants 
at  the  breast.  The  disease  is  most  frequent  between  the  ages  of  30  and  60. 
It  is  more  serious  in  the  young,  recovery  in  very  young  subjects  being 
almost  unknown.  It  is  much  more  frequent  in  males  than  in  females, 
in  the  proportion  of  nearly  three  to  one,  though  Senator's^  statistics  show 
that  under  the  age  of  20  more  females  are  affected  than  males.  Little  is 
known  of  the  effect  of  occupation,  though  it  is  thought  that  occupations 
taxing  the  mind  favor  it.  Heredity  has  in  Tyson's  experience  been  less 
conspicuous  than  European  writers  find  it.  From  ten  to  25  per  cent,  are 
thus  traced  by  different  Continental  observers.  On  the  other  hand,  it 
may  occur  in  several  members  of  a  family.  It  is  not  unusual  to  find  diabetes 
mellitus  in  some  members  of  a  family  and  gout  in  others. 

Etiology. — Inseparably  connected  with  the  etiology  of  diabetes  are 
the  phenomena  of  sugar  formation  in  the  economy.  During  life  there  is 
constantly  being  produced  and  stored  in  the  liver  and  muscles  of  man  and 
the  lower  animals  an  amyloid  substance,  which  was  named  by  its  discoverer, 
Claude  Bernard,  glycogen.^  Its  formula  is  Ce,  Hio,  O15,  that  of  starch, 
and  the  term  zoamylin,  or  animal  starch,  was  at  one  time  suggested  for  it. 
The  glycogen  formation  takes  place  whether  animal  or  vegetable  food  be 
taken,  but  it  is  much  larger  upon  a  vegetable  diet. 

In  health  the  amoimt  of  glucose  in  the  blood  is  remarkably  constant, 
ranging  from  o.  i  to  o.  15  per  cent.  The  source  of  this  sugar  in  the  blood  is 
largely  the  carbohydrate  food  taken  into  the  stomach.  These  starches 
are  converted  by  intestinal  and  salivary  digestion  into  simple  sugars  and 

1  See  Senator's  article  on  "  Diabetes  Mellitus  "  in  "  Ziemssen's  Cyclopedia  of  Medicine,"  vol.  xvi.,  p. 
866,  ad  fin. 

2  Bernard,  "  Nov.  Fonc.  du  Foie,"  Paris,  1853. 


798  COXSTirurrOXAL  DISEASES 

are  absorbed  largely  in  the  form  of  dextrose,  levulose  and  glucose.  They 
are  carried  to  the  liver  in  the  form  of  these  simple  sugars,  and  are  converted 
into  glycogen  by  that  organ  and  stored  there  and  in  the  muscles.  It 
is  evident  that  there  are  two  other  possible  sources  of  sugar,  the  proteins 
and  the  fats. 

It  is  now  proven  that  the  proteins  are  split  by  metabolic  process  into 
amino-acids,  and  from  the  fatty  acids  of  these  amino-acids  glucose  is 
formed,  and  is  used  in  the  economy.^  The  amount  of  sugar  thus  derived  in 
normal  metabolism  does  not  exceed  loo  grams  per  day  according  to  Alonzo 
Taylor.  This  author  believes  also  that  the  question  as  to  whether  the 
sugar  of  the  blood  is  derived  from  the  fats,  is  one  of  the  future.  Fat  is 
resorbed  from  the  intestines  as  such,  and  if  there  is  any  conversion  of  fat 
into  sugar,  this  also  must  be  a  metabolic  process. 

In  starvation  sugar  is  certainly  formed  from  the  protein  tissues  and 
possibly  from  the  fat  of  the  body.  The  conversion  of  fat  into  sugar  under 
these  changed  metabolic  relations,  is  maintained  by  Von  Noorden,  "New 
Aspects  of  Diabetes,"  New  York,  191 2,  who  believes  "the  liver  uses  fats 
for  the  purpose  of  forming  sugar,  only  when  the  poverty  of  other  materials 
makes  it  necessary." 

The  glycogen  formed  from  the  food  is  stored  in  the  liver  and  in  the 
muscles  in  about  equal  amounts,  about  150  grams  being  the  maximum 
in  each.  C.  von  Noorden  also  considers  that  fat  is  converted  into  sugar 
in  the  liver. ^ 

The  presence  of  glucose  in  the  urine,  in  appreciable  quantities,  is  an 
abnormal  condition,  and  its  persistence,  due  to  some  change  in  \'ital  organs, 
constitutes  the  disease,  diabetes  melHtus. 

Glucosuria,  or  the  presence  of  sugar  in  the  urine,  may  be  due  to  the 
overindulgence  of  glucose,  to  a  temporary  or  permanent  disturbance  of  the 
nervous  organism,  of  the  pituitary  body,  of  the  thyroid,  or  of  the  adrenals. 

The  term  diabetes  mellitus  should  be  confined  to  that  condition  of 
glucosuria  associated  with  thirst,  polyuria,  and  permanent  disturbance 
of  sugar  metabolism.  As  the  basis  for  this  permanent  disturbance,  there 
appears  to  be  always,  either  an  organic  or  a  functional  change  of  the 
pancreas. 

Alimentary  Glucosuria. — In  perfect  health  glucosuria  cannot  occur 
from  ingested  starch.  The  normal  glycogenetic  function  of  the  liver  is 
superior  to  the  digestive  capacity  of  the  intestine  for  starches  (Taylor). 
Chnically,  however,  cases  in  which  excessive  intake  of  starches  is  at  once 
followed  by  glucosuria  are  well  known.  There  are  individuals  who  are 
apparently  in  health  but  are  usually  fat.  The  sugar  in  the  urine  is  readily 
controlled  in  these  cases  bj'  limiting  the  starches,  and  one  must  consider 
that  such  individuals  have  some  impairment  of  the  glycogenetic  function 
of  the  liver  though  apparently  well.  On  the  other  hand,  excessive  ingestion 
of  carbohydrates  in  the  form  of  the  sugars,  especially  glucose,  may  easil}^ 
cause  glucosuria  in  a  normal  individual.  This  fact  is  made  use  of  in  de- 
erminingthr  carbohydrate  tolerance  of  individuals.  Normal  individuals  can 
take  100  grams  of   glucose  on    an    empty  stomach  without    developing 


'  Digestion  and  Metabolism.  A.  E.  Taylor,  lo 
*  New  Aspects  of  Diabetes.  New  York,  191 2. 


GLUCOSURIA  799 

glucosuria.  Any  case  which  develops  glucosuria  on  taking  a  slight  excess 
of  starch,  must  be  viewed  with  great  suspicion  as  probably  one  of  diabetes 
mellitus. 

Glucosuria  from  Disturbance  of  the  Pituitary  Body. — It  has 
long  been  known  that  acromegaly  is  often  accompanied  by  glucosuria 
It  has  remained  for  Gushing  to  establish  on  a  firm  basis  the  re- 
lation btween  disease  of  the  pituitary  gland  and  glucosuria.  In  this 
work  published  in  19 12  Gushing  makes  the  following  statements  based 
both  upon  clinical  and  experimental  experience.  "Normal  posterior  lobe, 
activity  is  essential,  to  effective  carbohydrate  metabolisms.  An  intra- 
venous injection  of  posterior  lobe  extract  produces  glycogenolysis,  and  its 
continued  administration  in  excessive  amounts  leads  to  emaciation.  A 
diminution  of  posterior  lobe  secretions  leads  to  an  acquired  high  tolerance 
for  sugars."  In  certain  cases  of  excessive  activity  of  the  hypophysis  there 
has  been  constant  glucosuria  with  emaciation  which  dominated  the  whole 
picture  for  a  long  while. 

Glucosuria  Due  to  Disfurbance  of  Cromaffin  System. — It  is 
a  fact  established  by  Herter  and  others,  that  the  injection  of  Adren- 
alin will  cause  rapid  and  severe  glucosuria,  but  repeated  injections  fail  to 
have  as  great  an  effect,  and  finally  it  looses  its  power.  This  action  is  antag- 
onistic to  that  of  the  pancreas  and  is  but  temporary  in  effect.  The  clinical 
value  of  this  observation  is  not  well  established. 

Glucosuria  Resulting  from  Nervous  Disturbance. — Claude  Ber- 
nard's puncture  of  the  medulla  between  the  levels  of  the  origin  of  the 
vagus  and  auditory  nerves  (the  well  known  "piqure")  long  since  proved 
that  certain  disturbances  of  the  nervous  system  can  cause  glucosiu-ia. 
This  same  center  can  be  excited  by  tumors  and  injiiries  and  it  can  also 
be  stimulated  by  fright,  pain,  and  other  nervous  stimuli,  thus  causing 
glucosvu"ia  in  the  persons  affected. 

Von  Noorden  believes  that  this  stimulation  is  carried  through  the  sym- 
pathetic to  the  adrenals,  and  the  latter  are  stimulated.  Here  glucosuria 
due  to  this  type  of  stimulation  is  really  adrenal  glucosuria.  He  also  be- 
lieves that  true  diabetes  can  be  greatly  influenced  by  certain  nervous 
disturbances.  He  believes  there  is  no  such  thing  as  a  true  neurogenous 
diabetes.  The  adrenal  and  nen,^ous  glucosuria  is  only  transitory.  There 
is  much  danger  in  concluding  that  recurrent  glucosuria  is  purely  of  nervous 
origin,  for  almost  without  exception  these  cases  are  neglected  until  one  is 
face  to  face  with  well  developed  diabetes  mellitus.  There  can  be  little 
doubt  that  shock  to  the  nervous  system  maj^  also  be  an  exciting  cause  of 
glucosuria . 

Pancreatic  Glucosuria.  True  Diabetes  Mellitus. —  Opie  in 
1903  published  in  book  form  his  classic  work  upon  the  effect  of  de- 
generation of  the  pancreas  upon  diabetes.  Nineteen  cases  of  diabetes 
with  disease  of  the  islands  of  Langerhans  were  cited.  Since  that  time 
practically  all  experimenters  and  writers  united  in  the  opinion  that  all 
cases  of  really  chronic  diabetes  are  due  to  pancreatic  insufficiency. 

This  insufficiency  is  due  either  to  disease  of  the  Islands  of  Langerhans  or 
of  a  functional  impairment  of  the  pancreas.  The  action  of  the  pancreas 
upon  the  sugar  production  is  one  of  inhibition. 


800  CONSTITUTIONAL  DISEASES 

When  the  Islands  of  Langcrhans  arc  destroyed,  the  inhibitory  power 
of  the  pancreas  is  removed,  and  more  sugar  enters  the  blood,  a  hypergly- 
cemia results,  and  from  this  glusosuria,  constituting  a  true  diabetes 
mellitus  accompanied  with  thirst,  polyuria,  and  emaciation  and  some- 
times with  the  tendency  to  acidosis. 

The  Liver. — Curiously  enough  diseases  of  the  liver  do  not  in  any  way 
interfere  with  the  amount  of  sugar  in  the  blood  and  do  not  so  far  as  is  known 
cavise  glucosuria.  It  is  probable  that  cases  of  liver  disease  wdth  diabetes 
are  accompanied  by  disease  of  the  pancreas. 

The  Kidneys. — Experimentally  a  severe  glucosuria  can  be  caused  by 
the  in  j  ection  of  phloridzin  into  animals.  This  glucosuria,  according  to  Ta^dor , 
is  not  preceded  nor  accompanied  by  hj'pergljxemia,  but  is  due  to  the  re- 
ductions of  the  property'  of  the  kidney  to  restrain  the  elimination  of  glucose. 
It  is  doubtful  if  disease  of  the  kidney  is  ever  the  cause  of  glucosuria,  though 
cases  of  gouty  nephritis  are  occasionallj^  accompanied  by  glucosuria. 

Morbid  Anatomy. — The  most  important  change  in  diabetes  is  in  the 
pancreas.  In  a  large  series  of  cases  50  per  cent,  to  97  per  cent,  of  the  cases 
were  accompanied  by  disease  of  the  pancreas.  The  islands  of  Langerhans 
were  always  diseased  where  the  pancreas  was  involved. 

The  liver  is  frequently  enlarged  and  cirrhotic  and  in  certain  cases 
"bronzed  diabetes,  there  is  a  cirrhosis  of  the  organ. 

The  kidneys,  primarilj^  unaffected,  are  in  many  cases  sooner  or  later 
influenced  by  the  constant  hyperemia  to  which  they  are  subjected  in 
eliminating  the  sugar.  The  appearances  commonly  met  are  those  of 
hyperemia  and  overgrowth  of  epithelium — in  a  word,  those  of  catarrhal 
nephritis.  Occasionally  the  changes  are  more  advanced,  and  the  epithe- 
lium is  fatty.  More  rarely  granular  contracted  kidney  is  present,  con- 
tributing a  more  serious  significance  to  the  albuminuria.  These  changes 
are  not  necessarily  attended  by  albuminuria  previous  to  death. 

The  Ivngs  are  often  the  seat  of  tubercular  deposits  and  cavities  result- 
ing from  their  softening;  also  of  bronchopneumonia  and  croupous  pneu- 
monia, which  may  terminate  in  gangrene.  In  many  cases  of  diabetes 
the  heart  is  found  normal  or  corresponds  to  the  general  nutritive  condi- 
tion of  the  patient.     Quite  often  it  is  enlarged. 

Symptoms.^Almost  invariably  the  eai-hest  symptom  noticed  by  the 
diabetic  is  thirst.  Frequently  diabetics  drink  quarts  of  water  in  twenty- 
four  hours.  Polyuria  is  one  of  the  cardinal  symptoms,  three  to  four 
quarts  of  luine  often  being  passed  in  twent}'-four  hours  causing  much  loss 
of  sleep  because  of  frequent  rising  at  night  to  luinate.  The  urine  is  of 
high  specific  gra-\rity.  It  occasionally  happens  that  a  dryness  of  tlie  fauces 
and  a  glutinous  viscid  character  of  the  saliva  attract  attention  before  any 
other  symptom.  Sometimes  it  is  observed  that  a  drop  of  urine  falling  upon 
the  boots  or  clothing  and  evaporating  there,  leaves  a  persistent  white  or 
yellowish  spot  due  to  sugar.  Dryness  and  harshness  of  the  skin,  due  to 
absence  of  perspiration,  soon  make  their  appearance  and  early  attract  the 
attention  of  those  who  ordinarily  perspire  freely,  and  occasion  varying 
amounts  of  discomfort.  Itching  of  the  skin  is  frequently  present,  especially 
about  the  pubic  bones.  The  temperature  of  the  bodj^  is  not  increased,  at 
this  stage  scarcely  altered,  although  later  in  the  disease  it  may  be  decidedly 


GLUCOSURIA  801 

lowered.  If  the  further  progress  of  the  disease  is  not  arrested,  a  voracious 
appetite  becomes  the  next  symptom,  notwithstanding  which  the  patient 
observes  that  he  slowly  loses  in  weight  and  grows  daily  weaker.  Extreme 
languor  and  weakness  are  characteristic.  The  rapidity  with  which  these 
symptoms  succeed  one  another  varies.  Sometimes  the  course  is  very  rapid, 
constituting  an  acute  form;  at  other  times  the  successive  stages  are  ex- 
ceedingly slow  in  developing  chronic  diabetes. 

The  early  loss  of  sexual  desire  is  common. 

Blood-pressure  in  Diabetes. — The  results  of  different  observers  as  to 
blood-pressure  in  diabetes  are  not  uniform.  Ovir  own  experience  would 
go  to  show  that  blood-pressure  is  certainly  not  increased  in  this  disease 
per  se.  Eliminating  complications,  the  tendency  is  to  be  normal  or  below 
the  normal,  say  1 15-130.  Where  complicated  with  arterio-sclerosis,  a 
very  frequent  complication,  of  diabetes  or  by  nephritis,  blood-pressure 
is  higher,  reaching  sometimes  160  or  more.  These  results  are  in  accord 
with  those  of  Vaquez,  Hensen,  Theodore  C.  Janeway  and  Arthur  R. 
Elliott,^  of  Chicago,  as  contrasted  with  Potain,  Jaques  Mayer,  Tiessier 
Schott,  Ebstein  and  others. 

Alterations  in  the  Blood. — It  has  already  been  mentioned  that  in  di- 
abetes the  blood  becomes  highly  charged  with  glucose  ("hyperglucemia") 
which  increases  from  a  normal  of  0.05  to  0.15  per  cent,  to  02  per  cent., 
and  in  extreme  cases  to  0.57  per  cent.,  and  from  this  hyperglycemia  comes 
glycosuria.  From  the  presence  of  the  first  we  should  naturally  expect  a 
higher  specific  gravity  of  the  blood-serum,  which  has  been  found  as  high  as 
1033,  as  contrasted  with  the  normal  1028.  On  the  other  hand,  the  serum 
has  been  found  thinner  than  normal,  containing,  according  to  different 
analyses,  from  80.2  to  84.8  of  water  instead  of  the  normal  78  to  79  per  cent. 
The  red  blood-disks  are  often  diminished.  The  alkalinity  of  the  blood  is 
also  lowered,  and  as  such  diminution  is  at  a  maximum  when  oxybutyric 
acid  is  being  excreted,  it  has  been  ascribed  to  the  presence  of  this 
substance. 

An  abnormal  amount  of  fat  in  the  blood,  producing  the  technical 
lipemia,  was  observed  by  the  earliest  students  of  diabetes,  and  is  attested 
by  many  analyses,  as  well  as  by  the  milk  appearance  of  the  serum  and  the 
intraocular  appearances  described  by  Albert  G.  Heyl.  The  analyses  of 
Simon  shown  from  2  to  2.4  per  cent,  instead  of  the  normal  i  per  cent. 

Dyspeptic  symptoms  m.B.Y  appear  at  various  stages,  seldom  very  early. 
Acid  eructations,  flatulence,  and  epigastric  pain,  or  an  indescribable  sen- 
sation described  as  "sinking"  of  the  epigastrium,  are  among  them.  Exces- 
sive hunger  amounting  to  boulimia  is  frequently  though  not  constantly 
present.  Constipation  is  sometimes  a  very  troublesome  symptom,  and 
adds,  in  our  experience,  to  the  seriousness  of  the  case;  on  the  other  hand, 
diarrhea  is  occasionally  present. 

The  foregoing  category  includes  aU  the  symptoms  which  present  them- 
selves in  the  milder  'form  of  the  disease.  In  severe  cases  all  these  symp- 
toms become  intensified.  The  patient  complains  of  constant  burning 
thirst,  is  continually  urinating,  and  as  constantly  drinking  water  to  quench 


1  "Clinical  study  of  Blood-pressure  Variations  in  Diabetes  and  their  Bearing  on  the  Cardiac  Compli- 
cations," "Jour,  of  Amer.  Med.  Assoc,"  July  6,  1907. 


802  CONSTITUTIONAL  DISEASES 

his  thirst,  and,  while  often  eating  enormously,  grows  emaciated,  although 
at  the  onset  of  the  disease  he  may  have  been  a  robust,  vigorous  man. 

As  the  disease  advances  there  is  a  peculiar  vinous  or  acetous  odor  of 
the  breath,  which  has  been  compared  to  that  of  stale  beer,  and  by  Sir 
Thomas  Watson  to  the  odor  of  a  place  in  which  apples  are  kept.  This 
is  believed  to  be  due  to  ,/?-oxybutyric  acid  in  the  blood  of  severe  cases  of 
diabetes,  and  which  shows  in  the  urine  as  diacetic  acid  and  acetone. 

Complications. — Bails  and  carbuncles  in  the  skin  are  also  of  frequent 
occurrence,  favored  by  the  malnutrition  growing  out  of  diabetes,  and  the 
former  are  occasionally  the  first  symptoms  recognized.  The  latter  never 
occur  early,  but,  when  present,  are  frequently  the  immediate  cause  of 
death. 

Gangrene  of  various  parts  of  the  body  is  another  of  this  class  of  symp- 
toms. It  is  sometimes  spontaneous,  but  more  frequently  is  immediately 
caused  by  some  trifling  injury  which,  under  other  circumstances,  would  be 
without  result.  It  has  been  known  to  start  from  a  blister  and  from  the 
cutting  of  a  corn.  Beginning  most  frequently  in  those  parts  of  the  body 
most  remote  from  the  center  of  the  circulation,  as  the  toes,  its  progress 
and  appearances  are  like  those  of  senile  gangrene.  Sometimes,  however, 
the  gangrene  is  moist. 

Eczema,  with  itching  and  burning  of  the  labia  and  "vicinity,  is  a  fre- 
quent and  troublesome  symptom  in  women  incident  to  the  extremely 
frequent  micturition.  In  the  male  the  meatus  urinarius  is  sometimes 
the  seat  of  a  similar  irritation.  Eczema  elsewhere,  as  on  the  palms  of 
the  hands,  is  also  a  symptom.  Tuberculosis  occurs  frequently.  Roberts 
thinks  it  occurs  in  one-half  the  cases. 

Acidosis. — The  presence  of  diacetic  acid  and  acetone  in  the  blood 
is  the  result  of  the  /3-oxybutyric  acid  in  the  blood.  It  occurs  in  many 
of  the  very  severe  cases  and  in  every  case  where  a  patient  is  suddenlj' 
deprived  of  his  carbohydrates.  The  latter  is  not  due  to  diabetes  but  is 
piu-ely  alimentarj^ — the  real  index  of  acidosis  is  the  daily  output  of  nitrogen 
in  the  urine.  Acidosis  may  be  a  danger  signal  but  under  proper  treat- 
ment may  last  a  long  while  without  danger,  it  is  characterized  by  a  heavy' 
^'inous  odor  on  the  breath  and  the  reaction  of  the  urine  to  the  chloride  of 
iron  test.  When  the  toxic  symptoms  occtur  the  patient  passes  into  diabetic 
coma,  first  described  by  Kussmatd  in  1874.  This  is  a  form  of  coma  which 
often  comes  on  in  advanced  stages  of  diabetes  and  terminates  in  death. 
The  condition  is  one  of  suddenly  or  gradually  supervening  unconsciousness, 
mth  or  without  pre\'ious  irritability  or  uneasiness,  anxiety,  vertigo,  or 
symptoms  resembling  alcoholic  intoxication.  Sometimes  it  is  preceded 
by  obstinate  constipation  or  intestinal  catarrh  or  severe  colick}-  and  mus- 
cular pain.  Convulsions  do  not  occur,  but  the  eyes  are  half  open,  the  pupils 
dilated,  and  the  eyeballs  wandering.  In  addition  to  coma  there  are 
frequent  and  feeble  pulse,  deep  inspiration,  ■wdth  short  expiration,  more 
or  less  frequent  than  in  health,  an  actual  air  hunger  and  gradually  invading 
cyanosis.  The  temperature,  at  first  slightly  elevated,  is  subsequently 
subnormal.  The  condition  lasts  for  from  24  to  48  hours,  when  death 
supervenes.  _ 

Severe  neuritis  in  the  brachial  and  crural  ner\'es  is^not  infrequent. 


GLUCOSURIA  803 

In  grave  cases  the  tendon  reflexes  are  diminished  or  absent.  Unilateral 
sweating  has  been  observed.  Senator  refers  to  three  cases — two  of  the 
left  half  of  the  face  and  one  of  the  right.  Edema  sometimes  appears 
late  in  the  disease,  and  is  not  necessarily  the  result  of  renal  complication. 

Among  the  rarer  complications  is  cataract,  the  association  of  which  with 
diabetes  was  long  ago  noticed  by  Prout.  It  develops  rapidly  and  is  nearly 
always  symmetrical,  involving  both  eyes  simultaneously,  but  not  to  the 
same  degree.  It  is  sometimes  a  very  nice  point  to  determine  whether 
cataract  is  due  to  diabetes  or  to  the  usual  causes.  The  earlier  the  age 
at  which  it  occurs,  the  more  probably  is  it  due  to  diabetes. 

Other  visual  defects  may  occur.  Among  these  are  myopia,  ambly- 
opia, presbyopia,  and  loss  of  accommodating  power  from  defect  of  the  ciliary 
muscle.  George  E.  de  Schweinitz  informs  us  that  a  sudden  develop- 
ment of  myopia  between  the  40th  and  60th  years  without  apparent  lesion 
is  characteristic  of  diabetes.  It  may  be  due  to  fine  edema  of  the  choroid, 
or  a  choroiditis  which  in  turn  determines  an  elongation  of  the  axis  of  the 
eyeball  and  thus  produces  myopia. 

The  ophthalmoscope  may  reveal  dilatation  of  the  retinal  vessels.  Many 
years  ago  Albert  G.  HeyP  described  a  condition  which  he  called  intra-ocular 
lipemia,  in  which  the  light  salmon  color  of  the  blood  contained  in  the 
branches  of  the  retinal  vein  and  artery  contrasted  with  the  cinnabar-red 
of  the  vein  and  yellow-red  of  the  artery,  also  by  the  greater  width  of  these 
vessels  and  the  lighter  yellow  of  the  fundus.  Finally,  atrophy  of  the  retina 
and  hemorrhagic  and  inflammator)^  affections  of  the  eye  have  been  de- 
scribed, and  total  blindness  has  been  ascribed  to  the  first  named.  ^  De- 
rangements of  other  special  senses  said  to  attend  diabetes  are  impairment 
of  hearing,  roaring  in  the  ears,  and  derangement  of  smell  and  taste. 

A  spongy  state  of  the  gums,  with  recession  and  excavation,  is  an  oc- 
casional complication,  resulting  in  extreme  cases  in  absorption  of  the 
alveolar  processes  and  falling  out  of  the  teeth,  called  pyorrhea  alveolaris. 

Changes  in  the  Urine. — The  peculiarity  of  diabetic  iirine  most  notice- 
able to  the  patient  is  its  enormous  quantity,  which  has  been  known  to 
exceed  70  pounds  (31.78  kilos)  in  24  hours,  while  apocryphal  accounts 
of  larger  amounts  are  extant.  From  70  to  100  ounces  (2100  to  3000  c.c.) 
are  frequent  quantities.  The  quantity  of  urine  passed  is  limited  by  the 
amount  of  fluid  ingested,  for  while  it  is  possible  that  the  amount  of  the 
former  secreted  may  exceed  for  a  very  short  period  the  quantity  of  the 
latter  ingested,  it  is  evident  that  this  cannot  continue  for  any  length  of 
time,  and,  in  point  of  fact,  it  is  found  to  be  almost  invariably  a  Uttle  less, 
the  remainder  being  removed  by  the  lungs,  skin,  and  bowels. 

But  the  most  important  change  is,  of  coxirse,  the  presence  of  glucose. 
Of  this,  the  quantity  varies  greatly  in  different  cases  and  at  different 
times  in  the  same  case.  The  sugar  should  be  easily  recognizable  by  the 
ordinary  tests  and  should  be  constant.  From  what  may  be  indicated  as 
"evident  traces"  the  proportion  of  sugar  may  reach,  it  is  said,  as  much 
as  IS  per  cent.  Reports  of  larger  quantities  are  made  which  can  scarcely 
be  credited.     The  24  hours'  quantity  varies  similarly. 

1  "Lipemia  and  Fat  Embolism  in  Diabetes  Mellitus,"  "N.  Y.  Med.  Rec."  vol.  xvii.,  p.  477, 1880. 

2  Dufresne,  "De  1'  Amblyopic  Diab^tique,"   "Gaz.  Heb.,"  November,  1861. 


804  CONSTITUTIONAL  DISEASES 

Concurrent  with  the  increase  in  quantity  of  urine  is  an  absence  of 
color,  which  in  extreme  degrees  is  almost  total,  so  that  the  urine  may  be 
as  clear  as  spring  water.  More  frequently  it  is  perfectly  clear  but  of  a 
greenish  hue.  Almost  all  diabetic  urine,  sooner  or  later  after  exposure 
at  a  moderate  temperature,  becomes  cloudy  from  the  development  of 
fimgi  coincident  with  fermentation.  The  odor  of  the  virine  is  usually 
normal  when  first  passed,  but  sooner  or  later,  in  consequence  of  fermenta- 
tion setting  up,  it  may  acquire  an  acetous  odor.  The  latter  change  also 
increases  the  normal  acid  reaction  and  maintains  it  much  longer  after 
exposure  to  the  air  than  is  the  case  with  normal  urine.  This  acetous 
odor  is  ascribed  to  acetone  and  diacetic  acid.  The  urine  may  have  a  sweetish 
odor  when  passed,  which  has  been  compared  to  "sweet  brier."  Diabetic 
urine  is  sometimes  quite  free  from  sediment.  At  other  times  there  is  a 
copious  sediment  of  iiric  acid.  In  the  sediment  may  also  be  included  the 
peniciliuni  fungus,  common  to  acid  urine,  as  well  as  the  more  characteristic 
yeast  or  sugar  fungus,  or  the  torula  cerivisicB.  This  also  sometimes  appears 
as  a  mold  on  the  surface  of  the  iirine. 

Of  abnormal  constituents,  albumin  is  often  present — perhaps  in  one- 
third  of  all  cases;  some  make  it  a  larger  proportion,  some  less.  The  albu- 
minuria is  not  generally  large  and,  in  our  experience,  is  not  often  a  serious 
symptom. 

Finally,  acetone,  diacetic  acid,  and  beta-oxybiityric  acid  arc  all  frequently 
met  in  diabetic  urine.  Source  of  these  substances  may  be  either  protein  or 
fat,  the  fatty  acids  probably  constituting  the  chief  source,  diacetic  or  aceto- 
acetic  acid  being  probably  first  formed  and  rapidly  transformed  into  ace- 
tone. '  When  but  little  diacetic  acid  is  produced,  it  is  all  converted  into 
acetone;  when  much  is  formed,  both  substances  appear  in  the  urine.  The 
conversion  takes  place  mainly  in  the  mine,  but  doubtless  also  in  the  tissues 
or  the  blood,  since  acetone  may  be  present  in  the  expired  air.  To  acetone 
is  ascribed  the  ^dnous  odor  sometimes  present  in  the  urine.  Acetone  is 
produced  in  health  in  a  slight  amount  in  the  normal  decomposition  of 
albumin,  freely  in  certain  diseases  other  than  diabetes.  According  to 
von  Noorden,  these  substances  are  formed  in  the  disintegration  of  the 
albumin  of  the  body  and  not  of  the  food — in  a  word,  when  the  patient  is 
"consuming  liis  own  proteids." 

Duration. — Though  the  course  of  a  few  cases  of  diabetes  is  so  rapid 
as  to  justify  the  name  acute,  the  nvunber  of  these  cases  is  not  sufficient 
to  justify  a  classification  into  acute  and  chronic.  In  such  rapid  cases 
death  has  taken  place  at  periods  ranging  from  two  days  to  six  weeks,  yet 
in  no  instance  can  it  be  averred  that  the  disease  was  of  as  short  duration 
as  it  seemed,  since  it  may  have  existed  some  time  before  it  was  discovered, 
while  in  several  it  was  evidently  of  longer  duration.  It  is  true,  therefore, 
that  diabetes  mellitus  is  a  disease  almost  invariably  of  long  duration. 
Cases  of  15,  18,  and  20  years'  duration  are  reported.  Tyson  has  had  a 
number  of  cases  under  his  care  for  more  than  ten  j-ears.  The  }-ounger  the 
subject,  the  shorter  the  duration  and  the  more  promptly  fatal  the  result, 
while  after  middle  age,  by  treatment,  the  duration  may  be  indefinitely 
prolonged. 

Diabetes  mellitus  is  sometimes  distinctly  intermittent  for  a  time,  re- 


GLVCOSURIA  805 

gardless  of  treatment.  Experience  has  taught  us  that  a  form  of  diabetes 
occtirs,  in  which  both  polyuria  and  glycosuria  may  disappear  without 
treatment,  to  recur  again.  Such  cases  are,  however,  easily  controlled  by 
treatment  when  discovered,  while  they  are  as  certain  to  pass  over  into 
the  permanent  form  if  neglected. 

Diagnosis. — The  diagnosis  of  daibetes  mellitxis  is  very  easy,  yet  it 
is  often  long  overlooked  by  the  practitioner.  Unnattiral  thirst  and  copious 
dixiresis  should  always  suggest  a  chemical  examination  of  the  urine,  and 
although  there  are  sources  of  error  in  testing  for  small  quantities  of  sugar, 
the  quantities  thus  overlooked  are  not  usually  of  clinical  significance. 
In  fact,  glucose  is  more  frequently  declared  present  by  inexpert  examiners 
when  absent  than  the  reverse.  Almost  any  one  of  the  tests,  therefore, 
which  are  foimd  in  the  various  manuals  for  the  examination  of  mine, 
apphed  with  ordinary  care,  will  respond  readily  to  quantities  which  are 
of  clinical  significiance.  Lactose  in  the  urine  of  women  due  either  to  the 
appearance  of  milk  in  the  breast  after  birth  of  a  child  or  its  disappearance 
at  the  end  of  lactation  ■n'ill  reduce  Fehling's  solution  just  as  it  is  reduced 
by  glucose.  However  it  •wall  not  be  fermented  by  yeast  and  can  thus  be 
distinguished. 

In  using  Fehling's  solution^  a  given  quantit}^  one  c.c,  of  Fehling's  solu- 
tion is  placed  in  a  test-tube,  diluted  with  about  four  times  its  bulk  of  water, 
and  boiled  for  a  few  seconds.  If  the  solution  remains  clear,  add  immediately 
the  suspected  urine,  drop  by  drop.  If  sugar  is  abundant,  the  first  few  drops 
wiU  usually  cause  the  red  or  yellow  precipitate,  but  if  the  reaction  does 
not  occur,  the  dropping  may  be  continued,  followed  each  time  by  heating 
until  an  equal  volume  has  been  added.  If  no  red  or  yellow  precipitate 
occitrs,  sugar  is  absent.  Now,  Fehling's  solution  is  so  composed  that 
if  an  equal  volume  is  exactly  reduced  by  an  equal  volume  of  urine,  that 
urine  contains  one-half  of  one  per  cent,  of  glucose;  if  h\  half  bulk,  one  per 
cent.;  if  twice  the  bulk,  one-fourth  per  cent.,  and  so  on,  whence  one  can 
easily  estimate  roughly  the  percentage.  Should  the  urine  contain  more 
than  one  per  cent,  of  sugar,  it  should  be  diluted  one  to  ten  and  the  result 
multiplied  by  ten. 

If  a  reduction  takes  place  on  boihng  the  test  fluid  alone,  a  new  supply 
may  be  obtained,  or  a  little  more  soda  or  potash  may  be  added,  the  fluid 
filtered,  and  it  is  again  ready  for  use.  Such  spontaneous  reduction  of  the 
cuprous  oxid  often  occiu-s  when  FehUng's  solution  is  kept  for  some  time. 

In  judging  the  progress  of  a  case  of  diabetes  under  treatment  it  is 
not  sufficient  to  test  the  urine  qualitatively,  but  a  quantitative  determi- 
nation of  sugar  must  be  made.  This  may  be  done  by  the  cUnical  method 
just  described  or  by  volumetric  processes  described  in  the  manuals  for 
the  examination  of  urine,  but  the  simplest  process  is  the  (3)  fermentation 
method  of  Roberts.     In  this  the  specific  gravity  of  the  urine  is  taken  be- 

^  Fehling's  Solution. — Dissolve  34.652  gm.  of  pure  crystallized  sulphate  of  copper  in  200  gm.  of  dis- 
tilled water;  175  gm.  of  chemically  pure  crystallized  neutral  sodic  tartrate  in  480  gm.  solution  of  caustic 
soda  of  specific  gravity  1.14.  and  into  this  basic  solution  the  copper  solution  is  poured,  a  little  at  a  time 
The  clear  mixed  fluid  is  diluted  to  one  liter,  or  1000  c.c. 

Ten  c.c.  of  this  solution  will  be  reduced  by  0-05  gm.,  or  50  milligrams,  of  diabetic  sugar.  If  Fehling's 
solution  is  to  be  kept  some  time,  it  is  absolutely  essential  that  it  should  be  placed  in  smaller  bottles  holding 
from  40  to  80  gm.,  sealed,  and  kept  in  a  cellar. 

Still  greater  security  may  be  obtained  by  dissolving  the  cupric  sulphate  in  50Q  c.c.  and  the  tartrate, 
salt  and  potash  in  500  c.c,  keeping  the  two  solutions  separate  in  lubber-stoppered  bottles.  Equal  volumes 
of  the  two  solutions  are  united  when  needed  for  use. 


806  CONSTITVTIOXAL  DISEASES 

fore  and  after  fermentation,  and  the  difference  in  the  two  results  indicates 
the  number  of  grains  of  sugar  in  each  fiuidounce  of  urine.  Suppose,  then, 
the  specific  gravity  before  fermentation  to  be  1045,  ^-^^d  after  fermentation 
1035:  the  quantity  of  sugar  is  ten  grains  to  the  fiuidounce,  or  0.65  gm.  in 
30  c.c.     These  figures  can  be  reduced  to  percentage  by  multiplying  by  0.23. 

Tests  for  Acetone,  Diacetic  Acid,  and  Oxybutyric  Acid. — In  view  of  the 
important  role  in  prognosis  assigned  to  acidosis  the  regular  examination 
of  the  urine  for  diacetic  acid  becomes  almost  as  important  as  that  for  sugar. 
Of  the  ntmierous  tests  for  acetone,  most  of  which  require  the  distillate  for 
their  successful  application,  Legal's  nitroprussid  of  sodium  test  is  the  most 
satisfactor}-  for  the  practitioner,  because  it  does  not  require  the  distillate. 

Legal's  Test  for  Acetone. — A  fresh,  rather  strong  solution  of  sodium 
nitroprussid  is  made  by  dissolving  a  few  fragments  in  a  little  water  in  a 
test-tube.  To  three  or  four  c.c.  of  the  suspected  urine  add  enough  liquor 
sodae  or  potassse  to  secure  a  distinct  alkaline  reaction.  To  the  mixture 
then  add  a.  few  drops  of  the  nitroprussid  solution,  when  the  whole  qiiickly 
assumes  a  red  color,  whether  acetone  is  present  or  not,  said  to  be  pro- 
duced by  creatinin  even  more  rapidly  than  by  acetone.  In  any  event 
the  red  color  disappears;  but  if  acetone  is  present,  the  addition,  of  a  few 
drops  of  concentrated  acetic  acid  causes  a  purple  or  violet-red  color.  If 
there  is  no  acetone,  this  final  change  does  not  occur,  while  the  purple 
color  also  fades  in  a  little  while,  even  if  caused  by  acetone. 

To  test  for  diacetic  acid  add  a  few  drops  of  a  15  per  cent,  solution  of 
neutral  or  only  slightly  acid  ferric  chlorid  to  a  small  quantity  of  the  urine, 
when  a  beautiful  Burgundy-red  reaction  occurs.  A  precipitate  of  phos- 
phates succeeds  the  adding  of  the  first  few  drops,  but  this  is  redissolved  by  a 
further  addition  of  the  chlorid.  The  test  is  confirmed  if,  after  heating  the 
original  fliiid,  there  is  no  response  on  application  of  the  chlorid  of  iron — 
the  effect  of  heat  being  to  dissipate  the  diacetic  acid.  A  more  brilliant 
reaction  is  obtained  if  the  urine  be  first  treated  with  a  solution  of  acetate 
of  lead,  filtering  out  the  white  precipitate  and  testing  the  filtrate.  Urine 
passed  after  the  administration  of  salicyhc  acid,  antipyrin,  carbolic  acid, 
salol,  phenocol,  kairin  and  other  drugs  furnishes  a  similar  reaction. 

Prognosis. — The  prognosis  of  diabetes  varies  vnth.  the  age  at  which  the 
disease  malces  its  appearance,  the  time  which  has  been  allowed  to  elaspe 
before  treatment  is  instituted,  and  the  treatment  itself.  Once  thoroughly 
established  early  in  life,  or  before  25  years  of  age,  recover^'  is  rarely  pos- 
sible, but  even  at  this  age,  if  treatment  is  instituted  sufficiently  early, 
much  may  often  be  done  to  avert  the  end.  Diabetes  is  a  disease  in  which 
the  expectant  plan  of  treatment  is  disastrous.  It  is  a  disease  which  never 
gets  well  of  itself,  and  usually  gets  worse  if  not  properly  treated.  At  the 
same  time  the  mild  cases  amenable  to  treatment  are  in  a  decided  majority. 
When  the  disease  appears  after  middle  life  in  fat  persons  or  those  disposed 
to  gout,  and  is  early  recognized  and  promptly  treated,  it  is  usually  easily 
controlled;  it  is  never  safe  to  declare  a  case  of  diabetes  absolutel}'  cured. 
As  a  rule,  however,  even  those  who  have  apparently  recovered  must  keep 
a  watch  upon  their  diet,  and  should  at  inter\'als  have  their  urine  examined 
with  a  view  to  sounding,  as  it  were,  their  condition.  We  are  entirely  justi- 
fied in  saying  to  a  diabetic  patient,  "As  long  as  your  urine  remains  free  of 


GLUCOSURIA  807 

sugar  you  are  practically  as  well  as  if  j'ou  had  no  tendency  to  diabetes." 
On  the  other  hand,  for  spare,  nervous,  and  hard-worked  persons,  especially 
mentally  overworked,  under  40,  there  is  a  much  more  unfavorable  outlook. 
Even  here,  if  the  co-operation  of  the  patient  can  be  secured,  much  maj-  be 
done.  Every  intermediate  degree  of  seriousness  may  occur.  The  cause  of 
death  is  very  frequently  some  intercurrent  or  consequent  disease,  as  phthisis 
or  diabetic  coma.  "If  there  is  such  a  thing  as  complete  recover}^  from  the 
disease  diabetes  mellitus  it  must  be  by  a  resumption  of  normal  carboh}-- 
drate  metabolism.  Now  such  return  is  favored  by  a  rest  of  the  gh-cogenic 
function  by  taking  away  its  office.  Hence  the  importance  of  completely, 
or  as  nearly  as  possible  removing  the  sugar  from  the  urine  and  in  the 
earliest  stages  cutting  out  carbohydrate  food.  If  the  crabohydrate  met- 
abolism is  eliminated  by  the  removal  of  foods  demanding  this  function, 
the  rest  thus  secured  permits  a  resimaption  of  function  more  or  less  com- 
pletely. Now  in  the  early  stages  of  the  disease  this  is  both  possible  and 
safe.  Hence  the  treatment  must  be  sufficiently  \-igorous  from  the  outset  to 
keep  the  sugar  out  of  the  blood  as  well  as  the  urine.  And  when  the  blood  is 
sugar  free  the  greatest  pains  should  be  taken  to  keep  it  so." — von  Noorden. 

Treatment. — This  resolves  itself  easily  into  the  dietetic,  the  hygienic, 
and  the  medicinal. 

I.  Dietetic  Treatment. — This  is  by  far  the  most  efficient,  and  no  per- 
manent results  have  ever  been  obtained  -nHlthout  it.  It  consists  essentially 
in  the  elimination  from  the  diet  of  such  articles  as  are  readily  convertible 
into  glucose — viz.,  the  carbohj^drates.  It  is  acknowledged  that  in  the 
early  stages  of  the  disease  only  the  saccharine  and  amylaceous  foods  fail 
to  be  consumed  in  the  economy  in  the  usual  way  and  appear  in  the  urine 
as  glucose.  Hence,  if  these  be  excluded  from  the  diet  and  their  place 
supplied  by  other  assimilable  articles,  the  symptom  disappears,  and  the 
disappearance  of  this  symptom  seems  to  be,  for  the  time  being  at  least, 
the  cure  of  the  disease.  In  excluding  the  carbohydrates  it  must  be  care- 
fully arranged  that  the  patient  receives  enough  and  not  too  much  food. 
The  value  of  calories  in  an  ordinary-  serving  will  be  found  in  the  Hst  of  foods 
allowable  in  diabetes. 

The  correct  treatment  of  diabetes  mellitus  demands  the  full  appre- 
ciation of  three  undoubted  facts: 

First,  each  case  of  diabetes  is  a  problem  in  itself.    " 

Second,  the  presence  of  sugar  in  the  urine  proves  that  the  indi^-idual 
is  taking  into  his  stomach  food  which  cannot  be  converted  into  energj', 
or  the  already  energized  food  is  being  excreted  in  the  form  of  sugar.  These 
two  facts  mean  that  the  person  is  on  starvation  diet. 

Third,  the  presence  of  glucose  in  the  urine  means  that  at  any  time, 
perhaps  at  the  time  of  examination,  substances  may  be  found  which  are 
poisonous  to  the  economy.  These  circulating  in  the  blood  may  cause 
death. 

These  postulates  being  accepted  as  facts,  treatment  becomes  a  question 
of  dietetics  and  hygiene.  Drug  exhibition  taking  an  entirely  secondary 
place  though  a  helpful  one. 

In  treating  diabetes  mellitus  we  must  realize  that  cases  fall  naturally 
into  three  classes,'^  first,  those  individuals  past  middle  life  who  without 


808  CONSTITUTIONAL  DISEASES 

treatment  have  constantly  a  fairly  large  amount  of  sugar  and  no  acetone 
bodies  in  the  virine,  who  are  well  nourished  and  apparently  in  perfect 
health;  second,  those  patients  who  are  on  the  border  line,  who  from  in- 
discretion or  advancement  of  the  condition  can  take  but  little  carbohydrates 
and  often  have  acetone  bodies  in  the  urine;  third,  those  usually  in  the 
earlier  years  of  life  who  suffer  in  many  ways,  who  are  distinctly  ill,  and  who 
sooner  or  later  succumb. 

Treatment  of  the  First  Class. — It  must  be  remembered  that  notwith- 
standing such  individuals  are  apparently  in  perfect  health,  that  they  suffer 
frequently  from  neuritis,  vertigo,  fiu-unculosis,  optic  neuritis;  that  they  lend 
themselves  as  easy  prey  to  any  infection;  that  they  are  subject  at  any 
time,  from  any  indiscretion,  to  a  sudden  acid  intoxication  which  may 
end  their  lives,  or  that  they  may  fall  a  victim  verj'  easily  to  suppuration 
or  gangrene. 

Therefore,  such  individuals  should  be  under  careful  supervision. 

General  Treatment  of  Slight  Cases. — It  is  very  generally  taught  at  the 
present  time,  that  rather  rapid  and  prolonged  withdrawal  of  carbohydrate 
food  in  such  individuals  is  likely  to  precipitate  a  fatal  acidosis.  Such 
has  not  been  our  personal  experience.  Surely  diacetic  acid  and  acetone 
appear  in  the  urine  under  such  circumstances,  but  it  rarely  does  harm. 
Von  Noorden  is  of  this  same  opinion  when  he  says  (New  Aspects  of  Diabetes, 
19 12):  "The  sugar  in  the  turine  diminishes  and  reaches  zero  after  a  few 
days  of  strict  diet.  But  about  two  or  three  days  after  we  have  excluded 
the  carbohydrates,  we  are  horrified  at  finding  a  strongly  positive  reaction 
with  chloride  of  iron;  a  quantitative  estimation  gives  about  i  gram  of 
acetone  and  2  to  5  grams  of  oxybutyric  acid,  or  perhaps  considerably  more. 
Unless  the  rationale  of  the  formation  of  acetone  is  well  understood,  the 
"strict  diet"  will  usually  at  once  be  abandoned.  The  doctor  fearing  the 
development  of  coma,  will  order  carbohydrate  food  perhaps  in  lavish  quan- 
tities and  with  precipitant  haste.  But  he  is  -wrong.  Bj^  this  he  throws 
away  all  his  chances  of  practically  influencing  the  morbid  processes  peculiar 
to  diabetes.  This  acetonuria  is  entirely  physiological;  healthy  individuals 
would  have  behaved  in  exactl}'  the  same  manner,  if  put  upon  the  same  diet. 
It  is  an  alimentary  and  not  a  diabetic  acetonuria.  If,  undeterred,  we  con- 
tinue upon  the  strict  diet,  the  acetonuria  will  again  disappear  in  about  eight 
to  fourteen  days,  and  the  normal  formation  of  acetone  wiU  again  be  estab- 
lished. In  the  many  thousand  cases  which  I  have  treated  in  the  course  of 
years,  I  have  never  seen  one  mishap  due  to  the  continuance  of  the  strict  diet 
under  these  circumstances." 

Therefore,  such  cases  should  within  a  week  begin  an  entirely  carbohy- 
drate free  diet,  great  care  being  taken  that  a  sufficient  amount  of  food  be 
given  to  keep  the  patient's  general  health  in  equilibrivun.  For  this  piu^pose 
the  following  list  taken  from  Janeway  ma}'  be  used  or  one  constructed  from 
the  list  on  page  813  of  this  book. 


GLVCOSURIA  809 

STANDARD  STRICT  DIET. 

Breakfast. 

2  Eggs. 

Ham,  90  grams  (3  ounces). 
Coffee,  with  45  grams  (i  1/2  ounces)  cream. 

Butter,  15  grams  (1/2  ounce)  on  the  biscuit  during  the  test  period;  cooked  with  the 
eggs  if  no  biscuit  or  bread  is  taken. 

Luncheon. 

Meat,  (steak  or  chop)  120  grams  (1/4  pound). 

Green  vegetables  (asparagus,  beet  greens,  Brussels  sprouts,  cabbage,  cauliflower, 
celery,  chicory,  cresses,  cucumbers,  egg-plant,  endive,  kohl-rabi,  leeks,  lettuce,  okra, 
pumpkin,  radishes,  rhubarb,  salsify,  sauerkraut,  spinach,  string  beans,  tomatoes,  vege- 
table marrow. 

White  wine,  2  claret  glasses  (6  ounces)  or 

Whiskey,  or  brandy,  2  tablespoonfuls  (i  ounce). 

Butter,  15  grams  1/3  ounce,  with  the  green  vegetables  if  no  biscuit  or  bread  is  taken. 

Afternoon  tea  with  15  grams  (1/2  ounce)  of  cream. 

Dinner. 
Any  clear  soup. 
Fish,  90  grams  (3  ounces). 

Meat  (beef,  mutton,  turkey  or  chicken)  120  grams  (1/4  pound). 
Green  vegetables  from  this  list,  2  tablespoonfuls. 
Salad  with  15  grams  (1/2  ounce)  of  oil  in  the  dressing. 
Cream  cheese,  30  grams  (l  ounce). 
White  wine,  2  claret  glasses  (6  ounces)  or 
Whiskey  or  brandy,  2  tablespoonfuls  (l  ounce). 
Demitasse  of  coffee. 

Butter  30  grams  (i  ounce)  on  the  fish,  meat  and  green  vegetables,  if  no  bread  or 
biscuit  is  taken. 

Bedtime. 
Bouillion,  with  I  raw  egg. 
Nitrogen — 18  grams.     Total  calories  2550. 
Omitting  ham,  nitrogen — 15  grams.     Total  calories  2200. 

In  from  two  weeks  to  one  month  after  the  urine  is  sugar  free,  the  patient 
may  be  given  carbohydrates  tentativel3^  beginning  with  30  grams  of  white 
bread.  This  may  be  very  slowly  increased,  daily  examination  of  the  urine 
being  raade  to  be  assured  that  no  sign  of  sugar  appears.  When  sugar  ap- 
pears, then  drop  at  cnce  either  to  a  strict  diet  which  usually  is  necessary,  or 
to  one  of  the  diets  with  which  the  patient  did  not  show  sugar  in  the  urine. 

Mild  cases  need  this  constant  care,  because  they  frequently  can  thus  be 
kept  in  excellent  health  and  never  die  of  coma.  Such  cases  imder  such  care 
rarely  need  drugs.  They,  however,  should  avoid  overwork,  overexci  tement, 
and  must  keep  to  their  diet.  These  patients  may  be  given  salicylates 
daily,  10  grains  of  sodium  salicylate,  or  10  grains  of  acid  acetyl  salicylic. 
In  this  way  the  line  of  tolerance  may  be  even  increased.  After  these  cases 
are  well  established  in  their  routine,  they  may  be  given  the  table  found 
on  page  813  of  this  book  for  their  guidance,  but  the  urine  should  be 
examined  every  two  or  three  months  to  make  certain  the  case  is 
progressing  properly.  In  addition  to  these  measures,  it  is  highly  important 
that  the  bowel  movements  be  kept  free.  To  this  end  phenolphthalein  in 
doses  of  5  grains,  three  times  a  day  may  be  used,  or  Rochelle  salts  or 
Epsom  salts.  If  desirable  one  of  the  purgative  waters  may  be  used,  but 
they  are  in  no  way  superior  to  the  ordinary  salines. 

Treatment  of  Borderline  Cases.  (Moderately  severe  cases). — It 
must  be  remembered  that  any  case  of  mild  character,  may  at  any  time  be- 
come a  moderately  severe  cdse  or  a  very  severe  one,  either  by  the  advance 


810  CONSTITUTIONAL  DISEASES 

of  the  lesion  in  the  pancreas  or  by  neglect.  Therefore,  the  great  necessity 
of  keeping  such  a  case  without  even  a  fraction  of  one  per  cent,  of  sugar. 
Attention  to  hygiene  and  to  diatetics  will  usually  do  this  in  these  mild 
cases,  because  of  the  very  slow  advance  of  the  disease  of  the  Islands  of 
Langerhans. 

A  moderately  severe  case  is  one  described  as  being  unable  to  take  60 
grams  of  white  bread  without  the  appearance  of  sugar  in  the  urine,  and 
which  usually  has  acetone  bodies  in  the  urine.  Until  such  a  case  is  well 
started  upon  a  diet  which  will  keep  them  in  the  line  of  safety,  it  is  much 
better  to  have  the  patient  either  in  a  hospital  or  sanatorium,  or  under  a 
trained  nurse.  Daily  examinations  of  the  urine  are  a  necessity.  Careful 
diet  is  imperative.  This  is  usually  impossible  in  a  private  case  left  to  his 
or  her  own  resources. 

Here  the  carbohydrates  must  be  very  slowly  reduced.  It  is  in  these 
cases  where  a  severe  and  dangerous  acidosis  may  occur  if  these  ingredients 
are  rapidly  reduced.  At  least  two  weeks  should  be  occupied  and  the 
symptoms  of  acidosis  carefully  watched  for.  Von  Noorden  says  that,  "in 
accordance  with  our  scheme  of  treatment  we  slowly  reduce  the  input  of 
carbohydrates  to  zero;  the  glucosuria  diminishes,  but  does  not  disappear. 
At  the  same  time,  the  amount  of  acetone  bodies  in  the  urine  rises  consider- 
ably, the  reaction  with  chloride  of  iron  becomes  strongly  positive,  and  we 
find  I  to  2  grams  of  acetone  in  twent^^-four  hours'  urine.  Nevertheless, 
we  persevere  with  the  restricted  diet,  and  the  amount  of  acetone  continues 
to  rise,  or  at  least  remains  very  high.  No  doubt  by  this  we  are  exposing 
the  patient  to  a  certain  amount  of  risk,  but  this  can  be  reduced  to  some  extent 
by  administering  about  10  to  15  grams  of  bicarbonate  of  soda.  We  also 
keep  a  sharp  lookout  on  the  patient,  and  as  soon  as  we  discover  any  symp- 
toms pointing  to  impending  diabetic  auto-intoxication — such  as  headache, 
excitement,  hyperesthesia  of  the  stomach,  etc. —  we  shall  add  carbohydrates 
to  the  diet.  We  have  been  advancing  too  rapidlj^  and  must  wait  a  little 
while,  and  then  begin  again  to  try  and  eliminate  the  carbohydrates."  A 
diet  which  does  well  in  these  individuals  is  one  poor  in  protein.  This  is 
also  taken  from  Janewa^'. 

TABLE  III.— STANDARD  DIET  WITH  RESTRICTED  PROTEIN. 

Bre.^kfast: 

2  eggs. 

Bacon,  ig  grams  (1/2  ounces). 

Coffee  with  45  grams  (i  1/2  ounces)  of  cream. 

Butter  20  grams  (2/3  ounces). 

Lf NCHEON : 
I  egg- 
Bacon,  15  grams  (1/2  ounce). 

Meat  (lamb  chops,  ham  or  beef  steak)  60  grams  (2  ounces). 
Salad  with  15  grams  (1/2  ounce)  of  oil  in  the  dressing. 
White  wine,  2  claret  glasses  (6  ounces)  or 
Whisky  or  brandy,  2  tablespoonfuls  (l  ounce). 
Butter  40  grams  (i  1/3  ounces). 

Afternoon  tea  with  15  grams  (i  1/2  ounces)  of  cream. 

Dinner: 

Any  clear  soup. 

Meat  (roast  pork,  beef,  mutton,  turkey,  or  lamb  chops),  90  grams  (3  ounces). 
Vegetables  and   salads — asparagus,   beet  greens,   brussels  sprouts,   cabbage,   cauli- 
flower, celery,  chicory,  cresses,  cucumbers,  egg-plant,  endive,  kohl-rabi,  leeks,  lettuce, 


GLUCOSURIA  811 

orka,  pumpkin,  radishes,  rhubarb,  salsify,  sauerkraut,  spinach,  string  beans,  tomatoes, 
vegetable  marrow. 

Salad  with  15  grams  (1/2  ounce)  of  oil  in  the  dressing. 

Cream  cheese,  30  grams  (l  ounce). 

White  wine,  2  claret  glasses  (6  ounces)  or 

Whiskey  or  brandy,  2  tablespoonfuls  (i  ounce). 

Demi-tasse  or  coffee. 

Bedtime: 

Bouillion  with  I  raw  egg. 

Nitrogen,  10  grams;  total  calories,  2500. 

Omitting  30  grams  of  butter  and  1/2  ounce  of  bacon,  2250  calories. 

This  diet  list  may  be  persisted  in  until  the  patient's  tuine  is  both  free 
of  sugar  and  acetone  bodies.  When  this  occiu-s,  then  the  more  free  diet 
may  be  used,  the  one  which  is  printed  on  page  S13.  If  in  spite  of  this 
strict  diet,  sugar  and  acetone  both  appear,  then  it  is  vnse  to  put  the  patient 
on  practically  starvation  diet,  or  what  Janeway  caUs  Green  Da^-s.  This 
diet  of  Janeway's  follows.     It  should  be  used  for  two  days. 

TABLE  IV.— GREEN  DAYS. 

Breakfast: 

One  egg,  boiled  or  poached. 
One  cup  of  black  coffee. 

Dinner: 

Spinach,  with  a  hard-boiled  egg. 
Bacon,  15  grams  (1/2  ounce). 
Salad  with  15  grams  (1/2  ounce)  of  oil. 

White  wine,  1/4  liter  (4  ounces)  or  whisky  or  brandy  30  c.c.  (l  ounce). 
4.30  P.  ^.: 

Cup  of  beef  tea  or  chicken  broth. 

Supper: 

I  egg  scrambled,  with  tomato  and  a  little  butter. 

Bacon,  15  grams  (1/2  ounce). 

Cabbage,  cauliflower,  sauerkraut,  string  beans,  or  asparagus. 

White  wine,  1/4  liter  (4  ounces)  or  whisky  or  brand}',  30  c.c.  (i  ounce). 

Sodium  carbonate,  15  to  30  grams  (1/2  ounce  to  I  ounce)  in  24  hours. 

Nitrogen,  s  grams,  carbohydrates,  about  s  grams — calories,  575. 

The  above  limited  diet  shotild  then  be  followed  for  two  days  by  Von 
Noorden's  oatmeal  diet,  and  then  again  the  patient  is  to  be  put  upon  the 
restricted  diet,  as  is  shown  above  in  Table  III. 

TABLE  v.— OATMEAL  DAYS. 

Porridge  made  from  oatmeal,  250  grams  (1/2  pound)  with  butter,  250  grams  (1/2 
pound)  salt  and  pepper  to  taste. 

Black  coffee,  light  white  wine,  1/2  liter,  (8  ounces)  or  cognac,  5o  c.c.  (2  ounces). 
The  whites  of  six  eggs  may  be  added  to  the  porridge  if  desired. 

N.  Calories. 

Oatmeal 6.2         170.  1025 

Butter 0.4  1975 

6 . 6  3000 

Alcohol  (40  grams)  210 

6  eggs  whites  3.6  90 


In  regard  to  this  oatmeal  diet,  Von  Noorden  says  he  was  severely 
criticised  for  suggesting  its  use  at  first.  Now  he  is  forced  to  criticise 
physicians  because  they  use  it  too  freely.  It  should  not  be  used  beyond 
two  or  three  consecutive  days.  After  careful  watching  and  changes  of 
diet,  after  weeks  or  months  perhaps  the  patient  will  be  both  sugar  free  and 
acetone  free,  and  then  perhaps  we  can  add  a  little  carbohydrates  to  the  diet 


812  CONSTITUTIOXAL  DISEASES 

without  the  appearance  of  sugar  in  the  urine.  That  is,  if  the  patient  docs 
not  have  any  hypcrglycinia  and  hence  no  sugar  in  the  urine. 

Treatment,  Severe  Cases. — The  severe  cases  of  diabetes  usually  occur 
in  the  first  three  decades  of  life,  but  as  before  stated  may  occur  at  any  age, 
They  are  those  which  cannot  be  made  sugar  free  by  the  withdrawal  of 
carbohydrates  from  the  food,  in  other  words,  they  manufacture  sugar  in 
the  liver  not  only  from  carbohydrates  but  from  proteins  as  well.  Von 
Noorden  is  of  the  opinion  that  the  albumen  of  meat,  of  casein  and  of  the 
cereals  are  harmful  in  those  conditions  in  the  order  named.  It  is  impor- 
tant in  these  cases,  to  as  much  as  possible  limit  the  proteins  as  well  as  the 
carbohydrates.  Here  the  list  recommended  with  limited  proteins  may  be 
used.     Tabls  III. 

By  severe  cases  one  understands  cases  in  which  by  careful  nursing, 
honest  obedience  on  the  part  of  the  patient,  and  by  strict  diet,  glucose  still 
appears  in  considerable  amounts  in  the  urine,  usually  with  acetone  and 
diacetic  acid.  Here  the  patient  is  best  treated  by  a  more  liberal  diet ;  60  to 
70  grams  of  the  various  starch  foods  are  given  daily.  By  interposing  days 
of  starvation  (Green  Days),  days  of  strict  diet,  and  oatmeal,  the  case  can 
get  along  often  well,  again  getting  back  to  the  diet  containing  starch.  All 
the  time  these  patients  should  be  taking  soda  in  large  amounts. 

Treatment  of  Acidosis. — In  cases  of  slight  glycosuria,  as  stated  before, 
the  acetonuria  which  occurs  when  carbohydrates  are  suddenly  and  com- 
pletely wnthdrawn  may  be  disregarded,  or  they  may  be  given  15  to  20 
grams  of  sodium  bicarbonate  daily. 

In  the  more  severe  forms  a  careful  watch  must  be  kept  and  alkaUcs 
must  be  given  constantly.  The  role  that  alkalies  play  is  not  that  they  pre- 
vent the  formation  of  acid,  they  combine  with  them  and  cause  them  to  be 
more  readily  excreted,  and  prevent  the  extracting  of  the  aU-iali  from  the  blood 
and  tissues. 

In  the  stage  immediately  preceding  coma,  where  acetone  bodies  are 
present  in  the  urine  in  large  quantities,  where  there  is  the  peculiar  air 
hunger  and  tendency  to  somnolence,  alkalies  should  be  freely  used,  both 
by  the  mouth  and  by  intravenous  use  of  sterile  solutions. 

Diet  as  stated  before,  strict  diet,  oatmeal  days,  green  days,  fat  days. 
Often  one  has  to  resort  to  carbohydrates.     The  bowels  must  be  kept  open. 

Feeding  is  important.  Levulose,  100  grams  in  lemonade,  milk  250  c.c. 
every  two  hours,  oatmeal  diet. 

Von  Noorden  suggests  no  food.  Whisk}'  given,  100-150  c.c.  daily, 
will  do  them;  then  after  three  or  four  days,  milk  and  oatmeal,  soups. 

Coma  ends  in  death.  Even  Von  Noorden  wHth  all  his  experience  so 
states.  This  mal<es  the  treatment  very  unsatisfactory.  Nevertheless, 
one  should  persist  in  giving  such  patients  who  are  in  deep  coma,  intravenous 
injections  of  four  per  cent,  sterile  solution  of  bicarbonate  of  soda. 

Drug  Treatment. — Salicylic  acid  perhaps  is  the  best  drug,  but  the 
opiates  in  the  form  of  opium  or  codein  are  most  valuable. 

Health  Resorts. — Residence  at  the  various  health  resorts,  is  sometimes 
valuable  for  several  reasons.  In  the  first  place,  the  patients  learn  that 
strict  diet,  attention  to  their  general  health,  and  obedience  to  orders  mil 
make  them  feel  well,  and  perhaps  will  teach  them  to  follow  the  instructions 


GLUCOSURIA  813 

learned  at  these  institutions,  when  they  get  back  to  their  ordinary  condi- 
tions of  life;  but  if  a  patient  goes  to  a  health  resort  wth  the  idea  that  a 
few  weeks  or  months'  residence  there  will  cure  him,  he  goes  with  entirely 
a  false  idea.  He  must  continue  with  the  instructions  he  received  there 
after  he  goes  home. 

The  cases  must,  when  able  to  be  let  alone,  be  given  diet  tables. 

The  following  classified  svimmary  of  articles  of  food  admissible  for 
diabetics  will  be  found  convenient  for  reference,  with  caloric  value  of  a 
serving  of  each. 

Shell-fish. — Oysters  84  cal.,  mussels  and  clams  50  cal.,  raw  or  cooked  in 
any  way,  without  the  addition  of  flour. 

Fish  of  all  kinds,  fresh  or  salted,  including  lobsters  84  cal.,  crabs  84  cal., 
sardines  269  cal.,  and  other  fish  in  oil;  fish  roe  128  cal.,  ca^^are.  Fish 
average  150  cal.  to  a  serving. 

Meats  of  every  variety  except  livers,  including  beef  144  to  238  cal., 
mutton  362  cal.,  chipped  dried  beef  150  cal.,  tripe,  ham  227  cal.,  tongue, 
bacon  100  cal.,  and  sausages.  Also  poultry  108  cal.,  and  game  of  all  kinds, 
with  which,  however,  sweetened  jellies  and  sauces  should  not  be  used. 

Soups. — Clear  bouillon  and  other  soups,  beef-tea  and  broth  made  with- 
out flotu",  rice,  vermicelli,  or  other  starchy  substances;  and  without  the 
vegetables  named  below  as  inadmissible.  Soups  are  of  very  Httle  caloric 
value  for  16  to  20  cal.  for  each  serving. 

Vegetables. — Cabbage  35  cal.,  cauliflower,  Brussels  sprouts,  broccoH, 
green  string-beans,  the  green  ends  of  asparagus,  spinach,  dandelion,  mush- 
rooms, tomatoes,  lettuce,  endive,  coleslaw,  olives,  cucumber  (fresh  or 
pickled),  radishes,  sorrel,  young  onions,  watercresses,  mustard  and  cress, 
turnip  tops,  celery  tops,  artichokes,  gherkins,  okra,  parsley,  or  any  other 
green  vegetables.     Each  ser\nng  amounts  to  from  8  to  30  cal. 

Bread  and  cakes  made  of  pure  gluten,  bran,  aleuronat,  roborat,  soya, 
peanut-  or  almond-fiour,  inulin,  with  or  without  eggs  and  butter.  Griddle- 
cakes,  pancakes,  biscuit,  porridges,  etc.,  made  of  these  flours.  Oatmeal 
porridge  with  cream.  Where  especial  stringency  is  required,  the  last  should 
be  altogether  omitted.  The  great  difficulty  in  obtaining  pure  gluten  flour 
is  so  great  and  practically  all  the  gluten  breads  on  the  market  contain  much 
starch  that  one  had  much  better  use  white  bread  in  proportion  as  instructed 
above.  The  amount  of  white  bread  can  be  converted  into  proper  amounts 
of  potato  and  other  starches. 

Eggs  in  any  quantity  and  prepared  in  all  possible  ways,  without  sugar  or 
ordinary  flours. 

Butter  and  Cheese. 

Nuts. — AH  except  chestnuts,  including  almonds,  walnuts,  Brazil  nuts, 
hazelnuts,  filberts,  pecan  nuts,  butternuts,  cocoanuts. 

Condiments. — Salt,  vinegar,  and  pepper  in  moderate  quantities. 

Fruits. — Cranberries,  plums,  cherries,  gooseberries,  red  currants,  straw- 
berries, acid  apples,  lemons,  oranges  sparingly — all  without  sugar.  Acid  fruits 
may  be  stewed,  with  the  addition  of  bicarbonate  of  sodium  instead  of  sugar. 

Jellies. — None  except  those  not  sweetened  with  sugar.  Saccharin  may 
be  used  for  sweetening  instead  of  sugar.  Jellies  may  be  made  of  calf's 
foot  or  gelatin  and  flavored  with  wine. 


814  CONSTirUTIOXAL  DISEASES 

Drinks. — Coffee,  tea,  and  cocoa-nibs,  with  milk  or  cream,  but  without 
sugar.  Also,  millc,  cream,  soda-  (carbonated)  water,  and  all  mineral 
waters  freely;  lemonade  without  sugar,  acid  wines,  including  clarets,  Bor- 
deaux, Rhine,  and  still  Moselle  wines,  and  very  dry  shern,'.  Unsweetened 
brandy,  whisky,  and  gin.  No  malt  liquors  except  those  ales  and  beers  which 
have  been  long  bottled  and  in  which  the  sugar  has  all  been  converted  into 
carbonic  acid  and  alcohol.  Saccharin  may  be  used  for  sweetening  tea  and 
coffee. 

To  be  Especially  Avoided. — Cantaloupes,  watermelons,  peaches,  grapes, 
and  all  other  sweet  melons  and  fruits;  potatoes  (white  and  sweet),  rice, 
beets,  carrots,  turnips,  parsnips,  peas,  and  beans;  all  vegetables  containing 
starch  or  sugar  in  any  quantity;  sweet  wines,  including  sherry,  Madeira, 
port,  and  champagne. 

2.  Hygienic  Treatment. — Next  in  importance  to  the  dietetic  is  the 
hygienic  treatment  of  diabetes.  This  consists  in  bathing,  and  attention 
to  the  skin,  together  with  outdoor  muscular  excercise  and  perfect  ventilation 
within  doors. 

The  diabetic  should  breathe  the  freshest  and  purest  air.  While  the 
cases  are  not  numerous  in  which  embarrassed  respiration  results  in  glu- 
cosuria,  there  are  undoubted  instances  in  which  this  has  occxirred,  as  in 
croup  and  whooping-cough;  and  it  is  well  known  that  asphy.xiated  lower 
animals  are  likely  to  have  glycosuria.  Although  the  glycosuria  thus 
resulting  is  probably  reflex,  it  can  hardly  be  expected  that  the  diabetic 
should  improve  under  unfavorable  respiratory  conditions.  He  should  not, 
therefore,  live,  work,  or  sleep  in  a  confined  atmosphere,  but  secure  the  most 
perfect  ventilation,  spending  much  of  his  time  out  of  doors,  and  sleeping  in 
large,  well-ventilated  chambers,  ^vith  windows  open,  etc.  Especially 
should  he  avoid  inhalation  of  irrespirable  gases.  Attention  to  the  skin, 
is  most  important  to  the  diabetic.  He  should  bathe  at  least  t^sace  a  week 
in  tepid  or  hot  water  on  going  to  bed  in  winter,  and  on  rising  take  a  cool 
sponge-bath  daily.  In  summer  he  may  take  a  cool  bath  on  rising  and  on 
retiring.  He  should  groom  his  skin  thoroughly  daily,  either  after  the  bath 
or  independent  of  it  on  the  days  on  which  he  does  not  bathe.  Two  table- 
spoonfuls  of  sodium  carbonate  to  an  ordinar\-  bath  is  a  suitable  addition 
to  the  latter,  softening  the  skin  and  facilitating  its  action  by  removing 
the  eft"ete  epithelium. 

Muscular  exercise  should  be  taken  daily  by  the  diabetic,  both  by  walking 
and  gjTnnastics.  Glj^cogen  is  undoubtedly  consumed  in  the  muscles  during 
their  action,  and  it  is  quite  certain  that  in  diabetes  there  is  an  undue  accumu- 
lation of  sugar  in  the  muscles.  Exercise  should  be  sustained  regularly 
day  by  day,  even  in  wet  weather,  care  being  taken  to  keep  the  feet  dry, 
while  it  should  never  be  carried  to  the  point  of  fatigue. 

Attention  to  other  secretions,  particularly  to  that  of  the  bowels,  is  of 
the  greatest  importance.  Diabetics  who  are  constipated  are  always  more 
difficult  to  relieve.  It  is  probably  partly  on  account  of  their  action  in  this 
respect  that  the  alkaHne  and  alkaUne-saUne  aperient  waters,  as  those  of 
Vichy,  Vals,  and  Carlsbad,  are  so  useful.  To  those  who  \'isit  these  springs, 
a  part  of  the  benefit  is  ascribable  to  the  other  favorable  hygienic  influences, 
such  as  rest,  fresh  air,  and  exercise,  by  wliich  they  are  surrounded.     Inde- 


GLUCOSURIA  815 

pendently  of  these  influences,  however,  there  is  reason  to  believe  that  the 
alkaUne  waters  are  of  service  to  diabetics,  and  when  their  cost  is  not  a  con- 
sideration, a  quart  of  Vichy  or  Vals  and  half  as  much  Carlsbad  may  be  taken 
during  the  day,  beginning  before  breakfast.  The  Vichy  is  a  more  alkaline 
water,  containing  35  grains  (2.3  gm.)  of  carbonates  to  a  pint  (0.5  liter), 
while  Carlsbad  contains  but  11  grains  (0.51  gm.),  but  twice  the  proportion 
of  chlorids,  eight  grains  (0.7  gm.)  to  a  pint  (0.5  Hter),  and  nearly  ten  times 
as  much  sodium  sulphate,  or  19  grains  (1.25  gm.) ;  hence  its  more  purgative 
quality  to  which  some  of  the  good  effect  may  be  due. 

The  waters  of  the  celebrated  Saratoga  Springs  in  this  country  have  an 
imdoubted  action  on  the  liver,  probablj'  through  the  chlorids  they  contain, 
which  are  in  very  large  proportion,  reaching  in  the  Geyser  Spring  70  grains 
(4.6  gm.)  to  the  pint  (0.5  liter),  and  in  the  Empire  and  Hathorn,  63  grains 
(4.19  gm.)  to  the  pint  (0.5  Hter).  They  contain  no  sulphates,  but  the 
carbonates  are  present  in  considerable  proportion,  though  much  less  than 
in  the  Vichy  waters. 

3.  The  Medicinal  Treatment. — Like  all  diseases  in  which  treatment  bv 
drugs  is  relatively  inefficient,  diabetes  has  its  full  share  of  reputed  remedies, 
most  of  which  are  useless.     This  dare  not,  however,  be  said  of  all. 

The  only  drug  that  can  be  relied  upon  to  produce  an  effect  in  diminishing 
glucosuria  is  opium.  It  seems  that  it  was  used  for  diabetes  as  early  as  the 
second  century  by  Archigenes.  It  was  also  used  by  JJtius  the  physician, 
in  the  fourth  century,  and  in  the  latter  part  of  the  i8th  century  and  beginning 
of  the  19th  by  Rollo,  Frank,  Tommasson,  and  especially  the  Enghsh 
physician,  Pelham  Warren,  in  1812.  It  is  certainly  a  useful  agent  in  dia- 
betes, but  its  use  is  united  with  disadvantages  in  the  locking-up  of  the 
secretions.  On  account  of  its  comparative  freedom  from  these  effects, 
codein  has  come  to  be  the  favorite  alkaloid  of  opium  in  diabetes.  It  may 
be  given  in  1/4  grain  (0.016  gm.)  doses  three  times  a  day,  or  1/2  grain  (0.032 
gm.)  twice  a  day,  increasing  1/4  grain  (0.016  gm.)  daily  until  the  desired 
effect  is  produced  or  it  proves  useless.  If  the  sugar  disappears,  the  drugs 
should  be  gradually  withdrawn.  If  constipation  is  caused  by  it,  aperient 
remedies  should  be  associated,  and  very  suitable  are  the  natural  aperient 
waters,  including  the  bitter  waters,  Friedrichshalle,  Hunyadi  Janos,  Racokzy 
Piillna,  etc.,  and  in  this  country  Pluto  water  from  the  French  Lick  Springs 
in  Indiana  and  the  water  from  the  Vichy  and  Geyser  Springs  at  Saratoga, 
N.  Y.  One  of  us  has  seen  a  patient  entirely  relieved  under  its  use,  and 
it  alone,  with  no  return  of  the  sugar  after  its  omission.  Rarely  as  much 
as  ten  grains  (0.65  gm.)  a  day  are  given,  and  its  use  should  be  deferred 
until  other  measures  are  found  insufficient. 

After  opium,  arsenic  has  longest  maintained  its  reputation  as  a  remedy 
in  diabetes,  and  it  should  be  used  in  all  mild  cases.  Fowler's  solution  is  the 
best  preparation.  Possibly  it  acts  partly  on  the  gastro-intestinal  tract 
and  partly,  on  the  red  blood-disks,  increasing  their  oxidizing  power  over 
glucose.  The  best  plan  is  to  give  small  doses  long  continued  rather  than 
to  attempt  to  bring  about  its  physiological  action.  Hence  three  drops 
twice  or  thrice  a  day,  continued  indefinitely,  is  now  a  favorite  dose. 
Salicylates  are  quite  strongly  recommended  by  v.  Noorden. 

The  bromid  of  potassium  is  sometimes  efificient  in  diabetes  accompanying 


816  CONSTITUTIONAL  DISEASES 

functional  nervous  disorders  due  to  mental  overwork  or  psychic  disturbance. 
Bromin  and  arsenic  are  combined  in  the  shape  of  Clemens'  solution  of  bro- 
mid  of  arsenic,  of  which  the  dose  is  from  3  to  5  minims  (0.184  to  0.3  c.c). 
\^eronal  may  be  of  use  in  like  conditions. 

Substances  which  possess  the  power  of  oxidizing  sugar  in  the  blood 
have  long  been  sought.  The  alkalies,  and  especially  the  alkaline  carbonates, 
acquired  considerable  reputation  in  the  .treatment  of  diabetes,  after  Mialhe 
claimed  for  them  the  power  of  destropng  the  sugar  in  the  blood,  and  of 
neutralizing  the  volatile  acids  retained  within  the  organism  in  consequence 
of  the  defective  action  of  the  skin.  They  prevent  abstraction  of  alkalies 
from  the  tissues  and  continue  to  be  used  with  results  which  justify  the 
practice,  and  almost  invariable  practice  is  to  place  diabetic  patients  on 
sodium  bicarbonate  in  doses  of  a  dram  (4  gm.)  or  more  three  times  daily 
if  there  is  acidosis.  It  neutralizes  the  acidosis  which  we  have  ascertained 
to  be  a  dangerous  condition.  The  efficiency  of  the  alkaline  mineral  waters 
is  thus  explained. 

Salicylate  of  sodium  has  warm  advocates,  and  in  gouty  cases  it  may  be 
useful.  According  to  von  Noorden,  it  is  especially  in  netirogenous  diabetes 
that  the  sodium  salicylate  is  useful,  quieting  the  irritability  of  the  central 
nervous  system. 

lodid  of  potassium  has  produced  some  striking  results  in  the  case  of 
diabetes  due  to  syphilitic  lesions  of  the  brain. 

While  we  realize  that  drugs  are  not  of  much  use  in  diabetes  mellitus, 
it  is  a  mistake  to  throw  them  aside.     The  patient  often  looks  for  them 
and  when  they  are  applied  rationally  and  in  safe  and  harmless  doses  they 
ought  not  be  ruthlessly  excluded  from  our  treatment. 
Treatment  of  Complications. 

Eczema  and  Prnritiis. — These  sometimes  intensely  annoying  symptoms 
commonly  abate  with  the  reduction  of  the  glycosuria,  but  require  also  other 
measures.  In  the  first  place  scrupulous  cleanliness  is  necessary,  accom- 
plished by  warm,  tepid  bathing.  In  addition,  we  may  use  solutions  of 
boric  acid  2  drams  (8  gm.)  to  the  quart  (i  liter)  or  sodium  hyposulphite, 
I  ounce  (30  gm.)  to  a  quart  (i  liter)  of  water;  also  zinc  ointment,  ointment 
of  acetate  of  lead;  solutions  of  corrosive  sublimate,  very  weak — i  to  3000 — 
and  tumenol-sulphonic  acid  m  10  per  cent,  alcohol  solutions.  CarboUc  acid 
5  to  10  minims  (0.3  to  0.6  gm.)  glycerine  3ij  (8  c.c.)  and  water  an  ounce 
(30  c.c.)  make  a  soothing  preparation.  As  a  last  resort  in  pruritus  nitrate  of 
silver  may  be  used  in  the  strength  of  20  grains  (1.3  gm.)  to  the  ounce  (30 
c.c),  making  da'ly  appHcations,  which  though  sometimes  painful,  are  ulti- 
mately effectual. 

DIABETES  INSIPIDUS. 

Definition. — Any  excessive  secretion  of  nonsaccharine  and  nonalbu- 
minous  urine  which  has  continued  for  a  long  time.  Willis  in  1674  separated 
it  from  diabetes  mellitus. 

Etiology. — The  condition,  unlike  diabetes  mellitus,  affects  more  fre- 
cjucntly  younger  persons,  being  rare  in  those  over  50  years  of  age,  relative!}' 
frequent  in  infancy,  and  most  common  between  the  ages  of  twenty  and 
thirty.     It  may  be  congenital  and  not  infrequently  is  hereditary. 


GLUCOSURIA  817 

As  to  sex,  it  is  much  more  frequent  in  males  than  in  females,  affecting 
two  or  three  times  as  many  of  the  former  as  of  the  latter. 

As  to  causes,  Futcher  reported  nine  cases  of  diabetes  insipidus ;  in  four 
of  them  was  a  history  of  cerebral  syphilis,  wth  improvement  under  iodid 
of  potassium,  the  same  uncertainty  prevails  as  with  diabetes  mellitus. 
An  examination  of  cases  shows  an  association  with  a  certain  number  of 
conditions,  such  as  cerebral  disease,  including  tumor  of  the  brain,  meningitis, 
paralysis  of  the  sixth  nerve,  sunstroke,  cerebrospinal  fever,  falls  and  blows 
on  the  head;  exposure  to  cold  and  the  drinking  of  cold  fluids,  drunkenness, 
pregnancy,  hysteria,  emotion,  especially  fright,  hereditary  influence,  syph- 
ilis, and  previous  disease,  etc.,  but  this  does  not  show  causation.  The  pro- 
portion, however,  of  cases  in  which  the  condition  is  associated  with  brain 
disease  and  injuries  to  the  head,  taken  in  connection  with  the  fact  of  Ber- 
nard's discovery  that  puncture  of  the  floor  of  the  fourth  ventricle  above  the 
diabetic  center  produces  polyuria  without  glycosuria,  makes  it  Yevy  likelj- 
that  central  nervous  irritation,  however  induced,  is  at  the  bottom  of  the 
symptom.  It  is  reasonable  to  suppose,  too,  that  diabetes  insipidus  may  be 
the  restilt  of  some  irritation,  direct  or  reflex,  of  this  center  in  the  medulla 
oblongata,  or  of  the  sympathetic  ganglia  in  the  abdomen.  The  latter 
explanation  also  applies  to  cases  of  polyuria  attending  the  presence  of 
abdominal  diseases,  such  as  tumor,  aneiirysm,  or  peritonitis,  though  it  is 
doubtful  whether  these  should  be  regarded  as  cases  of  true  diabetes  insipidus. 

Cases  associated  with  evident  organic  lesion  as  of  the  brain  or  syphilis 
are  known  as  secondary  or  symptomatic  while  cases  not  thus  associated 
are  known  as  primary.  From  Futcher's  reports  there  would  seem  to  be  a 
nearly  equal  proportion  of  each.  Certain  cases  of  tumor  of  the  hypophysis 
are  characterized  by  polyuria. 

Morbid  Anatomy. — The  essential  morbid  anatomy  of  diabetes  insipidus 
would  be  the  lesions  of  the  nerve  centers  or  sympathetic  ganglia  which  may 
underlie  the  symptoms.  But  as  these  are  often  undiscoverable,  or  at  least 
indefinite,  it  is  impossible  to  describe  them.  Notably  is  this  the  case  with 
lesions  of  the  third  and  sixth  nerves.  Associated  central  nervous  lesions, 
when  present,  are  found  more  frequently  in  the  vicinity  of  the  base  of  the 
brain. 

Symptoms. — The  enormous  secretion  of  urine  of  almost  spring- water-like 
clearness,  and  of  specific  gravity  often  as  low  as  1003,  is  the  most  con- 
spicuous symptom,  but  more  annoying,  probably,  is  the  extreme  thirst 
which  always  attends  it.  These  may  be  said  to  be  the  essential  symptoms, 
others  which  may  or  may  not  be  present  being  rather  their  consequence. 
Very  constant  among  the  latter  are  dryness  of  the  skin  and  absence  of  per- 
spiration. The  health  may  be  otherwise  perfect,  though  emaciation  and 
weakness  are  often  present.  The  debility  is  sometimes  extreme.  Occa- 
sionally there  are  derangements  of  digestion,  and  sometimes  also  the  appetite 
is  ravenous,  as  in  diabetes  mellitus,  though  less  frequently  so.  Severe 
lumbar  pains  are  frequent,  together  with  diarrhea  and  derangement  of 
mental  and  sexual  functions. 

These  symptoms  may  occur  suddenly  in  the  midst  of  apparent  health, 
or  they  may  supervene  upon  others  or  be  substituted  for  them,  chiefly  those 
of  a  nervous  character,  which  may  be  the  result  of  the  nervous  lesion 


818  CONSriTUTIOXAL  DISEASES 

causing  the  polyuria.  Such  symptoms  are  headache,  restlessness,  irrita- 
bility, sleeplessness,  what  is  commonly  called  nervousness,  more  rarel}^ 
convulsions,  delirium,  paralyses — indeed,  any  one  or  more  of  the  great 
variety  of  symptoms  which  result  from  organic  or  functional  nen,^ous  disease. 
Sometimes  these  symptoms  succeed  upon  the  polyuria  or  are  increased  by 
it.  It  is  certain  that  the  milder  nervous  symptoms  are  sometimes  the  result 
simply  of  the  inconvenience  and  annoyance  caused  by  the  two  cardinal 
symptoms,  polyuria  and  thirst.  The  patient  is  kept  busy,  as  it  were,  night 
and  day,  in  passing  water.  It  is  not  surprising  that  such  a  patient  should 
be  fretful  and  irritable,  and  that  sooner  or  later  his  health  should  be  broken 
if  the  symptoms  are  not  relieved. 

Physical  and  Chemical  Characters  of  the  Urine. — As  to  the  quantity  of 
urine  passed,  it  is  enormous,  exceeding  often  the  amount  passed  in  saccharine 
diabetes.  As  many  as  43  liters  (90  pints)  are  recorded  by  Trousseau,  and 
one-fourth  this  quantity  is  common.  It  has  been  said,  even,  that  the 
quantity  secreted  sometimes  exceeds  the  amount  of  fluid  ingested,  but  this 
is  impossible  for  any  length  of  time,  unless  water  is  absorbed  from  the 
atmosphere,  which  is  not  impossible.  In  point  of  fact,  the  water  excreted  is 
alwaj^s  a  Uttle  less  than  that  ingested,  either  as  drink  or  in  the  solid  food. 
As  the  quantity  of  urine  excreted  increases  or  its  normal  acidity  diminishes, 
its  color  disappears  and  its  specific  gravity  dechnes.  In  one  case  under  our 
care  the  specific  gravity  was  scarcely  looi,  while  the  urine  in  moderate  bulk 
was  absolutely  colorless.  Again,  a  faint  greenish  tinge  is  exhibited  by  the 
urine  in  bulk. 

The  duration  of  the  condition  varies  greatly.  Sometimes  it  continues 
through  life  with  no  inconvenience  except  that  from  the  constant  diuresis 
and  thirst.  Willis  records  a  case  lasting  50  years.  On  the  other  hand,  it 
is  seldom  of  brief  dtiration;  indeed,  there  is  needed  a  certain  chronicity  in 
order  to  admit  it  in  the  category  of  diseases.  One  case  is  reported  as  termi- 
nating fatally  in  seven  weeks.  Under  prognosis  will  be  found  some  further 
information  as  to  duration,  but  it  may  be  said,  in  general,  that  most  cases 
which  terminate  unfavorably  and  most  which  recover  completely  do  so 
within  a  year.  Tyson  had  under  his  care  for  1 1  years  a  lad  of  1 7 ,  who  was 
able  to  work  quite  hard  much  of  the  time. 

No  complications  arise  except  such  as  cause  the  disease  or  result  from  it. 
Among  the  latter  is  occasionally  dilatation  of  the  pelvis  of  the  kidney, 
and  atrophy  of  this  organ  is  mentioned,  due  to  pressure  of  the  accumulated 
urine  and  resulting  in  a  sacculated  condition.  The  svinptoms  of  the  malady 
are  almost  always  influenced,  and  sometimes  even  cut  short,  by  intercurrent 
disease,  especially  of  a  febrile  character,  or  even  by  a  profound  physical 
impression,  as  long-continued  suppuration  after  a  blister.  The  boy  re- 
ferred to  was  an  aggravated  choreic  before  he  became  diabetic. 

Diagnosis. — The  diagnosis  of  diabetes  insipidus  is  very  easy.  The 
persistent  thirst,  polytuia,  and  absence  of  sugar  from  the  urine  are  pathog- 
nomonic. The  only  possible  error  is  mistaking  the  poh'uria  of  chronicall}^ 
contracted  kidney  of  interstitial  nephritis  for  that  of  diabetes  insipidus.  In 
addition,  however,  to  the  fact  that  a  careful  examination  for  albumin  will 
disclose  it  in  the  urine  of  contracted  kidney,  there  are  casts  in  the  urine  of 
nephritis  and  physical  examination  w\\\  show  hj^pertrophy  of  the  heart  with 


GLUCOSURIA  819 

high  blood-pressure,  the  quantity  is  never  so  large,  nor  is  the  thirst  so  ex- 
treme; so  that  it  would  seem  only  necessary  to  mention  the  possibility  of 
such  an  error  in  order  to  avoid  it. 

Prognosis.— It  is  extremely  unusual  for  a  case  of  diabetes  insipidus  to 
terminate  unfavorably  unless  there  have  been  also  present  sj^mptoms  point- 
ing to  serious  nervous  lesion.  Recovery  is  not  infrequent.  According  to 
Roberts,  of  67  cases  collected,  16  are  reported  as  complete  recoveries  and  14 
erided  fatally,  nearly  an  equal  proportion.  The  remaining  37  were  still  in 
progress.  In  cases  of  recovery  or  death  the  duration  is  comparatively 
short.  Of  the  16  recoveries,  in  nine  the  duration  was  less  than  a  year;  in  one, 
four  years;  in  two,  18  and  19  years,  and  in  the  remainder,  some  years.  Of 
the  14  fatal  cases,  nine  terminated  in  less  than  a  year,  oneiw  seven  weeks,  and 
two  in  two  months;  the  other  two  sur\'ived  18  months  and  20  years,  re- 
spectively. Of  the  3  7  cases  in  progress,  only  five  continued  for  a  year  or  less. 
The  remainder  lasted  for  periods  ranging  from  something  over  a  year  to  59 
years. 

These  results  seem  to  be  tolerably  independent  of  treatment.  It  may  be 
said,  therefore,  that,  as  a  rvile,  cases  that  last  more  than  a  year  are  likely 
to  continue,  but  ordinarily  only  require  to  be  furnished  with  an  abundance 
of  water  to  keep  them  tolerably  comfortable.  According  to  Dickinson, 
cases  due  to  drunkenness  are  more  likely  to  run  a  severe  and  rapid  course,  usu- 
ally terminating  fatally  within  a  few  months,  and  one  terminated  thus  in  two 
months. 

Treatment. — A  Wasserman  test  should  be  made  in  all  cases.  For 
syphilic  cases  are  often  amendable  to  treatment.  The  treatment  of  diabetes 
insipidus  would  naturally  resolve  itself  into  the  treatment  for  the  disease 
of  which  it  is  the  symptom  rather  than  of  the  symptom  itself;  but  as  the 
former  is  very  frequently  undiscoverable,  it  must  consist  mainly  of  efforts 
to  diminish  the  secretion  of  urine,  and  with  it  the  thirst. 

First,  it  is  generally  conceded  that  there  should  be  no  restriction  in  the 
drinking  of  water  or  other  harmless  fluids,  for  the  diuresis  is  not  so  much 
caused  by  the  great  ingestion  of  water  as  the  thirst  is  caused  bj^  the  diuresis. 
It  should  be  mentioned,  however,  that  one  or  two  instances  are  reported 
wherein  improvement  seems  to  have  resulted  from  such  restriction;  and  if,- 
as  in  some  cases,  a  habit  of  drinking  has  been  the  initial  event,  moderate 
restriction  may  be  reasonable.  Caution  should  be  used  in  the  administra- 
tion of  drugs,  though  our  experience  is  not  that  of  Dickinson,  who  says  that 
"remedies  designed  to  restrain  the  urinary  secretion  seldom  fail  to  do  harm." 
The  older  remedies  are  ergot,  opium,  gallic  acid,  and  valerian ;  of  all,  the  doses 
ultimately  used  are  usually  large.  In  one  patient  the  symptoms  subsided 
under  the  use  of  gallic  acid  after  full  doses  of  ergot  had  failed.  In  another, 
probably  due  to  syphilis,  the  effect  of  the  iodid  of  potassium  was  shown  in  an 
aggravation  of  the  symptoms  whenever  it  was  discontinued  and  an  ameUora- 
tion  when  it  was  resumed.  Of  all  drugs,  the  iodid  of  potassium  is  most 
frequently  followed  by  improvement. 

Trousseau  and  Rayer  claimed  extraordinary  results  from  the  use  of 
valerian,  the  former  using  the  fluid  extract  in  large  doses — 2  1/2  drams 
(6  c.c.)  a  day,  which  was  increased  to  i  ounce  (30  c.c.)  daily  in  one  instance. 
Rayer  used  the  powdered  valerian  and  the  valerianate  of  zinc,  giving  the 


820  COXSriTUTIONAL  DISEASES 

latter  in  pills  'n  gradually  increasing  doses  until  20  grains  (1.25  gm.)  a  day 
were  given.  At  the  present  day  the  more  palatable  elixir  of  valerianate  of 
ammonia,  combined  with  bromid  of  potassium,  is  to  be  preferred.  A 
gradual  reduction  of  the  intake  of  salt  and  protein  is  said  to  be  useful  at  times. 

James  B.  Herrick  reports  a  ease'  in  which  marked  reduction  in  the  amount 
of  urine  followed  lumbar  puncture.  The  constant  galvanic  current  has 
been  recommended,  and  in  cases  of  spinal  lesion  may  be  expected  to  be 
of  advantage. 

Tonics  and  nervines,  such  as  strychnin,  iron,  arsenic,  salts  of  quinin, 
cod-Uver  oil,  etc.,  are  appropriately  added  to  the  treatment  ^\'ith  a  \aew  to 
sustaining  the  strength  of  the  patient,  which  is  apt  to  faU.  To  these  are  to 
be  added  fresh  air,  sea  air,  exercise,  and  all  possible  favorable  hygienic 
influences. 

Hygiene  is  even  more  important  than  in  diabetes  mellitus,  and  should 
include  a  careful  attention  to  the  skin,  warm  clothing,  warm  baths,  frictions, 
etc.,  in  order  to  divert  a  portion  of  the  circulation  from  the  kidneys  to  the 
skin.  The  first  should  also  be  quenched  when  possible  by  bits  of  ice  and 
acidulous  fluids. 


OBESITY. 

Synonyms. — Adipositas  universalis;  Polysarcia  adiposa;  Corpulence. 

Definition. — Obesity  may  be  defined  as  an  inconvenient  accumulation 
of  adipose  tissue  in  the  body. 

Etiology. — The  most  usual  cause  of  an  excessive  accumulation  of  fat 
doubtless  is  overeating  associated  with  an  inactive  life;  and  though  it  may  be 
true  of  some  fat  persons  that  they  are  really  moderate  eaters,  careful  ex- 
amination will  generally  prove  that  they  are  not.  Heredity  exerts  an  un- 
doubted influence,  and  we  find  corpulence  running  in  famiHes.  Commonl)- 
it  does  not  make  its  appearance  until  after  3  5  years  of  age,  but  in  this  country 
particularly  it  is  often  seen  earlier,  in  boys  and  girls  of  ten  years  and  upward. 
Gouty  persons  are  often  fat,  probably  from  the  causes  which  produce  these 
diseases. 

Of  foods,  each  one  of  the  representative  varieties,  albiuninoids,  carbo- 
hydrates, and  fats,  is  capable  of  contributing  fat,  deposited  in  fat  vesicles 
in  the  body,  and  it  has  even  been  said  that  albtmiinoids  furnish  more  of 
the  fatty  tissues  of  the  body  than  the  carbohydrates.  Certain  it  is  that 
a  person  may  become  corpulent  who  eats  very  little  fat.  In  most  cases, 
however,  corpulent  persons  are  found  to  be  liberal  consumers  of  all  three  of 
the  food  elements.  While  the  carbohydrates  are  direct  sources  of  fat  pro- 
duction, it  is  generally  conceded  that  the}''  act  largely  by  sparing  the  fats 
derived  from  other  sources.  Thej'  decompose  and  oxidize  so  rapidly,  and 
thus  give  themselves  up  so  readily  to  force  production,  that  the  stored  fats 
are  not  called  upon.  Thus  it  is  that  sugars  and  starches  indirectly  favor 
corpulence.  To  this  class  belong  also  alcohol,  and  especially  beer,  which 
contains  over  five  per  cent,  of  carbohydrates,  in  addition  to  from  three  to 

foxir  per  cent,  of  alcohol,  and  it  is  well  known  that  liberal  beer  drinking  fur- 
4 

*  "Archives  of  Internal  Medicine."  July.  ipi2. 


OBESITY  821 

nishes  a  large  quota  of  fat  men.  A  second  method  in  which  large  quantities 
of  alcohol  contribute  to  adiposis  is  by  hastening  albuminous  metamor- 
phosis, setting  free  the  carbohydrate  group  of  the  fatty  molecule  readily 
converted  into  fat,  which  is  deposited,  among  other  situations,  in  the  liver, 
giving  rise  to  the  fatty  liver  so  constantly  found  in  drunlvards. 

Another  cause  of  corpulency  is  muscular  inactivity.  Fat  is  consumed  by 
muscular  contraction,  and  its  absence  must  contribute  to  fat  accumulation, 
and  one  need  not  go  far  to  see  its  evidence  in  many  who  lead  lives  of  idleness. 
Oertel  has  especially  called  attention  to  the  fact  that  a  simple  diminished 
ingestion  of  fluids,  without  other  changes  in  the  diet,  will  reduce  the  amount 
of  fat.  The  effect  may  be  brought  about  in  two  ways ;  first,  by  diminishing 
the  work  of  the  heart  and  thereby  favoring  oxidation ;  second,  by  an  effect 
which  is  not  so  much  the  diminution  of  fat  as  a  withdrawal  of  water — a  sort 
of  "desiccation,"  as  it  is  called  by  Strumpell. 

The  subjects  of  anemia  and  chlorosis  often  become  fat,  probably  be- 
cause of  defective  oxidation,  growing  out  of  a  diminished  supply  of  oxygen, 
which  the  crippled  corpuscles  are  unable  to  carry  in  sufficient  quantity. 

Sexual  continence  probably  contributes  to  corpulence,  since  eunuchs 
are  well  known  to  grow  fat,  and  both  women  and  men  are  disposed  to  grow 
fat  when  the  sexual  function  begins  to  abate.  Finally,  corpulence  itself 
favors  the  further  accumulation  of  fat,  first  by  interfering  with  the  muscular 
activity  of  its  subject,  and  therefore  with  the  oxidation  of  fat,  and,  again, 
diminishing  combustion  by  reason  of  a  reduced  demand  for  heat,  the  fat 
itself  conserving  heat  by  preventing  its  radiation. 

In  Cushing's  book  upon  Diseases  of  the  Pituitary  Body  attention  is 
called  to  the  marked  accumulation  of  fat  in  diseases  of  the  hypoph^^sis 
together  with  the  increase  of  sugar  tolerance.  The  "symptom  complex 
of  adiposity,  high  sugar  tolerance,"  etc.,  is  indicative  of  secretary  deficiency 
of  the  posterior  lobe  (of  the  pituitary  body).  In  children  of  undergrowth 
of  slow  sexual  development  and  very  fat  there  is  doubtless  some  disease 
of  the  hypophysis. 

Morbid  Anatomy. — There  is  no  essential  morbid  anatomy  of  corpulence. 
Incidentally  the  liver  may  become  infiltrated  with  fat  and  enlarged,  as  may 
also  the  heart;  later  there  may  be  dilatation  of  the  latter.  The  lungs, 
too,  may  become  infiltrated  with  fat.  Even  the  blood-vessels  may  contain 
fat  drops  in  the  media  and  intima. 

Symptoms. — A  description  is  scarcely  needed  of  the  anatomical  condition 
which  constitutes  obesity.  The  round,  plump  face,  the  double  chin  and 
hanging  cheeks,  the  enormous  girth  of  the  body,  the  pendulous  belly  and 
elephantine  arms,  legs,  and  thighs  need  no  further  description.  The  labored, 
waddling  gait  is  often  conspicuous.  The  first  evident  indication  of  harmful- 
ness  due  to  corpulence  is  an  increased  frequency  in  the  breathing-rate,  at 
first  on  slight  exertion  and  later  independently  of  it.  This  is  in  part  a  true 
cardiac  asthma — due,  first,  to  the  fact  that  the  heart  cannot  push  the  blood 
through  the  lungs  rapidly  enough  to  permit  its  aeration  at  the  ordinary 
breathing-rate;  and,  second,  to  the  fact  that  the  motion  of  the  lungs  is  also 
restricted.  The  latter  is  due  to  the  accumulation  of  fat  over  the  thorax 
and  in  the  mediastinum,  and  to  the  accumulated  intraabdominal  fat  and 
probably  enlarged  liver,   which  interfere  with  the  proper*  descent  of  the 


822  CONSTirUTIOXAL  DISEASES 

diaphragm.  This  leads  at  first  to  cardiac  hypertrophy,  further  stimulated 
by  the  extra  work  demanded  of  the  heart  in  propelhng  the  increased  bulk 
of  the  blood;  further  augmented  by  resulting  arterio-sclerosis,  and  impeded 
venous  circulation.  Later  the  fatty  infiltration  of  the  muscular  walls  of 
the  heart  leads  to  further  embarrassment  in  its  action  and  to  impairment  of 
its  nutrition,  whence  come  cardiac  weakness  and  ultimate  failure,  with 
edema,  pericardial  and  pleuritic  effusion,  and  sometimes  sudden  death. 

The  pulse,  hai-d  to  find,  is  usually  frequent,  but  may  be  slow  and  irregu- 
lar. The  heart  can  be  examined  only  with  difficulty,  on  account  of  the 
large  accumulation  of  fat,  and  the  normal  sounds  are  feeble  and  distant. 
The  situation  of  the  apex  can  be  found  only  by  the  aid  of  the  stethoscope. 
Intertrigo  is  often  an  annoying  symptom,  and  great  care  is  required  to  avert 
it.  Interstitial  nephritis  may  be  superadded.  By  no  means  all  corpulent 
persons  run  this  course.     Many  lead  lives  of  considerable  comfort. 

Treatment. — This  consists  in  acting  upon  two  principles:  first,  furnishing 
less  food  to  oxidize,  and,  second,  increasing  the  oxidation  of  the  fat  in  the  body. 

The  first  is  accompHshed  by  cutting  down  the  quantity  of  aU  kinds  of 
food,  but  especially  carbohydrates.  Sugar  should  be  prohibited  altogether, 
and  saccharin  substituted,  if  sweetening  is  desired.  Bread  may  be  taken  in 
small  amounts,  say  two  ounces,  well  toasted  and  with  it  a  thin  layer  of  butter ; 
or  hard  biscmt  may  be  substituted.  A  cup  of  tea  or  coffee  with  a  little  milk 
may  be  allowed;  also  a  single  egg  at  breakfast  or  luncheon;  meat  once  a  day. 
The  latter  may  be  of  any  kind,  and  with  it  maj^  be  taken  green  vegetables, 
such  as  peas,  string-beans,  tomatoes,  cabbage,  spinach,  Brussels  sprouts, 
lettuce,  celery  and  the  like,  omitting  altogether  rice,  potatoes,  and  the 
f  arinacea,  in  general.     A  little  cheese  may  be  allowed. 

Only  small  quantities  of  fluid  should  be  permitted  at  meals — just 
enough  to  aid  in  the  solution  and  digestion  of  food.  This  may  be  tea, 
coffee,  water,  or  skimmed  milk,  the  first  two  without  sugar  or  cream.  Beer, 
porter,  and  sweet  wines  should  be  prohibited,  but  a  glass  or  two  of  hock  or 
claret  with  an  alkaline  mineral  water  may  be  allowed. 

A  list  may  be  made  from  the  general  list  of  diabetic  diet.  The  amount 
necessary  in  an  individual  is  about  2000  calories  every  24  hours. 

A  diet  of  skimmed  milk  only  is  a  sure  way  of  reducing  fat,  and  a  start 
may  be  made  with  it,  commencing  with  2  ounces  (60  c.c.)  every  two  hours 
and  increasing  until  from  6  to  8  ounces  (180  to  240  c.c.)  are  attained.  Un- 
fortunately, Yery  few  persons  will  bear  this  treatment  for  any  length  of 
time,  but,  as  stated,  a  beginning  may  be  made  with  it,  and  when  the  patient 
tires,  the  other  treatment  just  described  may  be  instituted. 

The  second  indication  to  promote  oxidation  is  accomplished  bj^  exercise, 
gymnastics,  walking,  mountain-climbing,  or  cycling.  The  last  has  been 
effective  in  reducing  the  weight  of  the  corpulent,  and  if  combined  with  a 
proper  diet,  may  be  expected  to  do  more.  Massage  is  also  useful,  especially 
in  co-operation  with  the  Turkish  bath  and  steam  bath.  These  last  help  in 
the  "desiccation"  of  the  body,  which  in  turn  faciHtates  oxidation.  Great 
difficulty  is  experienced  in  getting  the  patient  to  carr}'  out  the  dietary  and 
to  exercise  assiduously.  Greatly  in  the  way  of  exercise  with  a  view  to 
reducing  adipositj'  is  the  vmwieldj'  and  cumbersome  body  and  early  fatigue 
which  ensues  on  effort. 


OBESITY  823 

Certain  health  resorts  have  much  reputation  for  their  efficiency  in  reduc- 
ing corpulence.  Hombiu^g,  Maricnbad,  and  Carlsbad  are  among  the  most 
celebrated  of  these,  and  I  have  seen  man}'  patients  return  thence  after  a 
cure  of  four  to  six  weeks  markedly  improved  in  all  the  sjinptoms  which 
come  from  obesitj'.  The  effect  is  probabh'  altogether  due  to  the  strict 
diet,  the  systematic  exercise,  and  the  bathing,  the  massage,  and  the  laxative 
e£fect  of  the  waters,  although  the  physicians  at  the  various  spas  which  have 
a  reputation  for  reducing  obesity  claim  also  that  the  effect  of  the  sulphate 
of  soda,  which  is  a  constituent  of  most  of  these  waters,  is  to  stimulate  oxida- 
tion in  the  direction  of  the  fatty  structures,  while  limiting  the  metamorphosis 
of  the  nitrogenous  substances.  This  intermittent  method  of  treating  obes- 
ity, by  recourse  to  baths  and  springs  once  a  year  while  the  inten^ening  period 
is  spent  in  free  eating,  is  not  to  be  recommended.  It  is  much  better  to  adopt 
a  continuous  method  which  may  not  be  as  rapid,  but  is  persistent.  It  must 
be  remembered  that  the  average  individual  does  well  on  a  diet  which 
contains  2300  to  2500  calories  in  the  twenty-foiu"  hours.  One  must  give  a 
diet  list  to  the  patients  consisting  of  mixed  foods,  the  total  calories  of 
which  for  the  twenty-four  hours  will  not  exceed  the  above  amount. 

Medicinal  Treatment. — This  is  unsatisfactory.  Dessicated  thyroid 
has  been  administered  with  claimed  advantage  in  doses  of  i  grain  (0.066 
gm.)  three  times  daU}',  and  may  be  gradually  increased  to  3  and  even 
5  (0.35  gm.),  with  the  same  precautions  as  advised  in  the  treatment  of 
myxedema.  Under  this  treatment  the  loss  of  weight  is  sometimes  quite 
rapid,  going  to  show  that  defective  thjToid  secretion  maj'  be  a  factor  in 
causing  obesity. 

Systems  of  Diet. — Mention  should  perhaps  be  made  of  the  so-called 
systems  of  diet  for  reducing  corpulency,  a  number  of  which  have  been  sug- 
gested. Those  especially  deserving  of  notice  are  the  Banting  s^'stem, 
Ebstein's  method,  the  method  of  Dancel-Oertel,  in  addition  to  the  mineral 
water  cures.  It  is,  of  course,  impossible  in  the  limited  space  of  a  text-book 
to  give  these  methods  in  full.  The  principles  of  their  appHcation  will  alone 
be  considered  and  the  student  is  referred  to  special  soiu"ces  for  their 
description.^ 

(i)  The  Banting  sj^stem  consists  in  the  administration  of  a  large  amount 
of  albuminous  food,  especiallj-  lean  meat  to  the  exclusion  of  fats  and  carbo- 
hydrates; green  vegetables  being  allowed  ad  libitum;  (2)  Ebstein's  method 
demands  moderation  and  restriction  in  the  quantit}^  of  foods  generally,  and 
for  the  fat-forming  carbohydrates  substitutes  fat  itself,  which  does  not 
increase  stored  fat  and  b}^  diminishing  appetite  favors  loss  of  weight. 
Sugar  and  potatoes  are  excluded;  (3)  the  Dancel-Oertel  method  reduces 
especially  the  quantity  of  water  and  other  Uquids,  only  a  maximum  of 
800  grams  (about  i  1/2  pints)  of  water  mixed  with  wine,  and  twHce  a  day  a 
cup  of  coffee  or  tea;  of  soUd  foods,  nitrogenous  alimentary-  substances  and 
vegetables,  especially  such  as  contain  Httle  water,  with  fat  only  in  such 
quantity  as  to  render  the  dishes  palatable.  Oertel  emphasizes  the  mechan- 
ical advantages  of  restriction  in  the  use  of  water  upon  derangements  of  the 
vascular  system;  (4)  von  Noorden's  dietarj^  as  follows:  Eight  o'clock,  So 
grams  of  lean,  cold  meat,  25  grams  of  bread,  one  cup  of  tea  with  a  spoonful 

>  "  Dietetic  and  Therapeutic  Hints  to  the  Visitors  o£  Bad  Homburg."     By  Heinrich  Will,  1893. 


824  COXSriTUnONAL  DISEASES 

of  milk,  no  sugar.  Ten  o'clock  one  egg.  Twelve  o'clock,  a  cup  of  strong 
meat  broth  One  o'clock  a  small  plate  of  meat  soup  flavored  with  vegetables, 
150  grams  of  lean  meat  of  one  or  two  sorts,  partly  fish  and  partly  flesh,  100 
grams  of  potatoes  with  salad  100  grams  of  fresh  fruit,  or  compote  without 
sugar.  Three  o'clock  a  cup  of  black  coffee.  Four  o'clock,  200  grams  of  fresh 
friiit.  Six  o'clock  a  quarter  of  a  liter  of  milk,  if  desired,  with  tea.  Eight 
o'clock,  125  grams  of  cold  meat,  or  180  grams  of  meat  weighed  raw  and 
grilled,  eaten  with  pickles  or  radishes  and  salad,  80  grams  of  Graham  bread, 
and  2  or  3  spoonfuls  of  cooked  fruit  without  sugar.  Von  Noorden  advises 
also  in  addition  to  the  three  meals,  smaller  quantities  of  food  at  shorter 
intervals,  so  as  to  remove  the  tendency  to  weakness  sometimes  complained 
of  by  these  patients.  He  permits  also  twice  a  day  a  glass  of  wine,  and 
mineral  waters,  weak  tea  or  lemonade  ad  libitum  at  the  meal  times  or  between. 
Occasionally  he  gives  a  "hunger  day;"  (s)  the  mineral  water  cures,  as  might 
be  expected,  are  based  chiefly  upon  the  use  of  such  waters,  especially  those 
containing  sulphate  of  soditim  and  chlorid  of  sodium,  the  cold  springs  being 
preferred.  The  springs  are  thus  classified:  (a)  cold  waters  containing  sul- 
phate of  soda — Marienbad,  Tarasp,  Schulz-Tarasp,  Frazensbad,  Elster, 
Cudowa,  and  Rolitsch — carbonic  add  waters;  (6)  hot  springs  containing 
sulphate  of  sodium — Carlsbad,  Bertrich;  (c)  cold  waters  containing  chlorid 
of  sodium — Homburg,  Kissengen,  Nauheim,  Neuhaus  and  Oeynhausen; 
in  America  the  Saratoga  springs;  {d)  springs  containing  iodin — Hall, 
Krankenheil,  Salzschlirf,  Kreuznach,  Miinster  am  Stein.  The  drinking  of 
waters  at  these  places  is  combined  with  the  use  of  saline,  carbonated,  mud, 
and  steam  baths. 

Prophylaxis  should  not  be  overlooked  especially  in  the  case  of  hereditary 
tendency  on  the  pri.nciple  of  the  old  claim  of  an  "ounce  of  prevention"  as 
contrasted  with  a  pound  of  cure,  and  much  may  be  accomplished  in  families 
in  which  there  is  tendency  to  corpulence. 

For  Adiposis  Dolorosa  see  Ner\'Ous  Diseases,  subheading  Neuritis. 


RICKETS. 

S  YNON  YM . — Rachitis. 

Definition. — "There  is  a  disease  of  infants  called  the  rickets,  wherein 
the  head  waxeth  too  great,  while  the  legs  and  lower  parts  wane  too  little" 
(Thomas  Ftdler,  1608-61).  This  quaint  description  of  the  celebrated 
Enghsh  chaplain,  written  over  250  years  ago,  remains  so  nearly  correct  at 
the  present  day  that  we  cannot  forbear  adopting  it.  It  is  further  defined  as 
a  constitutional  disease  characterized  by  deformity  in  bones,  due  to  cell 
overgrowth  and  deficiency  in  lime  salts. 

The  term  rickets  is  derived  from  the  old  English  word  wrickken,  to  twdst. 
"The  rickets"  was  evidently  known  for  some  time  by  the  laity  before  it 
received  its  description  by  F.  Glisson,  in  1650,  who  suggested  the  change  of 
name  to  rachitis  from  the  Greek  pax«,  the  spine. 

Etiology. — Rickets  rarely  begins  before  the  child  is  six  months  old  or 
later  than  the  age  of  18  months,  though  a  form  was  described  by  Sir  William 
Jenner  coming  on  as  late  as  the  ninth  or  even  the  twelfth  year.     Again, 


RICKETS 


825 


certain  races  tend  to  be  rickety,  especially  the  negro  and  the  Italian. 
Fold  air  and  bad  food,  absence  of  sunlight  and  exposure  to  dampness  and 
cold,  are  more  potent  factors,  and  it  is  likely  that  a  defective  composition 
of  the  breast-milk,  including  a  deficiency  in  the  phosphates,  is  the  strongest. 
Animal  fat  and  proteids  seem  deficient  in  those  foods  which  favor  the 
development  of  rickets.  There  is  also  a  lack  of  assimilation  of  lime  salts 
in  rickety  children.     Prolonged  lactation  may  contribute  to  such  deficiency. 


Fig.  132. — Deformed  Skeleton  from  a  Case  of  Rachitis — (from  Atlas  du  Musee  Duputren). 

Poor  feeding  of  infants  with  certain  proprietary  foods  unquestionably  causes 
rickets  because  of  their  deficiency  in  required  constituents.  Sterilized  milk, 
and  unhygienic  siurroundings  are  fertile  sotu-ces  of  the  disease.  It  is  a  dis- 
ease of  the  city  rather  than  of  the  country,  and  of  the  Continent  of  Europe 
rather  than  of  America.  Vienna,  London,  and  Paris  are  prolific  fields.  In 
the  first-named  cities  from  50  to  70  per  cent,  of  aU  children  brought  to  the 
clinics  are  said  to  be  rickety.  Parrot  held  that  congenital  rickets  was  a 
form  of  syphilis,  basing  this  view  on  studies  in  the  French  capital.  Probably 
achondroplasia.     Boys  and  girls  are  equally  liable  to  rickets. 


826  COXSTnUTIOXAL  DISEASES 

Morbid  Anatomy. —  Minute  examination  recognizes  numerous  cells  in 
the  spongy  spaces  in  the  bone.  The  studies  of  Kassowitz  lead  him  to  believe 
that  a  hyperemia  of  the  periosteum,  the  marrow,  the  cartilage,  and  the  bone 
itself  is  the  fundamental  condition  responsible  for  the  abnormal  develop- 
ment. His  views  may  be  regarded  as  a  refinement  and  development  of 
those  originaU}'  suggested  in  1650  by  F.  Glisson,  who  held  that  an  excessive 
vascvdarity  was  at  the  bottom  of  the  changes. 

The  morbid  anatomy  shades  somewhat  into  symptomatolog\',  and  the 
two  can  scarcely  be  separated.  The  changes  are  mainly  in  the  bones  of 
the  skull,  the  long  bones,  and  the  ribs.  The  first  may  escape  if  the  disease 
sets  in  after  the  middle  or  end  of  the  second  year.  The  frontal  and  parietal 
eminences  are  exaggerated,  while  the  top  of  the  head  and  the  occiput  are 
flattened,  the  whole  effect  being  toward  making  the  head  square  or  "box- 
shaped."  The  fontanels  remain  open  some  time — until  the  second  or  third 
year  of  life — while  the  edges  of  the  bones  where  they  come  together  to 
form  the  sutures  are  thickened,  though  soft  and  yielding.  In  addition  to 
these  changes,  or  instead  of  them,  there  may  be  large  areas  of  delayed 
ossification  in  the  parieto-occipital  regions,  producing  yielding  spots, 
constituting  the  so-called  craniotabes  of  Elsasser;  but  as  craniotabes  occurs 
in  connection  with  syphilis  and  other  wasting  diseases  of  young  infants 
exhibiting  no  other  sign  of  rickets,  and  even  in  new-born  infants,  it  cannot 
be  regarded  as  pathognomonic. 

In  the  long  bones,  such  as  the  radius  and  ulna,  swelling  of  the  cartilage 
between  the  epiphysis  and  shaft  is  apparent.  Owing  to  the  rapid  prolifera- 
tion of  the  cartilage  cells,  resulting  in  a  broad  band  of  jelly-like  material 
between  the  cartilage  and  the  bone,  a  spong\-  structiu-e  is  rapidly  built 
up,  deficient  in  strength  and  stiffness.  Beneath  the  periosteum  the  same 
gelatinous  material  is  deposited,  and  a  spongj^  tissue  is  formed  instead  of 


Fig.  133. — Rickety  Chesl — {afler  Gee). 
Doited  line  indicates  the  shape  of  the  chest  of  a  healthy  infant  about  the  same  age. 

normal  bone.  The  process  of  bone  formation  does  not  proceed  further. 
There  is  no  deposit  of  lime  salts.  The  periosteum  is  loosely  attached. 
The  long  bones  bend  easily,  especially  the  tibia,  producing  the  characteristic 
bow  leg,  which  may  octur  even  before  the  child  waUcs,  when  it  is  caused 
by  sitting  cross-legged.  The  thighs  may  also  become  bowed,  the  iimer 
ends  of  the  condyles  prolonged  downward  and  the  tibia  set  outward,  pro- 
ducing the  "knock-knee."  This  does  not,  however,  appear  imtil  the  child 
begins  to  walk.  In  extreme  cases  the  long  bones  may  fractiu-e.  Some- 
times both  the  femora  and  tibiae  are  bowed  forward. 

Quite  as  characteristic  are  the  changes  in  the  chondral  ends  of  the  ribs 


RICKETS  827 

and  in  the  shape  of  the  chest.  The  former  are  enlarged  and  nodular  at 
the  junction  with  the  bone,  producing  the  well-known  beaded  appearance, 
which  may  often  be  recognized  at  a  glance.  The  altered  shape  of  the 
chest-walls,  most  marked  in  children  who  have  had  much  cough,  is  due 
to  the  yielding  of  the  soft  costal  ends  of  the  cartilages  and  to  a  falling-in 
of  the  ribs  at  these  points,  while  the  sternum  and  cartilages  are  pushed 
forward,  as  seen  in  Fig.  85. 

This  is  especially  the  case  in  the  region  between  the  fourth  and  eighth 
ribs,  which  may  be  so  bent  in  as  to  form  a  vertical  groove,  increased  during 
inspiration.  Associated  with  this  is  sometimes  a  transverse  groove,  known 
as  Harrison's  groove,  starting  at  the  ensiform  cartilage  and  passing  trans- 
versely outward  toward  the  axilla.  At  the  same  time  the  arch  of  the  ribs 
below  may  be  widened  and  the  belly  thrown  forward  by  the  arching  inward 
of  the  vertebrae.  Extreme  degrees  of  this  chest  deformity  produce  the 
prominent  sternum  constituting  the  "chicken  breast"  or  "keel-shaped" 
thorax.  Other  changes  in  the  bones  are  an  exaggeration  of  the  normal 
double  ciu-ve  in  the  clavicle;  a  bending  of  the  humerus,  usually  at  the 
insertion  of  the  deltoid,  the  radius  and  ulna  may  be  ciu-ved  and  twisted, 
the  articulations  knotted  and  bulbous,  loose  and  mobile,  because  of  re- 
laxed ligaments.  The  spine  is  also  often  altered,  the  change  being  for 
the  most  part  an  increase  in  the  normal  curve  outward  in  the  cervico- 
thoracic  portion  and  inward  at  the  lumbo-sacral.  In  other  cases  there  is 
curvature.  The  scapula  is  often  thickened,  antero-posteribr  curvature. 
Lateral  curvature  is  not  so  common.  The  pelvis  is  distorted  and  twisted, 
and  the  antero-posterior  diameter  is  markedly  lessened.  The  rickety  pelvis 
is  one  of  the  well-recognized  causes  of  dystocia.  These  changes  are  all  the 
result  of  mechanical  causes,  such  as  the  weight  of  the  body  or  muscular 
traction. 

Chemical  analysis  of  rickety  bones  approximately  reverses  the  normal 
proportion  of  organic  and  mineral  constituents  (calcium  salts),  reducing 
the  latter  to  35  per  cent.,  while  the  gelatinous  or  organic  matters  amount 
to  65  per  cent. 

An  enlarged  liver  and  spleen  are  usually  present,  and  sometimes  also  the 
mesenteric  glands  are  enlarged. 

Symptoms. — The  earliest  symptoms  noticed  are  not  invariably  the  same. 
There  is  usually  profuse  sweating,  especially  about  the  head  and  neck,  and  a 
mild  degree  of  fever,  as  the  result  of  which  the  child  is  incHned  to  throw  off 
the  bed-clothing.  There  is  evident  discomfort  in  being  handled.  The  last 
symptom  is  apparently  due  to  a  tenderness  of  the  skeleton,  causing  pain 
when  the  child  is  raised  or  danced  up  and  down  after  the  manner  of  amusing 
children.  Along  with  these  are  the  less  distinctive  symptoms  of  indigestion, 
indicated  by  nausea  and  vomiting,  offensive  stools  containing  partly  di- 
gested milk,  and  flatulent  distention,  causing  the  belly  to  be  prominent. 
Among  other  less  essential  symptoms  may  be  mentioned  nervousness,  rest- 
lessness, peevishness ,  and  infantile  convulsions ,  the  relationship  of  which 
to  rickets  is  not  accidental,  and  was  pointed  out  by  Jenner.  Tetany  and 
laryngismus  stridulus  are  also  often  symptoms. 

Concixrrently  it  is  noticed  that  teething  is  delayed,  and  we  have  the 
authority  of  Sir  William  Jenner  that  if  there  are  no  teeth  at  nine  months 


828  CONSTirvriONAL  DISEASES 

there  is  somcthinj^  rickety  about  the  child.  But  dentition  is  often  delayed 
after  this  time  in  children  who  were  not  rickety  and  who  did  not  become  so. 
In  rickety  children  the  teeth  whch  arc  cut  soon  decay.  Muscular  weakness 
is  characteristic,  so  that  the  child  cannot  sit  up  and  makes  but  a  feeble  or 
no  eflEort  to  walk.  Such  muscular  weakness  has  been  mistaken  for  paralysis, 
whence  it  has  been  called  the  pseudoparesis  of  rickets.  Close  upon  these 
symptoms,  or  at  least  within  two  or  three  weeks  of  the  first  symptom,  follow 
the  skeletal  changes  described  under  morbid  anatomy,  page  826.  The  head 
is  large  in  comparison  with  the  face,  and  the  skin  is  pale  and  thin,  and  the 
child  has  often  an  old  and  a  wise  look  quite  beyond  its  years.  The  appear- 
ance of  the  beaded  ribs,  the  bowed  legs  or  "knock -knees,"  prominent 
belly,  and  curved  spine  often  serve  to  mal-ce  the  diagnosis  easy  at  a  glance. 
The  prominent  belly  requires  some  further  description,  as  it  varies  some- 
what at  different  periods.  Before  the  child  walks  the  normal  cervical 
anterior  curve  may  be  increased  and  a  posterior  curve  present  from  the 
first  dorsal  to  the  last  lumbar  vertebra,  which  may  be  recognized  by  hold- 
ing the  child  up.  After  it  begins  to  wallc,  however,  the  dorsal  spine  con- 
tinues curved  backward. while  the  lumbar  projects  forward.  The  latter, 
therefore,  contributes  also  to  the  prominent  bellj'  produced  in  part  by  the 
flatulent  distention,  and  partly  at  times  by  an  enlarged  liver  and  spleen. 

Complications. — These  include  especially  bronchial  catarrh  and  broncho- 
pneumonia, the  effects  of  which  are  aggravated  by  the  conformity  of  the 
chest,  the  weakness  of  the  ribs,  and  the  feebleness  of  the  respiratory  mus- 
cles. Collapse  of  the  lung  is  often  a  consequence  of  lung  aft'ections.  Chronic 
hydrocephalus  is  a  complication,  while  maxxy  of  the  conditions  mentioned 
under  symptomatology — viz.,  diarrhea,  convulsions,  larv^ngismus  stridulus, 
and  the  like — may  also  be  so  regarded.  The  rickety  child  is  weak  and  is 
\'ulncrablc  to  all  the  illnesses  of  childhood. 

Diagnosis. — This  is  usually  easy,  although,  of  course,  all  the  symptoms 
detailed  are  not  always  present  in  their  typical  expression.  The  various 
spinal  curvatiu-es  may  be  somewhat  confusing.  Thus,  the  question  of 
caries  may  arise.  But  the  rickety  spine  differs  from  that  of  caries  by  the 
\vide  curve,  the  absence  of  angularity,  the  flexibility  of  the  spine,  and  the 
fact  that  by  laying  the  child  flat  on  its  face  the  cvuve.  disappears.  The 
other  symptoms  of  rickets  are  also  present.  The  lordosis  of  rickets  produces 
a  deformity  resembUng  that  of  congenital  dislocation  oj  the  hip  and  of  hip 
disease,  but  here  again  other  signs  of  rickets  are  present,  while  the  distinctive 
signs  of  the  disease  in  question  are  absent.  Achondroplasia  is  frequently 
mistaken  for  rickets.     For  diagnosis  see  chapter  on  Achondroplasia. 

Prognosis. — Rickets  is  never  in  itself  fatal,  and  the  course  is  toward 
recovery.  But  the  child  is  always  in  danger  from  the  complications.  Such 
are  bronchitis,  bronchopneumonia,  lars^ngeal  spasm,  and  convulsions. 
Walking  is  always  delaj-ed,  and  the  child  may  be  still  imable  to  walk  at 
the  end  of  the  second  or  third  year.  Mention  has  been  made  of  the  fact  that 
the  rickety  pelvis  in  women  is  one  of  the  most  frequent  causes  of  difficult 
labor: 

Treatment. — We  should  seek  to  avert  rickets  by  a  judicious  prophj'laxis 
which  consists  in  keeping  the  health  of  the  mother  at  the  highest  point  at 
all  times;  this,  not  by  organic  food  only,  but  by  a  judicious  adnuxttu-e  of  salts 


RICKETS  829 

such  as  are  contained  in  the  whole  cereal  grain,  especially  in  wheat  and  bar- 
ley. Frequent  pregnancies  and  prolonged  nursing,  being  acknowledged 
causes,  should  be  interdicted. 

The  treatment  of  the  child  should  be  dietetic,  medicinal,  hygienic,  and 
operative  or  mechanical.  As  the  condition  depends  often  upon  the  lack  of 
ordinary  good  food,  the  simple  addition  of  such  food  in  lieu  of  the  mother's 
milk,  if  this  be  found  defective,  may  be  all  that  is  reqtiired,  especially  if  it 
be  possible  to  secure  that  rarely  attainable  article,  a  healthy  wet-nurse. 
In  the  absence  of  this,  beef-juice,  the  yolk  of  eggs,  peptonized  milk,  and 
beef  peptonoids  may  be  substituted.  Due  consideration  must,  however, 
be  paid  to  digestion  in  the  selection  of  food,  the  stools  should  be  examined 
daily,  and  if  undigested  residue  is  found,  the  food  shotild  be  changed  Cod- 
hver  oil  inunctions  are  invaluable,  and  though  in  some  respects  unpleasant. 
So  many  children  seemingly  wrested  from  death  by  their  use  that  we  value 
nothing  more  highly.  Saccharine  and  starchy  foods  should  not  be  allowed, 
except  in  very  moderate  quantities.  The  flours  of  the  whole  cereals,  well 
baked  and  cooked  as  thin  gruels  and  strained,  make  a  suitable  addition  to 
the  food,  while  the  fruit-juices  of  orange  and  lemon  may  be  given  in  small 
quantities.  Medicines  should  be  cautiously  given.  Among  them  are 
lime  salts,  as  the  hypophosphite  of  calcitun  or  lactophosphate  of  calcium, 
lo  grains  (0.65  gm.)  of  either  three  times  a  day,  or  lime-water,  or  the 
official  syrups  containing  the  salts  mentioned.  Doses  should  be  carefull}^, 
regulated,  as  digestion  is  feeble.  Minute  doses  of  iron,  preferably  the  citrate 
or  malate,  may  be  given.  Phosphorus  was  recommended  by  Kassowitz, 
and  is  indorsed  hy  Wegener,  Jacobi,  and  Striimpell,  in  doses  of  from  1/200 
to  i/ioo  grain  (o.  00033  to  o.  00066  gm.)  two  or  three  times  a  day  dissolved 
in  olive  oil  or  cod-liver  oil.  The  principle  of  the  administration  of  these 
two  drugs  is  different.  The  salts  previously  mentioned  are  convenient 
modes  of  administering  calcium,  while  phosphorus  is  supposed  to  stimulate 
bone  growth. 

The  hygienic  treatment  is  more  important  than  the  medicinal.  Fresh 
air  and  outdoor  life  are  indispenable.  If  the  child  is  warmly  clothed  and  well 
protected,  it  may  be  taken  out  even  in  cold  weather.  It  shovild  sleep  in  a 
room  with  the  windows  iip.  This  can  be  done  in  the  poorest  surroundings, 
but  is  certainly  neglected.  There  is  no  reason  why  the  poor  cannot  get 
as  good  air  as  there  is  in  the  neighborhood,  if  they  will  keep  windows  and 
doors  open.  It  should  not  he  allowed  to  walk  or  even  to  sit  up  unless  properly 
supported — in  fact,  shoiold  be  handled  as  little  as  possible. 

Mechanical  appUances  maj'  be  employed  with  advantage,  especially 
in  lateral  bowing,  before  the  bone  is  hardened.  Forcible  manual  straighten- 
ing may  also  be  employed  in  moderate  grades  of  deformity,  but  should  be 
relegated  to  the  experienced  orthopedic  surgeon.  After  ossification  is  com- 
plete, deformities  may  be  corrected  by  the  orthopedic  surgeon,  by  osteotomy 
chiefly  of  the  bones  of  the  lower  extremities,  though  the  radius  and  ulna  are 
sometimes  operated  on. 


830  COXSTITUTIOXAL  DISEASES 

ACHONDROPLASIA. 

Synonyms. — Chondrodystrophia  fetalis;  Epiphyseal  dystrophy. 

Definition. — A  prenatal  disease  due  to  deficiency  in  the  cartilage  at  the 
ends  of  the  bones.  The  long  bones  cease  to  grow,  while  the  flat  bones, 
which  arc  not  formed  from  cartilage  but  from  membrane,  such  as  the 
cranial  bones  and  scapulae,  have  a  normal  growth.  As  a  consequence  the 
legs  and  arms  are  ver>'  much  shortened,  while  the  cranivun  and  trunk  are 
nearly  normally  developed.  The  bridge  of  the  nose  is  depressed  and 
the  fingers  are  shortened  and  trident.  The  joints  are  enlarged  from 
hyperplasia  of  the  epiphyses.  Hence  the  subject,  whether  child  or  an 
adult,  shows  the  effects  of  the  disease  more  especially  when  standing, 
the  patient  being  always  below  normal  height  and  often  a  dwarf.  The 
shortening  is  increased  by  some  tendency  to  bowing  of  the  bones  of  the 
legs.  The  arrest  of  development  begins  in  fetal  life.  Premature  birth  of 
achondroplastic  fetuses  is  common. 

Etiology. — The  cause  is  unknown,  but  the  joints  are  enlarged  from 
hyperplasia  of  the  epiphyses,  while  the  arrest  in  the  growth  of  the  diaphysis 
seems  to  be  due  to  fibrous  outgrowth  from  the  periosteum  of  the  shaft  and 
the  epiphysis,  restricting  development  of  the  former  and  causing  failure 
of  ossification  of  the  cartilage  cells. 

Diagnosis. — The  conditions  with  which  achondroplasia  can  be  con- 
founded are  rickets,  cretinism,  congenital  syphihs  and  osteogenesis 
imperfecta.  Achondroplasia  is  a  congenital  disease.  The  lesions  are 
complete  at  birth.  The  deformities  present  are  but  exaggerated  with  the 
growth  of  the  individual.  Rickets  is  a  postnatal  disease.  The  lesions 
are  entirely  different  in  the  two  affections,  and  may  at  once  be  dift'erentiated 
by  the  X-ray.  In  achondroplasia,  the  lesion  is  in  the  cartilage ;  the  epiphy- 
ses are  about  normal;  the  enlargement  at  the  ends  of  the  bone  is  due  to 
cup-like  projections  of  the  diaph^'ses.  In  rickets  the  enlargement  at  the 
ends  of  the  bones  is  in  the  epiphysis  itself.  There  are  enlargements 
forming  bosses  at  the  muscular  attachments  in  achondroplasia.  These 
are  absent  in  rickets.  In  achondroplasia  the  bones  are  hard.  In  rickets 
they  are  soft.  The  chest  and  trunk  are  normal  in  achondroplasia;  they  are 
affected  in  rickets.  There  is  pug-nose  in  achondroplasia,  which  is  absent 
in  rickets.  The  vault  is  normal  in  achondroplasia  and  bossed  in  rickets. 
The  bones  affected  in  achondroplasia  are  those  laid  down  in  cartilage, 
while  any  of  the  bones  may  be  affected  in  rickets.  Achondroplasia  is  a 
permanent  lesion.  A  patient  vnih  rickets  may  recover.  Apert  says,  "An 
individual  is  born  achondroplastic  and  remains  achondroplastic,  but  an 
individual  may  become  rachitic  and  recover." 

The  differential  points  from  cretinism  are  the  follownng:  A  cretin  lacks 
intelligence.  Achondroplastics  are  of  normal  or  unusually  bright  intellect. 
The  hair  of  cretins  is  scant  and  coarse;  that  of  achondroplastics  abundant 
and  normal.  The  tongue  of  a  cretin  is  protruded,  and  there  is  drooling; 
this  is  absent  in  achondroplastics. 

The  bone  lesion  in  cretinism  is  simply  an  underdevelopment.  This 
is  well  seen  in  X-ray  plates.     Cretins  recover  under  thyroid  extract  when 


OSTEOMALACIA  831 

treated  early.  This  material  has  no  effect  on  achondroplastics.  Umbilical 
hernia  is  the  rule  in  cretins,  but  absent  in  achondroplastics. 

Achondroplasia  may  be  mistaken  for  congenital  syphilis.  In  syphilis 
the  pug-nose  is  due  to  actual  bone  disease;  in  achondroplasia  it  is  due  to  a 
premature  union  of  the  bones  at  the  base  of  the  skull. 

The  X-ray  will  always  make  the  diagnosis. 

To  quote  Schirmer  in  regard  to  achondroplasia  and  osteogenesis  im- 
perfecta: "In  spite  of  the  analogous  clinical  symptoms,  the  anatomic 
substratum  of  the  two  affections  is  entirely  different.  Achondroplasia 
is  permanently  a  defect  in  the  cartilage,  while  osteogenesis  imperfecta 
is  a  functional  disturbance  of  the  periosteum  and  the  bony  tissue." 

Treatment. — No  known  substance  has  j^et  been  found  to  affect  achon- 
droplasia. Extract  of  thymus  gland  has  been  tried,  but  found  wanting. 
Perhaps  later  experiments  with  some  internal  gland  may  be  found  of  value, 
but,  as  the  disease  is  practically  complete  at  birth,  there  is  little  hope  of 
this.  Courtin  has  attempted  a  surgical  procedure  which  so  far  has  not 
been  confirmed. 

OSTEOAIALACIA. 

Definition. — A  softening  which  takes  place  in  the  bones  by  a  solution 
of  lime  salts  subsequent  to  their  complete  development. 

Etiology. — The  precise  cause  is  imknown.  A  geographical  distribu- 
tion, however,  exists,  in  accordance  with  which  it  is  common  on  the  Rhine, 
in  Westphalia,  in  eastern  Belgium,  and  in  northern  Itah'.  In  this  respect 
it  is  similar  to  goiter,  which  prevails  in  special  localities,  and  it  has  been 
suggested  on  this  account  that  it  may  be  due  to  some  local  cause.  It  is 
for  the  most  part  a  disease  of  adults  between  30  and  40  years  old,  and 
of  women  more  than  of  men.  It  is  favored  by  unhygienic  surroundings, 
such  as  damp  and  badly  ventilated  dwellings.  Frequent  pregnancy  is 
supposed  to  be  an  exciting  cause. 

Pathology. — There  is,  primarily,  increased  vascularity.  To  this  suc- 
ceed a  solution  and  disappearance  of  the  lime  salts  of  the  bone.  These 
take  place  from  within  outward,  from  the  marrow  cavity,  dissolving  out 
first  the  lime  salts,  and  then  melting  away  the  matrix,  enlarging  the  central 
cavity  until  the  cortical  portion  acquires  a  paper-like  thinness.  The  whole 
bone  has  been  compared  to  an  "inflated  and  dried  intestine."  The  product 
of  the  solution  at  first  is  a  mucoid  matter  that  mixes  with  the  marrow. 
The  latter  soon  loses  its  vascularity  and  gradually  acquires  a  thinner  but 
stiU  viscid  character  and  a  yellow  color.  The  periosteum  is  likewise 
hyperemic  and  at  first  thickened.  The  bones  are  soft,  friable,  and  easily 
cut.  They  sometimes  "feel  like  wet  paper."  The  process  is  compared  to 
the  artificial  solution  of  the  earthy  salts  from  bone  by  hydrochloric  acid, 
and  it  is  supposed  that  the  solvent  agent  exerts  its  effect  from  the  medullary 
spaces  and  Haversian  canals.  The  process  extends  unevenly.  It  differs 
from  rickets  in  being  a  degeneration  oj  fully  formed  hone,  while  the  latter  is  a 
degeneration  of  developing  bone. 

The  favorite  seats  of  the  process  are  the  vertebrae  and  the  bones  of  the 
pelvis  and  thorax;  also  of  the  thighs.     The  result  in  the  former  is  an-  S- 


832  CONSTirUTIOXAL  DISEASES 

.  like  ciin,^e  of  the  spinal  column,  due  to  a  kyphoscoliosis  or  backward  cur\-a- 
ture  of  the  dorsal  and  a  lordoscoHosis  or  forward  curvature  of  the  lumbar 
part,  while  the  cervical  portion  in  connection  with  the  upper  dorsal  portion 
]jrotrudes  anteriorly.  The  thorax  is  distorted  and  compressed  laterally, 
while  the  sternum  is  prominent  and  bent.  The  pelvis  is  also  compressed 
laterally,  the  symphysis  projects  like  the  prow  of  a  ship,  and  the  sacrum 
projects  forward  producing  a  deformity  of  the  pelvis  often  discoverable 
only  b>'  internal  examination. 

Symptoms. — The  symptoms  are  slow  in  presenting  themselves.  The 
first  recognizable  symptom  is  usually  pain,  deep  seated  and  severe,  oftenest 
in  the  sacral  region,  nape  of  the  neck,  back,  and  thighs,  and  this  pain  is 
persistent  and  increased  by  motion,  giving  rise  to  a  hobbling  gait.  There 
is  also  tenderness.  Walking,  therefore,  becomes  more  and  more  difficult 
and  finally  impossible,  and  the  patient  takes  to  bed.  But  this  affords  no 
relief,  the  pain  being  kept  up  by  the  pressure  of  the  bed-clothing  and  the 
weight  of  the  body.  In  the  meantime  the  deformities  described  under 
morbid  anatomy  take  place,  though  those  of  the  pelvis  are  less  obvious 
externally.  Difficult  labor  is  an  inevitable  consequence  should  the  patient 
conceive,  just  as  it  is  in  rickets.  Dyspnea  is  a  frequent  consequence  of 
compression  of  the  lung  by  the  distorted  thorax.  Fractures,  complete 
and  incomplete,  are  frequent  events,  even  of  the  ribs  as  well  as  of  the  ex- 
tremities. In  this  respect  osteomalacia  differs  from  rickets,  in  which 
the  bones  bend  but  do  not  break.  Such  fractures  repair  imperfectly. 
Sometimes,  on  the  other  hand,  the  limbs  are  soft  and  j-ielding,  and  may 
be  bent  like  a  lead  pipe.  The  bones  of  the  head  and  face  are  for  the  most 
part  exempt,  though  the  head  is  much  bent  toward  the  chest,  making 
the  stature  lower. 

The  general  condition  of  the  patient  often  remains  for  a  long  time  im- 
altered.  There  is  little  or  no  fever.  The  organic  functions  are  normally 
maintained.  The  presence  of  lactic  acid  in  the  urine  has  been  mentioned 
but  is  infrequent.  It  is  said  that  phosphoric  acid  is  diminished.  Albu- 
min is  also  sometimes  present.  Bence  Jones's  albumose  was  present  in  a 
case  reported  by  Dock.  Calcareous  concretions  have  been  found  in  the 
kidneys  and  bladder. 

Diagnosis. — At  first  there  may  be  doubt  as  to  the  nature  of  the  disease, 
but  as  the  characteristic  symptoms  present  themselves,  its  real  nature 
becomes  evident.  Disease  of  the  vertebrce  and  cord  has  been  confounded 
with  it,  but  the  hobbling  gait  peciiliar  to  it  does  not  usually  resemble  any 
of  the  gaits  of  spinal  disease.  Being  a  disease  of  adults,  it  is  not  likely  to 
be  mistaken  for  rickets.  Moreover,  it  is  a  disease  which  affects  the  shafts 
of  bones  rather  than  the  epiphyses. 

Prognosis. — The  disease  is  usually  ultimately  fatal,  although  death  is 
often  long  deferred  and  the  course  is  chronic — from  two  to  ten  years. 
Arrest  sometimes  occurs,  but  is  only  temporary.  The  disease  again  starts, 
and  its  course  is  generally  irresistible.  Death  commonly  takes  place 
from  exhaustion  or  from  some  complication  like  pneumonia.  Recovery 
is  not  impossible.  The  so-called  cystic  degeneration  of  bone  is  said  to  be 
a  consequence. 

Treatment. — Theoreticall)',  the  indications  are  the  same  as  for  rickets 


MULTIPLE  MYELOMA  833 

— viz.,  to  supply  the  blood  with  Hme  salts.  Practically,  they  have  not 
proved  of  much  value.  They  may,  however,  be  prescribed  in  the  shape 
of  the  syrup  of  the  lactophosphate  of  lime  in  the  dose  of  from  i  to  2  flui- 
drams  (4  to  8  c.c.)  or  the  syrup  of  the  hypophosphates  in  the  same  dose 
or  the  latter  in  combination  with  iron  or  with  cod-Hver  oil.  Proper  hygiene 
and  good  food  are  of  the  utmost  importance.  Phosphorus  itself  is  a  drug 
highly  commended.     (See  Rickets.) 

Women  who  are  subjects  to  osteomalacia  should  be  warned  against 
marriage. 

MULTIPLE  MYELOMA. 

Synonyms. — Myelopathic  Albumosuria;  Kahler's  Disease. 

Definition. — A  disease  characterized  by  bony  deformities,  especiallj'' 
those  of  the  trunk,  the  presence  of  Bence  Jones's  albumose  in  the  urine  and 
a  more  or  less  rapidly  fatal  course.  This  is  briefly  treated  under  Albu- 
mosuria.    Up  to  June,  1904,  3S  cases  were  reliably  reported. 

Morbid  Anatomy. — The  cases  which  have  come  to  autopsy  have  re- 
vealed a  more  or  less  diffuse  neoplasm,  sarcomatous  in  structure,  invading 
simtdtaneously  several  bones  of  the  trunk,  without  the  occurrence  of 
metastases.  It  consists  of  round  cells  resembling  those  of  the  normal  cells 
of  the  bone-marrow.  This  neoplasm  replaces  the  bony  structure  in  the 
cavity  of  the  bone  sometimes  causing  swelling  of  the  bone  and  spontaneous 
fracture. 

Etiology. — The  condition  has  as  yet  been  traced  to  no  cause. 

Symptoms. — Along  with  albumose  in  the  tuine,  severe  intermittent 
pain  in  the  affected  bones  is  the  most  constant  symptom.  The  pain  may 
be  in  the  thigh,  in  a  part  or  all  of  it;  in  the  bones  of  the  arm,  the  sternum 
or  the  ribs,  or  the  spinal  column.  The  pain  is  described  as  dull  and  continu- 
ous. The  pain  disappears  at  times  regardless  of  treatment  There  is  at 
first  no  tenderness,  but  as  the  disease  continues  points  of  tenderness  develop 
when  moderate  pressiu-e  or  even  the  physician's  percussion  may  cause  in- 
tense pain.  "When  the  disease  is  established,  motion  of  the  body,  even 
that  of  breathing,  aggravates  the  pain.  As  it  continues,  extreme  weakness 
develops  with  anemia.  There  may  be  also  attacks  of  nausea  and  vomiting 
with  intermittent  diarrhea,  although  the  visCera,  including  liver,  spleen,  and 
lymphatic  glands  are  normal.  There  is  no  fever,  the  temperature  not  ex- 
ceeding 99 ;  the  pulse  is  moderately  frequent,  rising  to  120.  The  bones 
become  friable  and  easily  broken.  There  is  no  edema  of  the  extremities, 
though  death  may  be  preceded  by  edema  of  the  lungs.  Pleurisy  has  been 
found  antecedent  as  in  Meltzer's  case."- 

Urine. — As  stated,  the  urine  contains  large  quantities  of  Bence  Jones's 
albumose,  one  of  the  intermediate  products  of  albumin  digestion  between 
albumin  and  the  ultimate  product  peptone. 

Albumose  is  thus  recognized:  It  is  precipitated  from  urine  by  nitric 
acid,  more  abundantly  than  albumin,  as  a  rule,  but  is  redissolved  by  heating 

"  Myelopathic  Albumosuria."     Reprint  from  "  New  York  Medical  Record."  June 


834  CONSTITUTIONAL  DISEASES 

to  the  boiling  temperature.  It  is  precipitated  when  the  urine  is  heated 
before  it  reaches  the  boiling  point.  When  the  temperature  reaches  the  boil- 
ing-point the  coagvdum  redissolves  leaving  only  a  sUght  turbidity.  As  the 
urine  cools  the  albumose  precipitates  again,  and  again  dissolves  on  boiling. 

The  course  of  the  disease  is  usually  rapid,  although  one  case  described 
by  Kahler,  that  of  a  physician,  lasted  over  eight  j^ears. 

Diagnosis. — The  presence  of  albumose  in  the  urine  and  the  above 
symptoms  are  pathognomonic  of  mj^eloma. 

Prognosis. — The  termination  is  invariably  fatal  usually  after  a  rapid 
covuse,  but  sometimes  the  disease  is  more  prolonged  as  in  the  case  of  Kahler's 
physician  referred  to. 

Treatment. — No  remedy  has  been  found  which  can  be  regarded  in  any 
sense  as  ciarative.  A  local  application  of  ice  in  Meltzer's  case  relieved  the 
pain. 


SECTION  IX. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

GENERAL  INTRODUCTION. 

HISTOLOGY  OF  THE  NERVOUS  SYSTEM. 

The  difficulties  in  the  diagnosis  of  diseases  of  the  nervous  system  are 
gradually  diminishing  as  the  thread  of  its  histology  is  being  unraveled. 
The  studies  of  Golgi,  His,  Forel,  Waldeyer,  Ramon  y  Cajal,  Dejerine, 
Lenhossek,  van  Gehuchten,  and  others  have  considerably  altered  pre\'iously 
accepted  views.  A  brief  statement  of  the  fundamental  features  of  histology 
seems,  therefore,  necessar3^ 

The  studies  of  these  and  other  observers  resolve  the  nen^ous  sj^stem  into 
an  immense  number  of  units,  to  which  Waldeyer  has  given  the  name  neurons 
— whence  the  name  neuron  theor}^     Each  neuron  is  made  up  of: 

1.  A  nerve  cell  body. 

2.  Protoplasmic  processes,  or  dendrites. 

3.  An  axis-cylinder  or  axon  continuous  with  the  nerve-fiber. 

4.  Terminal  ramifications  of  the  axis-cylinder. 

The  axis-cylinder  of  a  motor  spinal  cell  gives  off  at  different  intervals 
lateral  branches  known  as  collaterals.  These  collaterals  or  paraxons,  and 
finally  the  axis-cylinder  itself,  break  up  into  many  fine  fibers,  known  as  ter- 
minal ramifications,  or  end  brushes,  or  branch  tufts.  Each  neuron  has  been 
believed  to  be  independent  of  every  other — that  is  no  protoplasmic  process 
of  one  neuron  is  continuous  with  that  of  another,  nervous  communication 
being  through  simple  contact  or  proximity.  More  recent  investigations, 
however,  throw  some  doubt  on  this.  The  protoplasmic  processes  dentritis 
conduct  impulses  to  the  cell,  are  cellulipetal,  as  named  by  Cajal;  the  axis- 
cylinders  axons  conduct  impulses  away  from  it  and  are  cellulifugal.  The 
nutrition  of  the  neuron  depends  largely  on  the  cell  body.  If  the  latter  is 
intact,  the  processes  are  preserved.  If  it  is  injured  they  waste,  or  if  they 
are  cut  off  they  degenerate;  on  the  other  hand,  the  cell  body  suffers  when 
its  processes  become  diseased. 

The  motor  neurons  having  their  cell  bodies  in  the  gray  matter  of  the 
brain,  are  called  central  neurons;  those  neurons  having  their  cell  bodies  in 
the  spinal  cord  and  in  the  ganglia  on  the  posterior  roots,  are  called  per- 
ipheral neurons.  The  end  brushes  or  terminal  ramifications  of  a  central 
motor  neuron  surrovmd  the  body  and  protoplasmic  processes  of  a  peripheral 
motor  neuron,  while  those  of  the  peripheral  neiu^on  are  in  connection  with 
a  motor  plate.  The  axis-cylinders  of  the  central  and  peripheral  neurons 
traverse  chiefly  the  white  tracts  of  the  brain  and  spinal  cord  and  the  per- 
ipheral nerves.  The  cells  of  the  anterior  roots  of  the  spinal  nerves  lie  in 
the  anterior  comua  of  the  gray  matter,  and  have  the  protoplasmic  processes 
short  and  the  axis-cylinders  long.     (See  Fig.  135.) 

835 


836 


DISEASES  OF  THE  NERVOUS  SYSTEM 


The  cells  of  the  posterior  roots  are  situated  in  the  ganglia  on  those 
roots;  the  axis-cylinders  of  these  cell  bodies  divide  soon  after  leaving  the 
cell  body,  one  process  passing  to  the  peripherj^  the  other  to  the  spinal  cord. 
Communication  between  different  parts  of  the  ner\'ous  system  and  mth  the 
rest  of  the  body  is  thus  rendered  possible.  The  processes  extending  to  the 
periphery  receive  impressions  from  the  exterior  and  carr}-  them  cellulipetal 
to  the  ganglion  cells  on  the  posterior  roots  of  the  spinal  nerves,  whence  they 
are  conveyed  by  the  axis-cylinders  cellulifugal  to  the  cord.  This  impres- 
sion may  result  in  a  reflex  act,  or  it  may  proceed  to  the  brain  and  gi\'e  rise 
to  a  volitional  act  through  the  m.otor  tract. 


Fig.  134. — Diagram  of  an  Element  of  the  Motor  Path — {after  Strum  pell,  modified). 
C.  Motor  ganglion  cell  in  the  cerebral  corte.x.     Py  S.  Lateral  pyramidal  tract,  central  or 
upper  motor  neuron.     V.  Ganglion  cell  of  anterior  horn.     m.  Motor  nerve,  peripheral 
neuron.     M.  Muscular  fiber. 


A  motor  impulse  starting  from  the  brain  cortex  must  pass  through  at 
least  two  sets  of  nevu"ons  before  it  can  reach  the  muscles.  In  this  course 
it  is  cellulifugal  from  the  cell  in  the  cortex,  cellulipetal  to  the  cells  in  the  gray 
matter  at  different  levels  in  the  anterior  cornua,  and  thence  celltdifugal 
from  the  latter  cells  to  the  various  muscles  of  the  body,  ending  in  the  end- 
plates.  Hence  we  speak  of  the  motor  tract  as  being  composed  of  two 
segments,  an  upper  and  a  lower.  The  neurons  of  the  upper  motor  segment 
have  their  cell  bodies  and  protoplasmic  processes  in  the  cortex  in  front 
of  the  fissure  of  Rolando.  The  axis-cylinder  processes  run  through  the 
internal  capstile  and  the  cerebral  peduncles,  through  the  pons,  medulla 
oblongata,  and  cord,  ending  in  terminal  ramifications  around  the  proto- 
plasmic processes  and  cell  bodies  of  the  lower  segment.     The  neurons  of 


HISTOLOGY  OF  THE  NERVOUS  SYSTEM  837 

the  lower  segment  arc  those  having  their  cell  bodies  and  protoplasmic 
processes  in  the  anterior  cornua  of  the  gray  matter,  while  their  axis-cylinders 
leave  the  spinal  cord  by  the  anterior  roots  of  the  spinal  ner^^es,  to  be 
distributed  as  described.  The  upper  segment,  in  large  extent  at  least,  is  a 
crossed  tract — that  is,  the  neurons  composing  it  have  their  cell  bodies  and 
protoplasmic  processes  in  the  cortex,  while  their  axis-cylinders  cross  the 
middle  line  to  end  about  the  cell  bodies  in  the  opposite  half  of  the  spinal 
cord;  so  that  motor  impulses  starting  in  the  left  half  of  the  brain  produce 
contraction  in  the  muscles  of  the  right  half  of  the  body,  and  vice  versa. 
although  both  sides  of  the  brain  probably  inner\'ate  unequally  each  side  of 
the  body.  (Fig.  135.)  The  lower  motor  segment  is  a  direct  tract — that  is, 
its  neurons,  and  the  muscles  to  which  they  are  distributed,  are  all  on  the 
sane  side  of  the  body. 

The  path  for  sensory  conduction  is  also  composed  of  segments,  but  the 
direct  route  of  sensorj'  conduction  is  more  complicated  and  our  knowledge 
is  much  less  exact.  The  cell  bodies  of  the  lower  neurons  are  in  the  gan- 
glia on  the  posterior  roots  of  the  spinal  nen^es  and  in  the  ganglia  of  the  sen- 
sory cranial  nerves.  These  ganglion  cells  have  a  single  process,  which, 
after  leaving  the  cell,  divides  in  a  T-shaped  manner,  one  branch  running 
into  the  central  nervous  sj^stem  and  the  other  toward  the  periphen,-. 
(Fig.  134.)  The  process  which  connects  mth  the  peripherv-  is  regarded 
by  some  as  a  protoplasmic  process,  while  that  which  passes  to  the  center 
is  known  as  the  axis-cylinder.  The  former  runs  in  the  sensory  nerv^es, 
starting  from  the  various  specialized  sensor\-  apparatus  of  the  peripher}-. 
The  axis-cylinder  enters  the  cord  by  the  posterior  roots.  After  entering 
the  cord  it  divides  into  an  ascending  and  a  descending  limb,  which  traverse 
the  posterior  columns.  The  descending  branch  runs  a  short  distance  and 
ends  in  the  gray  matter  of  the  same  side  of  the  cord,  giving  off  a  number 
of  collaterals,  which  also  end  in  the  gray  matter.  The  ascending  branch 
may  end  in  the  gray  matter  soon  after  entering  the  cord,  or  it  may  run 
in  the  posterior  columns  as  high  as  the  medulla  oblongata,  ending  in 
the  nuclei  of  the  posterior  colvunns.  Thus  the  lower  segment  is  also  a 
direct  tract  terminating  in  the  gray  matter  of  the  posterior  cornua  at  different 
levels,  and  in  the  gray  matter  of  the  medulla  oblongata.  (See  also  section 
on  Spinal  Cord.)  The  upper  segment  starting  from  these  is  a  crossed  tract, 
crossing  at  different  levels,  so  that  sensorj'  impressions  are  ultimately 
lodged  in  the  brain  on  the  side  opposite  that  whence  they  start  in  the 
periphery.  The  so-called  muscular  sense,  perhaps  better  called  the  sense 
of  position,  is  probably  conducted  upward  on  the  same  side  in  the  columns 
of  Burdach  and  Goll  on  each  side  of  the  posterior  median  fissure.  The 
exact  termination  of  the  sensory  fibers  in  the  cerebral  hemisphere  is  not 
known,  but  they  pass  up  in  the  tegmenttun  of  the  pons  and  possibly  in 
the  internal  capsule.  It  is  believed  b}^  many  that  these  processes  terminate 
in  the  optic  thalamus,  and  that  from  here  the  impulses  are  conducted  to  the 
cortex  by  means  of  another  set  of  neurons.  Recent  investigations  seem  to 
show  that  the  sensory  area  of  the  brain  is  posterior  to  the  Rolandic  fissure. 

Both  motor  and  sensory  spinal  nerve  roots  are  connected  with  definite 
segments  of  the  spinal  cord.  They  descend  a  variable  distance  within  the 
spinal  canal,  unite  within  the  intervertebral  foramen,  but  external  to  the 


838  DISEASES  OF  THE  NERVOUS  SYSTEM 

point  where  the  roots  perforate  the  dura  mater  and  pass  through  the  fora- 
mina as  spinal  nerves.  But  in  their  distribution  they  do  not  retain  the  same 
definiteness,  the  same  sensory  and  motor  areas  being  supplied  \vith  nerve 
fibers  from  different  segments  of  the  cord,  and  there  is  an  overlapping,  as  it 
were,  of  parts  supplied  by  different  nerve  fibers.  At  the  same  time,  by  the 
combined  aid  of  experiment  and  ihorbid  physiology,  we  have  learned  that 
movements  in  certain  muscles  are  accomplished  by  motor  nerves  which 
emanate  from  corresponding  segments  of  the  spinal  cord,  and  that  from 
certain  sensitive  areas  are  gathered  up  impressions  which  are  carried  to 
corresponding  sections  of  the  spinal  cord.  By  the  same  means  we  have 
learned  that  there  are  areas  in  the  cortex  of  the  brain  that  preside  over 
certain  motions,  and  areas  which  have  to  do  with  sensation;  though  with 
respect  to  the  latter  our  knowledge  is  much  less  definite.  We  know  about 
as  much  of  the  cortical  localization  of  the  special  senses  as  of  sensibility. 
These  facts  are  the  foundation  of  what  is  known  as  topical  diagnosis,  in  the 
case  of  the  brain  as  cerebral  localization,  by  which  is  meant  the  inference, 
from  the  study  of  local  derangements  of  sensation,  motion,  and  other  func- 
tions of  the  more  or  less  exact  site  of  lesions  in  the  nervous  centers.  These 
will  be  considered  with  appropriate  detail  in  our  study  of  the  diseases  of 
different  parts  of  the  nervous  system. 


GENERAL  SYMPTOMATOLOGY. 

(Investigation  of  a  Case  of  Nervous  Disease.) 

The  advantages  of  a  careful  method  in  the  study  of  disease  are  perhaps 
more  apparent  in  the  case  of  the  nervous  system  than  that  of  any  other 
of  the  anatomical  divisions  of  the  human  body.  This  is  partly  because 
of  the  number  and  variety  of  the  affections  to  which  the  nervous  system 
is  subject,  and  partly  because  of  the  association  of  certain  identical  symp- 
toms with  widely  different  lesions. 

The  primary  steps  of  family  and  personal  histor>'  are  the  same  as  for 
other  diseases,  including  age,  sex,  occupation,  and  whether  married  or 
single.  We  ma}^  therefore  pass  at  once  to  the  study  of  such  symptoms 
as  are  special. 

I.  Phenomena  of  Motion. — It  is  immaterial  whether  we  examine  first 
sensory  or  motor  phenomena,  but  it  appears  somewhat  easier  to  begin 
with  derangements  of  motion,  and  of  these  (i)  voluntary  motion  is  natu- 
rally first  investigated.  To  this  end,  the  patient  is  asked  to  move  his 
limbs,  while  the  strength  of  whatever  motion  he  is  capable  is  easiest  meas- 
ured by  resisting  it,  and  by  testing  the  power  of  his  hand-grasp.  For 
more  accurate  measiu-ement  of  dynamometer  is  used,  an  instrument  de- 
vised to  measure  both  compression  and  traction,  although  it  is  more  com- 
monly restricted  to  the  former.  Advantage  may  be  taken  of  the  fact,  too, 
that  the  same  motion  requires  different  degrees  of  strength  in  different  posi- 
tions of  the  body.  Thus  it  is  easier  to  draw  up  the  thigh  when  lying  on 
the  back  than  when  on  the  side,  and  it  may  be  possible  in  the  former  posi- 
tion when  it  is  not  in  the  latter.  Both  extensor  and  flexor  muscles  must 
be  thus  tested.     By  such  an  investigation  we  discover  the  presence  of  a 


GENERAL  SYMPTOMATOLOGY 


839 


complete  paralysis  or  total  loss  of  voluntary  motion,  and  paresis  or  simple 
weakening  of  such  power. 

By  a  monoplegia  is  meant  an  isolated  paralysis  of  one  part  of  the  body, 
as  of  an  arm  or  a  leg.  By  a  hemiplegia  is  meant  a  paralysis  of  the  entire 
lateral  half  of  the  body,  including  half  of  the  face,  one  arm,  and  one  leg, 
also  known  as  unilateral  paralysis.  By  a  paraplegia  is  meant  a  simultaneous 
paralysis  of  the  upper  or  lower  halves  of  the  body.  Paralysis  of  the  two  arms 
is  known  as  a  superior,  or  brachial,  paraplegia,  of  the  two  legs  as  an  inferior, 
or  crural,  paraplegia,  while  the  word  paraplegia  alone  is  often  used  for  the 
latter  condition.  A  diplegia  is  a  paralysis  in  which  upper  and  lower  limbs 
are  affected  on  both  sides  of  the  body,  usually  attended  with  spasm  of  all  the 
extremities,  although  the  term  is  also  emploj^ed  for  bilateral  facial  paralysis. 
Though  commonly  congenital,  diplegia  may  also  be  acquired. 


Jh:irt 


Face 


■PS/j:. 


'£xtremi/i/ 


Fig.  135. — -Illustrating  Crossed  Paralysis — {after  Eirt). 

0.   iledulla  oblongata,  pyx.   Decussation  of  anterior  pyramids.     E.  Nerve  fiber  going  to 

extremities.     F.  Nerve  fiber  to  face. 


Impairment  of  voluntary  muscidar  power,  as  thus  tested,  must  be  the 
result  of  structural  change  in  the  motor  area  of  the  cortex,  in  the  motor 
tract  of  the  brain  or  cord,  or  impairment  in  the  integrity  of  the  efferent 
nerves,  or  it  may  be  more  rarely  in  the  muscle  itself,  "myopathic  palsy"; 
or  the  power  of  the  will  may  be  abrogated.  In  diseases  of  the  peripheral 
ner\^es,  when  the  paralysis  is  called  peripheral,  it  is  limited  to  the  region  of 
distribution  of  the  affected  nerves,  whether  one  or  many.  It  msiy  be  said 
in  general  that  hemiplegia  is  the  usual  form  of  cerebral  paralysis,  while 
paraplegia  is  the  expression  of  spinal  paralysis.  Monoplegias  are  due  to 
lesions  of  the  cortex,  or  of  the  anterior  gray  matter  of  one  side  of  the  spinal 
cord,  as  in  poliomyelitis,  or  are  peripheral  palsies;  cortical  monoplegia  is 
rare. 

In  all  hemiplegias  caused  by  lesions  above  the  pons,  the  palsy,  including 
that  of  the  face  and  extremities,  is  on  the  side  opposite  the  lesion,  but  in 
most  lesions  in  the  middle  or  lower  part  of  the  pons  there  is  crossed  paralysis 
— that  is,  there  is  paralysis  of  the  extremities  on  one  side,  and  of  the  face 
on  the  other  side,  provided  the  central  fibers  of  the  extremities  and  the 


840  DISEASES  OF  THE  NERVOUS  SYSTEM 

facial  nerve  are  in\'olvcd  in  the  lesion.  The  reason  of  that  is  that  the  central 
fibers  of  the  facial  nerve  cross  much  higher  than  do  the  fibers  to  the  extremi- 
ties, and  in  such  a  lesion  the  intra-medullary  portion  of  the  facial  nerve, 
and  not  the  central  fibers  connecting  its  nucleus  with  the  brain  cortex  are 
injured.  The  result  is  a  paralysis  of  the  face  on  the  same  side  as  the  lesion 
and  of  the  extremities  on  the  other.  This  would  be  the  case  wdth  a  lesion 
at  b,  Fig.  136.  If,  on  the  other  hand,  the  lesion  is  higher  up,  above  the 
decussation  of  both  the  facial  and  pyramidal  tracts,  as  at  a,  the  paralysis 
is  on  the  side  opposite  the  lesion  in  both  face  and  extremities.  Other 
nerves  may  substitute  the  facial  in  this  crossed  paralj'sis  as  the  oculomotor 
(third  nerve)  or  hypoglossal  (twelfth  nerve)  or  abducens  (sixth  nerve). 
In  rarer  instances  it  is  possible  that  a  lesion  at  the  decussation  of  the  pyra- 
mids, by  cutting  the  motor  fibers  of  one  extremity  before  they  cross,  and 


Fig.  136. — Illustrating  the  possibility  of  paralysis  of  arm  on  one  side  and  of  leg  on  the  other. 

those  of  another  after  crossing,  may  produce  the  ver>'  rare  condition  of 
paralysis  of  an  arm  on  one  side  and  of  a  leg  on  the  other.  That  this  is 
theoretically  possible  may  be  seen  from  Fig.  137,  in  which  the  black  lines 
represent  fibers  to  the  upper  extremities  and  red  lines  fibers  to  the  lower, 
and  the  red  circle  the  seat  of  a  small  hemorrhage. 

(2)  Having  determined  this  question  of  muscular  strength,  and  the 
corollaries  which  grow  out  of  it,  we  have  next  to  ascertain  to  what  extent 
the  power  of  co-ordination  is  influenced.  Every  muscular  act  requires  the 
duly  proportioned  co-operation  of  a  number  of  muscles;  and  as  the  com- 
plexity of  the  act  increases,  the  number  of  muscles  required  to  co-operate 
also  increases.  Such  co-operation  is  termed  co-ordination,  and  its  absence 
is  well  recognized  in  the  staggering  gait  of  the  drunkard,  and  the  condition 
is  known  as  ataxia.  There  are  certain  parts  of  the  nervous  system  which 
preside  over  co-ordination — such  as  the  cerebellum,  the  posterior  columns, 
and  probably  the  direct  cerebellar  tract,  of  the  spinal  cord.  Disease  of 
any  of  these  may,  therefore,  produce  ataxia.  The  ataxic  or  tabetic  gait  is 
described  mider  Tabes  Dorsalis,  p.  911. 

A  corollary,  growing  out  of  the  im-estigation  of  the  co-ordinating 
power,  is  the  study  of  station,  or  the  steadiness  with  which  one  stands  with 
the  eyes  closed  or  open,  and  it  is  measured  by  sway  of  the  head  and  body, 
laterally  and  antero-posteriorly.  In  health  a  lateral  sway  of  the  head 
.exists  to  the  extent  of  half  an  inch  (1.25  cm.),  and  an  antero-posterior 
sway  of  an  inch  (2.5  cm.).  A  sway  much  beyond  these  limits  is  abnormal. 
Co-ordinating  power  is  also  tested  bj^  attempting  to  bring  together  the 


GENERAL  SYMPTOMATOLOGY  841 

ends  of  the  index-fingers  with  the  eyes  closed,  an  effort  which  will  be  unsuc- 
cessfijl  if  co-ordinating  power  is  lost. 

(3)  After  ascertaining  the  condition  of  voluntary  motion,  co-ordination, 
and  station,  we  must  inquire  into  the  question  of  possible  motor  irritation 
or  excessive  muscular  action  or  spasm.  vSpasm  may  be  continuous — i.  e., 
lasting  for  minutes,  hours,  or  days — when  it  is  known  as  tonic  or  tetanic ;  it 
may  be  intermittent  or  clonic;  or  it  may  be  an  admixture  of  both,  when  it 
is  termed  tonic-clonic.  Tonic  spasm  is  well  illustrated  by  trismus  or  lock- 
jaw, while  tetanic  contraction  of  the  muscles  of  the  back  produces  opisthot- 
onos, in  which  the  vertebral  column  is  arched  and  the  body  rests  upon 
the  back  of  the  head  and  upon  the  heels.  Tonic  spasms  are  often  attended 
with  pain,  probably  due  to  pressure  on  intramuscular  nerves,  when  they 
are  called  "cramps."  Spasm  occurs  also  in  involuntary'  nonstriated 
muscular  tissue.  The  presence  of  spasms  implies  irritation  of  motor  centers, 
motor  tract,  or  motor  nerves,  but  motor  irritation  may  also  be  excited 
secondarily  by  some  reflex  route,  the  result  being  a  reflex  spasm. 

Spasm  and  paralysis  are  often  associated.  Thus,  a  limb  may  be  para- 
lyzed in  a  state  of  contraction,  exhibiting  a  peculiar  rigidity,  and  to  such  a 
condition  the  name  spastic  paralysis  is  applied.  This  condition  may  also 
exist  as  a  state  of  persistent  contraction  of  the  antagonists  of  the  paralyzed 
muscles,  constituting  the  so-called  contractures.  Paralyses  in  which  there 
is  no  such  resistance  to  passive  motion  are  known  as  flaccid  paralyses. 

Through  the  combination  of  tonic  and  clonic  spasm  result  different 
varieties  of  morbid  involuntary  movements  more  or  less  complex.  Some 
of  these  are  the  following: 

1.  The  Epileptiform  Convulsion. — This  consists  in  a  succession  of  clonic 
and  tonic-clonic  spasms  extending  over  the  whole  or  a  part  of  the  body, 
throwing  the  part  involved  into  violent  motion.  The  masseter  and  the 
temporal  muscles  share  in  the  contraction,  whence  the  tongue  is  often 
bitten.  The  convulsion  of  epilepsy  is  the  type  of  this  form,  but  the  con- 
vulsions of  uremia,  or  hysteria,  and  of  organic  disease  of  the  brain  ma^' 
be  epileptiform. 

2.  Rhythmical  Contractions. — These  occur  in  single  groups  of  muscles, 
and  are  sometimes  seen  in  apoplexy,  and  cerebral  sclerosis.  They  may 
usher  in  the  epileptiform  convulsion,  or  the  convulsion  maj^  terminate  by 
a  gradual  substitution  of  the  rhythmical  contractions  for  the  more  violent 
spasms.  Among  rhythmical  movements  may  be  included  athetosis,  a 
peculiar  slow,  involuntary  rhythmical  movement,  usually  of  the  fingers 
and  hands,  but  also  of  the  head  and  trunk,  or  of  the  toes.  The  fingers 
make  slow  movements  of  the  nature  of  extension  and  flexion,  spreading 
and  approximating  each  other  in  a  striking  way.  They  are  a  symptom  of 
certain  central  nervous  diseases,  especially  of  the  cerebral  palsies  of  children. 

3.  Tremors  or  Trembling  Motions. — These  are  limited  movements — i.e., 
movements  of  short  excursion  which  rapidly  succeed  each  other.  Tremor  is 
characteristic  of  paralysis  agitans  and  of  some  other  nervous  affections. 
It  occtu-s  in  old  persons  as  senile  tremor,  and  in  abusers  of  alcohol  and 
tobacco.  When  it  occurs  or  increases  during  voluntary  motion,  it  is  known 
as  intention  tremor,  and  is  characteristic  of  multiple  sclerosis.  The  im- 
mediate anatomical  changes  on  which  tremors  depend  are  not  known. 


842  DISEASES  OF  THE  NERVOUS  SYSTEM 

4.  Single  Contractions. — These  are  either  sudden  twitchings  or  slow 
contractions  of  muscles,  seen  especially  in  diseases  of  the  ner\'es — as,  for 
example,  in  old  facial  palsy.  They  may  be  single  or  multiple  and  persistent. 
They  may  be  the  result  of  direct  motor  irritation  or  reflex  in  origin. 

5.  Fibrillary  Contractions. — These  are  contractions  of  separate  small 
bundles  of  muscular  fibrilla;,  comparable  to  the  "quivering"  of  raw  flesh. 
They  are  independent  of  voluntary  or  passive  motion.  The}^  may  be  pro- 
nounced and  wave-like  over  the  muscular  substance.  They  are  seen  espe- 
cially when  the  motor  nerve  cells  are  degenerating,  as  in  progressive  spinal 
muscidar  atrophy  or  bulbar  paralysis.  The  "qtuvering"  of  the  eyelid  and 
of  the  orbicularis  muscle  below  the  eye,  the  so-called  "jumper,"  often  an 
annoying  symptom,  is  an  instance  of  this  condition. 

6.  Choreic  Movements. — These  are  inco-ordinated  movements,  usually 
separated  by  short  intervals  of  time,  often  first  seen  in  the  face,  later  in  one 
limb  or  over  the  whole  body.  They  may  be  very  complex  and  general. 
They  are  characteristic  of  chorea,  but  also  accompany  other  ner\'ous  affec- 
tions, such  as  posthemiplegic  chorea.  Under  the  term  posthemiplegic 
chorea,  however,  various  movements  are  sometimes  included. 

7.  Constant  or  Co-ordinate  Spasms. — These  consist  in  irresistible  com- 
plicated movements,  like  moving  forward  or  moving  in  a  circle  or  rotating 
on  the  axis  of  the  body;  also  complicated  forms  of  spasm  resembling  jump- 
ing, laughing,  screaming,  all  involuntary  and  forced.  The  first  group  of 
these  is  especially  seen  in  disease  of  the  cerebellum  and  cerebellar 
peduncles,  the  latter  in  severe  forms  of  hysteria. 

8.  Nystagmus  is  a  clonic  rhythmical  oscillator}^  and  involuntary  move- 
ment of  the  eyeball,  usually  horizontal,  sometimes  rotatory,  more  rarely 
vertical.  It  is  noticed  in  congenital  and  acquired  affections  of  the  brain, 
including  Friedreich's  ataxia  and  insular  sclerosis;  also  in  albinism  and  in 
miners  who  work  in  dimly  lighted  mines,  using  the  pick  while  reclining  and 
directing  the  eyes  laterally. 

9.  Cataleptic  Rigidity. — In  this  there  is  also  a  tonic  contraction  of 
muscles  whereby  a  limb  remains  for  a  considerable  time  in  any  position  in 
which  it  may  be  passively  placed,  the  will  being  abrogated.  If  the  position 
of  the  limb  be  changed,  the  limb  remains  in  the  new  position,  and  from  a 
resemblance  to  the  beha\'ior  of  wax  under  like  circumstances  it  has  received 
the  name  of  "waxy  flexibility."  It  is  characteristic  of  certain  forms 
of  hysteria,  and  may  be  produced  at  times  .in  hypnotism.  In  hysteria 
it  is  commonly  associated  with  anesthesia  and  loss  of  consciousness.  It  is 
also  associated  with  psychoses,  especially  grave  forms  of  melancholia  known 
as  melancholia  attonita  and  with  katatonia. 

10.  Associated  Movements. — These  are  unintentional  and  uncontrollable 
movements  which  take  place  in  muscles  coincident  with  other  motions 
actually  intended — as,  for  instance,  a  motion  in  the  arm  when  the  patient 
wills  to  move  only  the  leg. 

(4)  Bladder  control  and  rectum  control.  FuU  control  over  the  acts 
of  these  organs  implies,  first,  an  integrity  of  the  sacral  portion  of  the 
cord,  in  which  reside  the  reflex  centers  regulating  these  acts;  second, 
the  integrity  of  volition,  which,  to  a  certain  extent,  fortifies  such  regu- 
lation ;  and,  thirdlj',  integrity  of  the  afferent  and  efferent  ner\^e  fibers  con- 


GENERAL  SYMPTOMATOLOGY  843 

stituting  the  reflex  arcs.  Through  the  operation  of  the  reflex  center, 
bladder  and  rectum  both  empty  themselves  when  a  certain  degree  of  disten- 
tion is  attained.  Through  the  operation  of  the  will  such  evacuation  is  put 
off  to  a  convenient  time.  Through  an  undue  irritability  of  the  reflex  center 
such  evacuation  is  imperative,  and  does  not  bide  the  will,  or  it  may  take 
place  while  the  will  is  in  abeyance,  as  in  sleep.  Thus  may  be  explained 
some  of  the  cases  of  incontinence  of  urine  in  children.  Again,  if  will-power 
is  lost  from  disease  of  the  cerebral  cortex,  evacuations  of  the  bowel's  and 
bladder  take  place  involuntarily  so  long  as  the  sacral  cord  is  intact,  but 
not  in  a  normal  manner.     . 


Fig.  137. — Diagram  Showing  Probable  Plan  of  the  Center  for  Micturition — {Gowers). 
MT.  Motor  tract.  ST.  Sensory  tract  in  the  spinal  cord.  jMS.  Sphincter  center,  and  ms  motor 
nerve  for  sphincter.  MD.  Detrusor  center,  and  md  motor  nerve  for  detrusor.  .?.  .\fierent 
nerve  from  mucous  membrane  to  S,  sensory  portion  of  center.  B.  Bladder.  At  r  the  posi- 
tion during  rest  is  indicated,  the  sphincter  center  in  action,  the  detrusor  center  not  acting. 
At  a  the  condition  during  action  is  indicated,  the  sphincter  center  inhibited,  the  detrusor 
center  acting. 


On  the  other  hand,  if  the  integrity  of  the  sacral  cord  is  lost,  there  will 
be  no  response  to  the  sensory  impressions  conveyed  from  a  full  bladder  or 
rectum,  because  the  reflex  arc  is  interrupted,  and  the  organ  remains  un- 
emptied;  whence  torpor  or  complete  paralysis  of  the  bowels  and  bladder 
are  common  symptoms  of  spinal  disease;  and  while  the  repletion  of  the 
latter  may  finally  overcome  the  resistance  of  its  sphincter  and  lead  to  drib- 
bling, the  rectum  may  go  on  filling  up  until  it  is  emptied  by  the  finger  or 
the  handle  of  a  spoon.  A  lesion  situated  higher  in  the  central  nervous 
system  than  the  sacral  portion  of  the-  cord  may  also  cause  similar  disturb- 
ance of  defecation  and  urination,  probably  because  of  a  spastic  condition 
of  the  sphincters,  so  that  the  latter  do  not  relax  until  the  bladder  or  rectum 
becomes  distended,  and  finally  they  lose  all  function. 

Again,  if  it  should  happen  that  the  sphincter  center  is  destroyed  while 
the  detrusor  center  is  intact,  there  would  be  dribbling  of  urine  from  the 
outset,'  but  this  is  not  likely  to  occur. 

(s)  The  state  of  the  reflexes,  as  they  are  called,  is  next  ascertained.     As 


844  DISEASES  OF  THE  NERVOUS  SYSTEM 

here  used,  the  term  "reflex"  is  applied  to  a  muscular  contraction  stimu- 
lated b}'  a  sensory  impression,  the  simplest  illustration  of  which  is  the  re- 
traction of  the  leg  of  the  sleeper  when  the  sole  of  the  foot  is  tickled.  For 
diagnostic  purposes  the  reflexes  are  divided  into  the  "cutaneous  reflexes" 
and  the  "tendon  reflexes." 

The  cutaneous  or  superficial  reflexes  are  muscular  contractions  which 
talte  place  in  different  parts  of  the  body  in  response  to  irritation  of  sensory 
nerv^es  of  the  skin,  as  by  tapping  the  skin  lighth'  or  dramng  the  finger  or 
a  pointed  instrument  lightly  over  it.  The  sudden  application  of  heat  or 
cold  or  the  prick  of  a  pin  or  pinching  are  modes  of  excitation.  The  contrac- 
tions are  generally  confined  to  the  neighborhood  of  the  locality  irritated. 
The  sl<in  reflexes  are  much  more  easily  excited  in  children  than  in  adults, 
and  in  the  lower  extremities  than  in  the  upper;  also  with  var\-ing  facility 
in  different  persons.  They  receive  various  names,  according  to  the  situa- 
tions where  they  are  readily  excited.  Thus  we  have  the  "plantar  reflex," 
where  contraction  is  excited  by  tickling  the  sole  of  the  feet,  resulting  in 
a  movement  of  the  toes  or  foot,  or  even  in  a  drawing  up  of  the  leg;  the 
"cremaster  reflex,"  contraction  of  the  cremaster  muscle  and  consequent 
drawing  up  of  the  scrotum  on  stroking  or  scratching  the  inside  of  the 
thigh.  The  retraction  may  take  place  on  the  one  side  of  the  scrotum 
only  or  on  both.  Then  there  is  the  "abdominal  reflex,"  or  a  contraction 
of  the  abdominal  muscles  when  the  skin  of  the  abdomen  is  stroked  or 
scratched.  A  subdivision  of  the  latter  is  the  "epigastric  reflex,"  produced 
by  an  irritation  on  the  side  of  the  thorax  in  the  fourth,  fifth,  and  sixth  inter- 
spaces. The  result  is  a  dimpling  of  the  epigastrium  on  the  side  stimulated. 
Cutaneous  reflexes  may  be  brought  out  in  other  portions  of  the  body,  as  in 
the  gluteal  region  by  irritating  the  skin  of  the  buttock.  A  contraction  of 
the  muscles  about  the  scapula,  the  "scapular  reflex,"  is  produced  by  an  irri- 
tation between  the  scapulae.  To  test  for  the  cutaneous  reflexes  is  more 
important  in  the  lower  extremity  than  in  the  upper. 

The  tendon  reflexes,  or  deep  reflexes,  are  so  called  because  they  are 
generally  ehcited  by  striking  upon  tendons,  whUe  the  corresponding  muscles 
are  placed  slightly  on  the  stretch,  care  being  taken,  however,  to  avoid  all 
active  tension  in  the  muscle  by  the  person  examined.  The  blow  is  made 
either  with  the  edge  of  the  hand  or  with  a  hammer  adapted  to  the  purpose, 
commonly  made  of  rubber.  A  sharp,  sudden  contraction  of  the  muscle 
usuall}'  takes  place.  A  similar,  though  less  decided,  contraction  may  be 
elicited  by  the  mechanical  irritation  of  parts  analogous  to  tendons,  as  peri- 
osteum and  fasciae,  and  by  striking  the  muscle  itself.  When  the  reflexes 
are  in  excess,  sudden  tension  alone  will  excite  them. 

The  most  commonlj^  tried  of  the  tendon  reflexes  is  the  knee-jerk,  or 
patellar  tendon  reflex,  produced  by  strilring  the  tendon  of  the  quadriceps 
femoris  between  its  insertion  and  the  patella,  while  the  leg  is  crossed 
upon  its  neighbor.  The  weight  of  the  pendent  leg  gives  a  sufficient  de- 
gree of  tenseness.  When  the  knee-jerk  is  normal,  there  is  a  decided  rise 
of  the  foot  vnih.  each  blow  of  the  hand  hammer.  This  motion  may  be- 
come abnormally  increased  or  diminished.  A  more  limited  movement 
may  also  be  produced  bj'  striking  the  patella  itself  or  the  quadriceps  ten- 
don above  the  patella,  and,  when  the  reflex  is  exaggerated,  by  a  ver>- 


GENERAL  SYMPTOMATOLOGY  845 

light  tap  in  these  situations  or  even  on  the  tibia.  When  thus  exaggerated, 
the  reflex  may  also  be  brought  out  in  bed,  as  follows:  the  quadriceps  ten- 
don being  put  on  the  stretch  by  pressing  the  patella  downward  in  the 
direction  of  the  leg  with  the  finger,  the  patella  is  percussed  in  the  same 
direction.  With  each  stroke  there  is  a  contraction,  and  the  finger  and 
patella  are  drawn  upward.  A  "clonus,"  or  repeated  contraction,  may 
even  be  produced  in  this  way. 

Similar  is  the  ankle  reflex,  produced  by  tapping  the  tendo  Achillis 
when  the  calf  muscles  are  placed  slightly  on  the  stretch  h\  a  slight  dorsal 
flexion  of  the  foot.  In  health  the  ankle  reflex  is  usually  producible,  but 
in  disease  in  connection  with  this  contraction  is  shown  the  most  remark- 
able of  the  exaggerated  reflexes,  the  "ankle  clonus"  or  "foot  clonus." 
It  consists  in  contractions  rapidly  repeated  so  long  as  the  tension  of  the 
calf  muscle  is  kept  up  by  pressing  the  foot  toward  dorsal  flexion.  From 
six  to  nine  such  contractions  may  occur  in  a  second,  and  sometimes  the 
whole  leg  is  thrown  into  vigorous  contractions.  Occasionally  a  rotary  or 
lateral  ankle  clonus  is  seen.  One  of  the  best  ways  to  obtain  the  tendo 
Achillis  jerk  is  to  have  the  patient  kneel  on  a  chair  with  the  feet  projecting 
over  the  edge  of  the  chair;  the  muscles  are  thus  relaxed,  and  a  tap  over 
the  tendo  Achillis  produces  a  movement  of  the  foot. 

The  Babinski  reflex  or  phenomenon  is  the  extension  or  turning 
upward  of  the  toes,  and  especially  of  the  great  toe,  obtained  by  stroking 
the  sole  of  the  foot.  In  the  normal  individual,  stroking  the  sole,  if  it  pro- 
duces any  response,  causes  plantar  flexion  or  turning  downward  of  the 
toes,  especially  of  the  four  outer  toes.  The  Babinski  reflex  usually  indicates 
a  lesion  or  compression  of  the  motor  tract  in  the  cord  and  brain,  or  probably 
also  of  the  motor  centers  in  the  brain.  The  response  is  usually  best  brought 
out  by  stroking  the  inner  surface  of  the  sole  from  the  heel  toward  the  toe, 
although  in  marked  cases  it  may  be  elicited  by  appljang  the  stimulus  to 
the  sole  in  various  positions  and  directions.  Some  observations  have 
shown  that  in  infancy  the  toes  tend  to  turn  upward  normally  when  the 
sole  is  stimulated.  The  reflex  is  obtainable  in  about  70  per  cent,  of  cases 
of  hemiplegia  and  diplegia,  and  in  about  the  same  proportion  of  diseases 
involving  the  motor  tract  in  the  spinal  cord. 

Reflexes  are  also  elicited  in  the  upper  extremities,  but  they  are  much 
less  striking,  and  occasionally  cannot  be  shown  in  health.  The  most  im- 
portant of  these  are  the  arm-jerks,  produced  by  stiiking  the  biceps  tendon 
at  the  elbow-joint  in  front,  or  by  striking  the  triceps  tendon  above  the 
olecranon.  So-called  periosteal  reflexes — reflexes  excited  by  striking  the 
periosteum — may  in  exaggerated  states  be  produced  in  the  supinator  longus 
and  biceps  of  the  upper  extremity  by  striking  the  lower  end  of  the  radius 
and  ulna;  also  in  the  adductors  of  the  thigh  by  striking  the  internal  condyle 
of  the  femur. 

A  wrist  clonus,  resembling  the  ankle  clonus  of  the  lower  limbs,  may 
sometimes  be  obtained  when  the  tendon  reflexes  of  the  upper  limbs  are 
much  exaggerated.  It  is  produced  by  pushing  the  hand  of  the  patient 
forcibly  backward  and  holding  it  dorsally  flexed;  involuntary  antero- 
posterior movements  of  the  hand  may  then  occur.  The  jaw-jerk  is  pro- 
duced by  tapping  on  the  front  of  the  jaw,  while  the  closing  muscles  of  the 


846  DISEASES  OF  THE  NERVOUS  SYSTEM 

jaw — viz.,  the  pterygoids,  masseters,  and  temporals — are  placed  on  the 
stretch  by  partially  opening  the  mouth. 

The  ophthalmic  (supraorbital)  reflex  is  a  pure  sensori-motor  reflex, 
elicited  by  mechanical  irritation  (tapping  lightly  ■with  the  percussion  ham- 
mer), or  by  the  application  of  heat,  cold,  or  pain-stimuli  over  the  dis- 
tribution of  the  ophthalmic  branch  of  the  fifth  ner\'e,  especiallj^  in  the 
distribution  of  the  supraorbital  branch  on  the  forehead.  It  is  manifested 
by  a  fibrillary  contraction  of  the  individual  fibers  in  the  inferior  half  of 
the  orbicularis  palpebrarum.  The  sensory  impulse  travels  through  the 
supraorbital  ner\^e  (purely  sensory)  to  the  pons  and  thence  through  the 
facial  fibers  (purely  motor)  to  the  orbicularis  palpebrarum. 

The  diagnostic  value  of  this  reflex  lies  in  the  loss  of  contraction  result- 
ing from  a  lesion  cutting  the  arc  in  the  ophthalmic  branch  of  the  trifacial, 
in  the  nucleus  of  the  trifacial  or  of  the  facial  in  the  pons,  or  in  the  fibers 
of  the  facial  going  to  the  orbicularis  palpebrarum.  It  is  therefore  of  value 
in  localizing  lesions  of  the  pons,  and  differentiating  a  facial  paralysis  due 
to  a  lesion  of  the  nucleus  or  its  peripheral  fibers  from  a  supranuclear  or 
cortical  lesion,  in  which  case  the  reflex  is  present  and  increased.  It  has 
the  same  significance  as  the  reflex  clostire  of  the  eyelids  from  irritation 
of  the  conjunctiva,  as  this  also  is  a  reflex  in  the  distribution  of  the  facial 
and  trigeminal  nerves. 

Hence  in  a  complete  examination  the  "muscle  jerk,"  or  idiomuscular 
contraction,  also  known  as  mechanical  muscular  irritability,  should  be 
tested  as  well.  It  is  done  by  a  sharp,  sudden  tap  on  the  muscle  with 
the  hammer.  The  response  is  of  two  kinds,  first  as  a  sudden  contraction, 
and  second  as  a  hump-like  rise  which  subsides  slowly.  The  pectoral  muscles 
are  favorite  sites  for  eliciting  the  pure  muscle  reflexes.  It  is,  of  covirse, 
impossible  to  deny  that  there  is  nerve  as  well  as  muscle  irritation  in  such 
a  blow. 

Both  the  tendon  jerk  and  muscle  jerk  are  capable  or  re-enforcement 
by  coincident  muscular  exertion,  as  in  lifting  weights  or  clinching  fists, 
originally  discovered  by  Jendrassik'  in  1883  in  the  case  of  the  tendon 
jerk.  Mitchell  and  Lewis-  also  discovered  in  the  course  of  their  study  of 
ataxic  cases  that  the  piu"e  muscle  jerk  or  hump  could  be  produced  after 
the  tendon  reflex  could  no  longer  be  elicited,  and  that  both  could  be  pro- 
duced by  the  re-enforcement  referred  to  after  they  had  disappeared  to 
ordinary  conditions. 

Significance  of  Abnormal  Reflexes. — What  are  the  conclusions  to  be 
drawn  from  modifications  in  the  reflexes?  In  the  first  place,  it  is  to  be 
remembered  that  they  vary  somewhat  within  the  limits  of  health.  Es- 
pecially is  this  true  of  the  cutaneous  reflexes,  which  are  also  less  easily 
elicited  than  those  of  the  tendons.  In  general  terms,  diminution  or  ab- 
sence of  a  reflex  normally  present  in  health  implies  either,  first,  a  breach 
of  integrity  somewhere  in  the  reflex  arc  as  formed  by  the  centripetal  nerv^e, 
the  motor  nerve  cells  in  the  spinal  cord  situated  in  the  anterior  comua 
of  the  gray  matter,  and  the  motor  nerve;  or,  second,  an  increase  in  the 

*  "Beitrage  zur  Lehre  von  den  Lehnenfieehsen,"  "Deutsches  Archiv  f.  klin.  Medicin,"  vol.  xxxiii.,  p. 
I7S.  1886. 

2  Mitchell  and  Lewis,  "Tendon  and  Muscle  Jerk."  "Trans.  Assoc,  of  Amer.  Physicians,"  vol.  i..  p.  13, 
1886. 


GENERAL  SYMPTOMATOLOGY  847 

reflex  cerebral  inhibitory  influence.  The  latter  would  be  irritative.  Thus, 
it  is  well  known  that  disease  of  one  cerebral  hemisphere  may  lessen  or 
abolish  the  superficial  reflexes  on  the  opposite  or  paralyzed  side  of  the  body 
soon  after  the  onset  of  a  hemiplegia.  Breach  of  integrity  may  lie  in  the 
spinal  cord  or  in  the  centrifugal  or  the  centripetal  nerve.  If  it  is  in  the 
centripetal  nerve,  it  may  be  accompanied  by  impaired  sensation;  if  in  the 
centrifugal,  there  will  be  defective  motion.  Disease  of  the  centrifugal 
nerve  and  of  the  motor  center  in  the  cord  may  also  cause  degeneration  and 
wasting  of  muscle  with  loss  of  its  irritability. 

Increase  of  the  reflexes,  on  the  other  hand,  implies  increased  irritability 
of  the  motor  areas  of  the  cord — when  the  reflexes  are  spinal  (anterior  cor- 
nua  and  possibly  of  the  pyramidal  fibers)  or  a  withdrawal  of  cerebral 
inhibition,  as  in  certain  cases  of  destructive  brain  disease  or  disease  of  the 
cord  high  up.  In  the  case  of  a  cortical  lesion  the  increase  in  the  reflexes 
is  greater  on  the  side  opposite  to  that  of  the  brain  lesion,  but  the  reflexes 
on  the  same  side  as  the  lesion  may  also  be  somewhat  increased.  In  cer- 
tain diseases  of  the  cord  there  is  a  delay  in  the  manifestation  of  the  cu- 
taneous reflexes  after  the  irritation  has  been  applied  to  the  skin,  an  inter\^al 
of  from  ten  to  fifteen  seconds  being  often  recorde  before  the  response 
ensues.  Increase  of  cutaneous  reflexes  is  manifested  by  an  unusual  readi- 
ness of  response  in  the  normal  areas,  or  an  extension  of  these  areas  beyond 
their  normal  boundaries. 

In  general  it  may  be  said  that  absence  of  the  tendon  reflexes  is  espe- 
cially characteristic  of  poliomyelitis  and  tabes  dorsalis,  and  of  all  peripheral 
paralyses  and  nexiritis;  also  of  advanced  diabetes  mellitus.  Abnormal 
increase  is  present  in  spastic  spinal  paralysis  and  in  cerebral  paralyses, 
being  due  in  the  latter  instance  to  withdrawal  of  the  normal  inhibitorj- 
influences. 

Segments  of  the  Cord  Presiding  over  Certain  Rexexes. — Further  accu- 
racy in  the  application  of  a  knowledge  of  the  reflexes  and  of  their  modifi- 
cations is  secured  by  a  knowledge  of  the  exact  portion  of  the  gray  matter 
presiding  over  the  most  important  of  them.  Premising  that  some  of  these 
centers  are  of  considerable  extent  vertically,  the  followdng  from  Gowers 
may  be  regarded  as  approximate  for  each  of  the  reflexes  named : 

Superficial  Reflexes. — Plantar,  opposite  second  sacral  nerve;  gluteal, 
fourth  lumbar;  cremaster,  second  lumbar;  abdominal,  sixth  to  seventh 
dorsal ;  epigastric,  sixth  dorsal ;  scapular,  fifth  cervical  to  first  dorsal. 

Tendon  or  Deep  Reflexes. — Calf  muscles  (foot  clonus),  fifth  lumbar 
and  first  sacral;  knee-jerk,  third  and  fourth  lumbar;  flexor  digitorum  and 
triceps,  seventh  cervical;  biceps  and  supinator  longus,  sixth  cervical. 

(6)  Paradoxical  contraction  is  a  sj^mptom  allied  to  the  reflexes  for 
which  no  satisfactory  explanation  has  been  afforded.  It  was  first  studied 
by  Westphal,  and  is  only  occasionally  observed.  In  the  tibialis  antictis 
muscle  it  is  induced  by  forcibly  flexing  the  foot  on  the  leg.  As  a  result, 
the  foot  remains  thus  flexed  for  a  considerable  time,  after  which  it  slowly 
relaxes.  In  one  case  the  flexion  continued  for  twenty-seven  minutes. 
On  repeating  the  flexion,  the  phenomenon  recurs,  but  the  response  gradu- 
ally diminishes  in  intensity.  Contractions  induced  by  faradism  may 
similarly  persist.     It  has  been  noticed  in  both  spinal  and  cerebral  disease, 


848  DISEASES  OF  THE  NERVOUS  SYSTEM 

including  the  early  stage  of  tabes  dorsalis,  mioltiple  sclerosis,  and  paral}^- 
sis  agitans.  More  rarely  it  may  be  induced  in  the  flexors  of  the  leg  and 
forearms. 

(7)  Electrical  excitation  of  motion  is  an  important  means  of  investiga- 
tion in  nervous  diseases.  In  health  ner\''es  and  muscles  are  excitable 
by  electricity,  and  in  diseased  conditions  these  reactions  are  liable  to  change. 
Motion  may  be  excited  by  electrical  stimulus  applied  to  the  muscle  through 
its  nerve  or  directly  to  the  muscle  itself.  The  latter  is  called  direct,  the 
former  indirect.  This  is  equally  true  of  the  constant  or  galvanic  current, 
and  of  faradism  or  the  induced  cturent.^^  Hence  ever\^  complete  investi- 
gation should  include  the  use  of  bcth  currents. 


Frontalis, 

Facial  (upper) 

Corrugator  supercilii 

Orbic.  palpebrarum 

Nasal  muscles.  ■ 

Zygomatic!^ 

Orbic.  oris, 

Facial  {middle) 

Masseter. 

Levator  menti. 

Quadratus. 

Triangularis. 

Hypoglossiis. 

Facial  {lo-jjcr) 

Platysma  myoides. 
Hyoid  muscles. 


Ext.  antcr, 
tJicracic  (pectoral: 
major). 


Ascending  frontal  and 
parietal  convolutions 
(motor  area). 


Third  frontal  convolu- 
tion and  insula  (cen- 
ter of  speech). 


Facial  {upper  branch), 

ft Facial  {trunk). 

■Posterior  auricular. 

Facial  {middle  bra}ick) 
Facial  {lower  branch) . 
■Splenius. 
Stemomasloideus. 

■Spinal  accessory. 
Levator  anguU 

scapulae. 
Trapezius. 
Dorsalis  scapulce 
(rhomboidei). 

iCircumftcx. 


Brachial  plexus. 


Phrenic.        Fifth  and  sixth  cervical. 
(deltoid,  biceps,  brachials 
anticus,  supinator  longus). 

Fig.  138. — Motor  Points  on  Face   and   Neck — {after  Erh  and  de  Watlcville). 


In  order  to  test  the  electrical  condition  of  muscles  and  nen'es,  one 
electrode,  the  indifferent  pole,  may  be  held  in  the  hand  of  the  patient  or 
placed  over  the  sternum  or  at  the  back  of  the  neck,  while  the  other  or 
testing  pole  is  applied  to  the  nen^e  or  muscles,  selected  in  accordance  wdth 
the  well-known  ncn^e  points  of  Erb  in  Ziemssen's  plates;  or  the  indifferent 
pole  may  be  placed  on  the  nerve  point  of  a  given  muscle  or  set  of  muscles, 
and  the  testing  pole  applied  to  the  belly  of  the  same  muscle.  The  testing 
electrode  should  be  small  enough  to  permit  the  isolation  of  a  single  ner\^e 
or  muscle. 


^  Under  all  ordinary  circumstances  electrical  contraction  produced  in  muscles  is  indirect- — that  is, 
through  the  nerve  filaments  distributed  to  the  muscle.  That  the  two  are.  however,  distinct  may  be  shown 
through  the  influence  of  curare,  which  destroys  nerve  irritability,  but  allows  that  of  muscle  protoplasm  to 
remain. 


GENERAL  SYMPTOMATOLOGY 


849 


With  the  faradic  or  galvanic  battery  contractions  may  generally  be 
produced  in  health  with  great  facility,  either  directly  or  indirectly,  al- 
though stronger  currents  are  required  for  direct  stimxilation.  Contrac- 
tions take  place  with  the  galvanic  battery  only  at  the  making  and  break- 
ing of  the  current  by  the  "commutator"  or  "reverser."     A  definite  law 


Triceps  (long  head) 


Flexor  sublimis  digitorum 
(index  and  little  fingers). 


Palmaris  brevis. 

Abductor  min.  digit. 

Flexor  min.  digit. 

Opponens  min.  digit. 


Abductor  poUicis. 


Fig.  139. — Motor  Points  on  Upper  Limb,  Flexor  Surface — (after  Erb  and  de  Watteville). 


of  response  exists  with  galvanism.  Thus,  beginning  with  very  weak  cur- 
rents, it  is  observed  that  contraction  first  takes  place  at  the  moment  of 
that  closure  which  makes  the  testing  pole  the  kathode  or  negative  pole — 
kathodal  closiure  (KaCl).  As  the  strength  of  the  current  is  increased 
the,  kathodal  closure  contractions  become  stronger,  and  anodal  closure 
(AnCl)  contractions  make  their  appearance.     With  still  stronger  currents 


850 


DISEASES  OF  THE  NERVOUS  SYSTEM 


the  anodal  opening  (AnO)  contraction  occurs,  and,  last  of  all,  when  the 
kathodal  closure  contractions  become  tetanic  (Te),  slight  kathodal  open- 
ing (KaO)  contractions  appear.  These  facts  are  equally  true  of  normal 
muscle  and  nerve  and  may  be  formulated.  Representing  slight  contraction 
by  a  small  "c,"  decided  contraction  by  a  large  "C,"  and  the  absence  of 
contraction  by  a  minus  sign  ( — ) : 

With  weak  currents,  KaClc,  AnCl — ,  AnO — ,  KaO — ;  with  stronger 


Deltoid  (poste- 
rior part). 


Muscnlospiral. 
Brachialis  anticus. 

Supinator  longus, 
Ext.  carpi  radial,  longior 
Ext.  carpi,  radial,  brevior 


Extensor  communis 
digitorum. 

Extensor  indicis, 

Ext.  ossis  metacarpi  polli 
Ext.  primi.  intemodii  pollicis. 


Dorsal'interossei.  ^tt" 


Triceps  (long  head). 


Triceps  (outer  head). 


Extensor  carpi  ulnaris. 
Supinator  bre\'is. 


Extensor  minin 
Extensor  indici 


Extensor  sccundi  intemodii 
pollicis. 


Abductor  minimi  digiti. 
Dorsal  interossei  (III  and  I\0. 


Fig.  140. — Motor  Points  on  Upper  Limb,  E.xtensor  Surface — (after  Erb  and  dc  Wallcrillc). 


currents,  KaClC,  AnClc,  AnO — ,  KaO — ;  with  still  stronger  currents, 
KaClC,  AnClC,  AnOc,  KaO—;  with  strongest  currents,  KaClTe,  AnClC, 
AnOC,  KaOc. 

In  pathological  states  two  sets  of  deviations  from  the  normal  reaction 
to  electrical  stimulus  are  obser\^ed — viz.,  quantitative  and  qualitative. 

In  the  qualitative  de\aations  there  is  simply  an  increase  or  a  diminution 
of  the  normal  irritability  of  both  ner\-e  and  muscle  to  either  faradism  or 
galvanism.     These  differences  ai'e,  of  coiu-se,  most  easily  measured  when 


GENERAL  SYMPTOMATOLOGY 


851 


the  alteration  exists  only  on  one  side  of  the  body,  which  may  then  be 
compared  with  the  other.  When  both  sides  are  affected,  estimates  can  be 
made  only  by  comparison  with  a  healthy  body  or  by  the  galvanometer. 
For  this  purpose  superficial  nerves,  such  as  the  facial,  iilnar,  and  peroneal, 
are  usually  selected.  Instances:  Increased  quantitative  changes  are  found 
in  tetanus  and  in  the  early  stage  of  certain  peripheral  palsies,  while 
diminished  electrical  excitability  is  found  when  the  lower  motor  segments 
(motor  spinal  cells,  motor  nerves,  including  the  muscles)  are  involved — 
as,  for  example,  in  progressive  spinal  muscular  atroph}-,  bulbar  paralysis, 
and  muscular  dystrophy. 

More  important  from  a  diagnostic  point  of  view,  at  least,  are  the  so- 
called  qualitative  deviations  from  the  normal  law  of  contraction  known 


Anterior  crural, 


Adductor  magnus. 
Adductor  longus. 


Vastus  intemus. 


>-Tensor  fascitc  femoris. 

Sartorius. 

Quadriceps  femoris. 
Rectus  femoris. 


>- Vastus  extemus. 


Fig.  141. — Motor  Points  on  Thigh,  Anterior  Surface — {ajter  Erb  and  de  Watteville). 


as  the  reaction  of  degeneration.  These  are  produced  by  the  galvanic  cur- 
rent only,  and  may,  in  general  terms,  be  regarded  as  a  reversal  of  the 
usual  order  of  response  to  interruption  of  currents  and  in  the  substitution 
of  a  slow  and  vermicular  contraction  for  the  usual  sudden  and  jerking 
contraction.  The  entire  group  of  events  is  best  illustrated  by  describing 
the  electrical  phenomena  which  present  themselves  in  an  ordinary  case 
of  peripheral  paralysis.  In  two  or  three  days  to  a  week  after  its  appear- 
ance there  begins  a  gradually  diminishing  response  in  the  nerve  to  both 
faradic  and  galvanic  cvurents.  This  goes  on  for  one  or  two  weeks,  at 
the  end  of  which  time  it  disappears  to  both  currents,  even  the  strongest. 
During  this  same  time  the  muscle  is  also  losing  its  responsiveness  to  the 
faradic  current,  but  not  to  the  galvanic.      There  may  be  also  at  first  a 


852  DISEASES  OF  THE  NERVOUS  SYSTEM 

slight  diminution  to  the  galvanic  current,  lasting,  say,  one  week,  and 
constituting  the  "first  degree"  or  "first  stage"  of  degeneration.  But 
during  the  second  week  this  is  substituted  by  an  increased  excitability, 
so  that  there  is  now  marked  response  to  weak  currents — incerased  quan- 
titative deviation.  But  there  is  also  qualitative  change.  The  anodic  closxu'e 
contractions  become  now  as  strong  as  or  stronger  than  the  kathodal  closure 
contractions.  Nay,  more:  the  kathodal  opening  contractions,  which  in 
health  were  exceedingly  weak  and  could  be  brought  about  only  by  the 
strongest  ciurents,  are  now  often  stronger  than  the  kathodal  closure. 
This  state  of  affairs  for  muscle  may  be  represented  thus: 

Muscle  Contraction — Reaction  of  Degeneration. 

f  Diminished    quantitative   response   to 
galvanism. 
No  qualitative  deviation. 


First  stage  of  reaction  of  degeneration — one  -i      galvanism, 
week:  [" 


( Increased  quantitative  response  to  gal- 
vanism. 
Second  stage  of  reaction  of  degeneration — four  I  Qualitative  deviation  as  follows: 
to  eight  weeks:  )  AnCl  =  or>KaClc. 

KaOOKaClc. 
[  Contraction  prolonged  and  vermicular. 

The  phenomena  of  qualitative  change  are  purely  muscular,  and  it 
should  be  mentioned  that  they  are  not  always  typically  present.  Even 
more  constant  and  equally  distinctive  and  more  reliable  as  a  sign  of  reac- 
tion of  degeneration  is  the  second  qualitative  change  in  the  muscular 
contractions  excited  by  galvanism  in  this  stage.  Instead  of  being  qmck 
or  sudden,  they  become  slow,  prolonged,  and  vermictdar. 

The  second  stage  lasts  from  four  to  eight  weeks,  increasing  during 
the  third  and  fourth.  In  cases  of  recoverj^  the  abnormal  muscle  irrita- 
bility to  galvanism  often  persists  after  retiun  of  voluntary  power,  but  it 
diminishes  as  the  faradic  irritability  returns.  In  severe  cases,  when  re- 
covery does  not  take  place  and  the  nerve  is  not  restored  to  its  natural 
state,  all  nerve  irritability  and  faradic  muscular  irritability  remaining  per- 
manently absent,  the  increased  galvanic  muscular  irritability  may  con- 
tinue for  months,  but  tiltimately  also  decreases,  disappearing  finally  with 
the  muscular  substance. 

Certain  exceptions  to  these  laws  must  be  mentioned.  Thus,  when 
the  nerve  lesion  is  slight,  the  fall  in  quantitative  nerve  irritability  is  some- 
times preceded  by  a  corresponding  rise,  or  the  rise  may  persist  throughout 
and  such  rise  may  be  considered  as  evidence  of  a  slight  lesion.  Ftu-ther, 
the  change  is  not  always  the  same  to  faradism  and  galvanism,  and  is  often 
brought  out  much  better  by  the  slow  interruptions  in  the  faradic  battery 
than  by  the  rapid  interruptions  in  the  same  or  by  the  galvanic  current. 
Gowers  noticed  in  one  instance  moderate  but  prolonged  diminution  of 
faradic  irritability  when  no  change  could  be  found  with  galvanism,  and 
Bernhardt  has  noticed  lessened  irritabiHty  to  faradism  with  distinct  in- 
crease to  galvanism  in  an  ulnar  nerve  the  seat  of  tratmiatic  paralysis. 
Again,  faradic  irritability  may  not  diminish  to  the  same  degree  in  the 
muscle  as  in  the  nerve  in  mUd  cases,  and  conduction  of  voluntary  im- 
pulses from  the  brain  may  be  possible  when  there  is  no  response  to  elec- 
trical currents,  and  there  may  be  response  to  electrical  currents  when  there 


GENERAL  SYMPTOMATOLOGY 


853 


is  no  conduction  of  voluntary  impulses  from  the  brain.  In  still  milder 
peripheral  paralyses  there  is  no  reaction  of  degeneration  at  all,  whence 
a  favorable  prognosis  may  always  be  made.  It  is  to  be  especially  ob- 
served in  recovery  from  nerve  lesions  that  voluntary  motion  often  returns 
decidedly  earlier  than  the  electrical  excitability  of  peripheral  nerves. 

What  do  reactions  of  degeneration  teach  usf  Simply  that  the  disease 
is  seated  in  the  anterior  cornua  of  the  gray  matter  of  the  cord,  or  in  the 
peripheral  nerves.  They  teach  us  nothing  as  to  the  nature  of  the  lesion. 
Upon  the  integrity  of  the  cells  in  the  anterior  cornua  and  their  "trophic 


Biceps  (long  head). 
Biceps  (short  head). 


Gastrocnemius 
(outer  head). 


Flexor  longus  hallucis. 


Gluteus  maximtis. 


#J —  Adductor  magnus. 
Semitendinosus. 
Semimembranosus. 


Posterior  tibial. 


Flexor  longus  digitorum. 


Posterior  tibial. 


Fig.  142. — Motor  Points  on  Lower  Limb,  Posterior  Surface— (o/Zer  Erb  mid  de  Wattevilk), 


influence"  depends  the  nutrition  of  the  nerve  and  the  muscle  over  which 
the  cells  preside.  Hence  with  disease  of  the  cornua  result  degeneration 
of  the  nerve  and  wasting  of  the  muscle.  The  muscular  fasciculi  become 
reduced  in  size  and  ultimately  totally  disappear.  This  is  associated  with 
a  certain  amount  of  interstitial  overgrowth.  In  the  transition  referred 
to,  certain  fasciculi  assume  the  yellow,  glassy  appearance  known  as  waxy 
degeneration.  The  sensibility  of  the  muscle,  if  the  sensory  nerve  is  intact, 
becomes  increased,  and  there  may  be  pain,  partly  due  to  compression  of 
the  nerves  by  morbid  contraction,  and  partly  to  a  morbid  sensitiveness 
of  the  nerve-endings  and  to  the  interstitial  inflammation.     The  recovery 


854 


DISEASES  OF  THE  NERVOUS  SYSTEM 


of  the  nen^e  is  followed  not  only  by  gradual  restoration  of  its  power  over 
the  muscle,  but  also  by  restoration  of  the  nutrition  and  development  of 
the  muscle.  For  this,  however,  much  time  is  required,  and  it  often  re- 
mains permanently  smaller  than  normal. 

Lesions  of  motor  nerves,  whether  inflammatory'  or  traumatic,  are 
followed  by  similar  results — degenerative  atrophy  of  nerve  and  muscle 
because  of  interference  with  the  conduction  of  the  trophic  influence.  Occa- 
sionally in  cerebral  palsies  and  in  spinal  paralyses  in  which  the  lesion  is 
above  these  ganglion  cells  there  is  some  wasting,  but  no  reaction  of  degen- 
eration is  developed,  because  the  nutrition  is  maintained  by  the  intact  cell 
body  of  the  lower  neuron. 


Tibialis  anticu 
Extensor  longus  digitoru 


Peroneus  brev 


Extensor  longus  halluc 


Gastrocnemius. 
Peroneus  longiis. 


Flexor  longus  hallucis. 


Extensor  brevis  digitorum. 


Fig.  143. — Motor  Points  on  Leg,  E.xlernal  Surface — {aflcr  Erb  and  dc  U'alleviUe). 


From  the  foregoing  the  diagnostic  and  prognostic  value  of  the  reac- 
tion of  degeneration  is  at  once  apparent.  The  seat  of  the  lesion,  what- 
ever its  nature,  is  easily  determined,  in  so  far  as  it  is  within  the  cerebral 
or  peripheral  motor  segments,  but  we  may  not  be  able  to  say  whether 
the  nerve-cells  or  their  peripheral  processes  (the  peripheral  nerves)  are 
diseased.  We  are  also  informed  that  recovery,  though  not  impossible, 
must  be  delayed  in  proportion  to  the  degree  of  degenerative  reaction, 
because  of  the  extensive  repair  necessitated  in  muscle  and  nerve.  Much 
experience  with  the  use  of  electricity  should,  however,  be  had  before  the 
physician  permits  himself  to  draw  conclusions. 

II.  Sensory  Phenomena. — Under  this  head  naturall}-  fall  first  the 
subjective  sensations  of  the  patient.     They  include,  strictly  speaking,  only 


GENERAL  SYMPTOMATOLOGY  855 

the  various  modifications  of  sensibility  appreciable  to  him  alone  and  in- 
dependent to  external  impression — pre-eminently,  pain.  They  also  in- 
clude those  peculiar  modifications  due  to  internal  irritation  as  contrasted 
with  external  impression,  and  known  as  paresthesias — viz.,  numbness, 
tingling,  prickling,  formication,  or  a  feeUng  as  of  ants  crawHng  over  the 
skin;  also  a  sensation  like  that  of  the  contact  of  wool  or  fur — a  iwrry  feel- 
ing— vertigo,  tinnitus  aurium,  or  ringing  in  the  ears,  and  a  sense  of  un- 
pleasant odors  or  tastes. 

After  these  come  modifications  of  the  different  varieties  of  cutaneous 
sensibility  as  excited  by  external  impressions — objective  sensations.  They 
are  of  the  nature  of  increase  or  decrease,  the  former  being  known  as  hyper- 
esthesias and  the  latter  as  anesthesias,  the  latter  being  further  character- 
ized as  partial  or  complete.  To  the  latter  the  term  paralysis  of  sensation, 
partial  or  complete,  is  also  applied. 

1.  Tactile  sensibility,  the  sense  of  touch  or  ptire  contact,  is  usually 
first  investigated.  The  simplest  method  is  by  the  touch  of  a  finger,  cotton 
wool,  or  blunt  object  of  about  the  same  temperature  as  the  body,  for  both 
heat  and  cold  must  be  eliminated  in  this  test.  The  patient  should  be 
directed  to  close  his  eyes  or  avert  his  head.  More  refined  measiu^es  are 
the  application  of  rough,  smooth,  or  coarsely  uneven  surfaces.  More 
deUcate  still  is  the  esthesiometer,  essentially  a  pair  of  compasses  with 
blunt  and  sharp  points  and  graduated  quadrant  attached,  by  which  the 
distance  between  the  two  points  is  accurately  measured.  By  this  instru- 
ment, in  connection  with  a  normal  standard  of  relative  sensibility  worked 
out  by  E.  H.  Weber,  the  degree  of  impairment  in  delicacy  of  touch  may 
be  measured.  Closer  approximation  may  be  recognized  if  the  two  points 
of  the  compasses  are  put  down  one  after  the  other  and  varjang  the  test 
by  touching  the  same  place  tmce  or  a  different  place  each  time.  Weber's 
table  is  as  follows : 

Minimum  distance  at  which  the  two  points  of  a  pair  of  compasses  in 
contact  with  the  skin  may  be  recognised  as  two  points : 

Cheek,  II  to  15  millimeters.  Backs  of  the  hands,  31  millimeters. 

Tip  of  the  nose,  6  millimeters.  Backs  of  the  fingers,  II  to  16  millimeters. 

Forehead,  22  millimeters.  Tips  of  the  fingers,  2  or  3  millimeters. 

Tip  of  the  tongue,  1.2  millimeters.  Back,  55  to  77  millimeters. 
Back  of  tongue  and  on  the  Hps,  4  or  5         Chest,  45  millimeters. 

miUimeters.  Thigh,  77  millimeters. 

Neck,  34  millimeters.  Leg,  40  millimeters. 

Upper  arm,  77  millimeters.  Instep,  40  rnillimeters. 
Forearm,  40  millimeters. 

These  figiu-es  can,  however,  only  be  used  -ndthin  Hmits,  as  they  are 
by  no  means  constant  for  different  individuals,  or,  indeed,  for  the  same 
individual  at  different  times.  Marked  deviations  from  them  may,  how- 
ever, be  accepted  as  indicating  derangements  of  tactile  sense. 

2.  The  sense  of  pain  is  of  equal  importance  to  that  of  pure  touch,  be- 
cause these  two  not  infrequently  fail  to  diminish  or  increase  pari  passu 
in  morbid  states.  Parts  insensible  to  touch  may  respond  decidedly  to 
painful  impressions.  Pain  is  most  easily  investigated  by  pricking  with 
a  pin  or  pinching  a  fold  of  skin,  by  painful  electrical  currents  or  painfully 
hot  metals.     The  special  term  analgesia  is  applied  to  loss  of  sense  of  pain 


856  DISEASES  OF  THE  NERVOUS  SYSTEM 

while  the  tactile  sense  is  preser\"ed.  Analgesia  exists  in  peripheral  and 
central  ner\'ous  disease  and  may  be  observed  especially  in  syringomyelia. 
Tenderness  or  pain  on  pressure  in  the  covtrse  of  nerves  should  be 
studied  in  connection  with  the  sense  of  pain.  It  is  found  in  nerves  which 
are  the  seat  of  inflammation,  especially  in  sciatic  neuritis  and  multiple 
neuritis. 

3.  The  sense  of  temperature  may  be  roughly  tested  by  ascertaining 
the  power  of  the  patient  to  discriminate  between  the  warm  breath  close 
to  the  skin  and  the  cooler  current  produced  by  blowing  from  a  distance. 
More  precisely,  the  sense  of  temperature  is  studied  by  testing  the  ability 
to  recognize  differences  in  the  temperature  of  flat-bottomed  test-tubes 
fiUed  with  water  of  different  temperatures  and  brought  into  contact  with 
the  slfin.  The  therm-esthesiometer  has  been  de\dsed  by  Eiilenburg  for 
the  same  purpose,  but  the  student  is  referred  to  works  on  nen^ous  diseases 
for  its  description. 

In  health  differences  of  0.5°  to  1°  F.  (0.27°  to  0.55°  C.)  may  be  recog- 
nized on  the  fingers  and  face  at  temperatures  from  So°  to  100°  F.  (26°  to 
37°  C),  while  on  the  back  differences  to  be  recognized  must  amount  to  2° 
F.  (1°  C). 

In  disease  we  sometimes  notice  complete  loss  of  sense  of  temperature, 
while  the  skin  appreciates  other  forms  of  irritation,  and,  again,  this  state 
of  affairs  is  precisely  reversed;  or  the  temperature  and  pain  senses  may 
be  lost  or  impaired,  while  tactile  sense  is  preserv^ed,  as  in  syringomyelia. 
This  is  known  as  dissociation  of  sensation.  It  occurs  most  commonly 
in  syringomyelia,  but  has  been  seen  in  other  diseases.  Strumpell,  has 
called  attention  to  a  peculiar  reversal  of  the  sense  of  temperature  as 
the  result  of  which  cold  objects  appear  warm.  This  has  been  noticed  in 
various  diseases. 

4.  Sense  of  Locality. — 'Qy  this  sense  we  know,  without  looking,  what 
part  of  the  body  is  being  touched.  While  cutaneous  sensibility  may 
remain  intact,  the  sense  of  locality  may  be  seriously  deranged.  Thus, 
a  patient  may  thinlc  he  is  being  touched  on  the  leg  when  the  contact  is 
with  the  foot. 

5.  Delayed  conduction  of  sensory  impressions  represents  a  form  of 
modified  sensibility  of  which  after-sensations  are  a  further  subdivision. 
In  delaj'ed  conduction  an  irritation,  more  particularly  a  painful  one,  like 
the  prick  of  a  pin,  is  noticed  by  a  patient  after  an  appreciable  inter\^al, 
whereas  in  health  the  recognition  is  instantaneous  so  far  as  the  unaided  per- 
ception is  able  to  judge.  Touch  and  pain  may  even  be  thus  separated, 
the  immediate  contact  of  the  pin  being  prompth'  recognized,  while  the 
sense  of  pain  presents  itself  a  few  seconds  later.  It  is  Ukely,  also,  that  the 
sense  of  touch  may  be  delayed. 

6.  An  after- sensation  is  a  prolonged  sense  of  pain  which  succeeds  a 
momentary'  impression.  Such  is  the  prolonged  burning  on  the  sole  of  the 
foot  which  sometimes  succeeds  the  prick  of  a  pin,  or  which  may  occiir  once 
or  oftener  after  a  short  interv^al,  as  if  additional  pricks  had  been  made. 
Occasionally  an  isolated  prick  of  a  pin  is  not  perceived,  and  repeated  pricks 
are  necessary,  the  whole  producing  a  painful  sensation;  this  is  known  as 
summation  of  sensation. 


GENERAL  SYMPTOMATOLOGY  857 

These   abnormal    sensations  occur  particularly  in  diseases  of  the  spinal 
cord  or  of  the  nerves,  and  especially  in  tabes  dorsalis. 

7.  The  muscular  sense,  it  were  better  named  the  sense  of  position  or  of 
passive  movement,  is  that  sense  by  which  we  become  aware  of  the  position 
of  any  of  our  limbs  without  the  aid  of  vision,  as  well  as  of  anj^  degree  of 
motion  by  them.  It  is  probable,  however,  that  the  sensibility  of  the  articu- 
lar surfaces,  ligaments,  tendons,  and  skin  aids  the  sensibility  of  the  mus- 
cles in  furnishing  this  information,  and  it  is  better  to  call  this  sense  the  sense 
of  position  when  we  speak  of  it  in  reference  to  the  position  of  the  limbs,  or 
deep  sensation.  This  power  is  diminished  in  nervous  diseases,  and  may  be 
tested  by  having  the  patient  first  touch  a  certain  object  with  his  eyes  open 
and  asking  him  to  repeat  the  act  with  the  eyes  closed;  or  by  mo'V'ing  the 
fingers  or  toeg  of  a  patient  and  requesting  him  to  give  their  positions  when 
his  eyes  are  closed  and  voluntary  movements  of  the  parts  are  restrained. 

The  "muscular  sense"  is  not  only  thus  estimated,  but  the  strength 
required  to  lift  a  leg  or  an  arm,  more  plainly  evident  when  one  is  tired, 
is  also  measixred  through  it.  It  is  the  muscular  sense  which  causes  the  paretic 
to  say  that  his  leg  feels  heavy. 

In  tabes  dorsalis,  the  muscular  sense  ma}'  be  defective.  It  is  also  found 
defective  in  diseases  of  the  peripheral  nerves  and  in  diseases  of  the  lemnis- 
cus, or  of  the  internal  capsiile,  or  of  the  nerve  fibers  passing  to  the  cortex 
behind  the  fissure  of  Rolando. 

The  muscular  sense  is  also  estimated  by  the  amount  required  to  be 
added  to  an  existing  weight  on  the  skin  before  the  addition  is  appreciated. 
Thus  it  has  been  ascertained  that  in  health  an  addition  of  1/20  or  1/30 
to  an  existing  weight  can  be  appreciated.  Thus,  if  a  weight  of  95  gm. 
be  placed  on  the  skin,  an  addition  of  a  single  gram  will  not  be  recognized, 
but  nearly  five  gm.  must  be  added  before  the  increase  is  appreciated, 
while  if  considerably  more  than  this  is  necessary,  it  means  that  the  sense 
of  pressure  is  less  delicate.  Sufficiently  accurate  measures  are  coins  of 
different  weights.  Temperature  must  be  eliminated  by  placing  non-con- 
ducting substances  between  the  weight  and  the  skin,  while  the  part  to  be 
tested  must  also  be  supported. 

It  is  not  unusual  to  find,  in  paralysis  of  the  muscular  sense,  failure 
to  recognize  a  doubling  and  even  tripling  of  weights.  It  is  more  espe- 
cially in  tabes  dorsalis  that  such  paralyses  are  found  while  the  tactile  sense 
proper  is  intact,  a  light  touch  of  the  skin  being  felt,  while  a  considerable 
pressure  is  not  appreciated. 

Astereognosis  is  the  inability  to  recognize  objects,  their  nature  and 
uses,  by  touch,  as  the  restilt  of  cerebral  disease,  but  not  because  of  any 
affection  of  the  peripheral  nerves  or  spinal  cord.  Most  frequently  it  oc- 
curs from  lesions  of  the  parietal  lobe.  The  attempt  has  been  made  to  limit 
the  term,  stereognosis  to  the  recognition  of  the  form  and  characteristics 
of  an  object,  while  symbolia  is  employed  for  the  recognition  of  the  object 
in  regard  to  its  uses.     This  distinction  is  likely  to  cause  confusion.' 

8.  Anesthesia  is  said  to  be  peripheral,  spinal,  or  cerebral,  in  accord- 
ance with  the  seat  of  the  broken  conduction  between  the  terminal    ap- 


1  See  Burr,  "American  Journal  of  the  Medical  Sciences,"  March  1901,       "Therapeutic  Gazette,"  Feb. 
IS,  1904. 


858  DISEASES  OF  THE  NERVOUS  SYSTEM 

paratus  and  the  cerebral  cortex.  Peripheral  anesthesia  occurs  after 
chilhng  of  the  skin  through  the  action  of  ether,  from  cocain,  aconite, 
veratrum,  as  well  as  corrosive  agents  like  acids,  alkalies,  and  carbolic 
acid.  Spasm  of  the  small  vessels,  forming  the  so-called  spastic  anemias, 
is  also  attended  by  anesthesia.  The  anesthesias  of  washer-women,  who 
have  their  hands  in  water  all  day  long,  may  belong  to  this  class.  Lesions 
of  neive  trunks  by  pressure,  inflammation,  and  degeneration  may  cause 
anesthesia.  The  paresthesias  referred  to — numbness,  formication,  and 
tingling — are  among  the  effects  of  such  lesions.  Spinal  anesthesias 
are  found,  especially  in  connection  with  disease  of  the  posterior  roots, 
posterior  coliimns,  and  posterior  cornua  of  the  cord.  Such  a  disease 
is  tabes  dorsalis  especially.  Anesthesia  is  found,  however,  also  in  myelitis, 
acute  and  chronic,  and  when  there  is  pressure  on  the  cord  from  hemor- 
rhage into  the  spinal  canal  or  pressure  by  diseased  or  broken  vertebrae 
or  from  tumors.  Such  anesthesia  is  usually  bilateral  and  is  known  as 
paraanesthesia.  Cerebral  anesthesia  occurs  as  the  result  of  hemorrhages, 
softening,  or  tumors,  which  impinge  on  the  posterior  limb  of  the  internal 
capsule,  through  which  the  sensory  fibers,  probably  after  interruption 
in  the  thalamus,  pass  upward  to  the  cerebral  cortex.  If  the  cerebral 
anesthesia  affects  half  of  the  body,  it  is  known  as  hemianesthesia,  and 
the  half  of  the  body  affected  is  opposite  the  hemisphere  of  the  brain  in 
which  the  lesion  lies,  since  the  sensory  fibers  also  decussate,  many  of  them, 
soon  after  their  entrance  into  the  cord  through  the  posterior  roots. 

The  hysterical  anesthesias,  and  anesthesias  due  to  the  narcotics  and 
anesthetics,  are  regarded  as  central  in  their  origin.  The  hysterical  hemi- 
anesthesia is  much  commoner  than  the  organic  cerebral  hemianesthesia. 

III.  Vasomotor  and  Trophic  Phenomena. — We  pass  next  to  the 
study  of  vasomotor  and  trophic  alterations.  Two  sets  of  vasomotor  nerves 
have  been  demonstrated  by  physiologists — the  vasoconstrictors  and 
vasodilators — the  former  contracting  the  arteries  when  stimiilated  and 
permitting  their  dilatation  when  paralyzed.  The  vasodilators  are  influenced 
in  an  opposite  manner  by  the  same  agencies,  but  their  number,  so  far 
as  proved,  is  not  great,  as  they  include  up  to  the  present  time  only  fibers 
in  the  chorda  tympani,  nervi  erigentes,  and  sciatic  ner\'e.  Blushing 
may  be  the  result  of  stimulation  of  vasodilators.  Moreover,  pathology 
has  as  yet  failed  to  separate  lesions  of  the  two  sets  of  nerv^es  and  their 
effects  ajid  vasomotor  phenomena  are  generally  regarded  as  results  of  a 
paralysis  or  of  an  irritation  of  vasoconstrictors.  Instances  of  the  former  are 
redness,  a  feeling  of  warmth,  and  sometimes  an  actual  elevation  of  tempera- 
ture, sweating,  all  in  circumscribed  areas  or  half  the  body.  They  may 
persist  or  intermit.  Instances  of  vasomotor  irritation  are  pallor,  cold- 
ness, accompanied  by  stiffness,  formication,  and  even  pain.  These  are 
phenomena  of  vasomotor  spasm.  A  more  or  less  permanent  condition 
of  the  hands  sometimes  results,  characterized  by  a  blueness  or  mottled 
appearance  accompanied  by  a  lowered  temperature  further  augmented 
by  external  cold.  Still  higher  degrees  are  said  to  have  produced  circum- 
scribed gangrene  (Raynaud's  disease). 

Symptoms  of  vasomotor  paralysis  occur  in  connection  \rith  cerebral 
and  spinal  lesions  and  with  injuries  of  the  sympathetic  system  and  nerve 


GENERAL  SYMPTOMATOLOGY  859 

trunks  containing  vasomotor  fibers.  The  essential  causes  of  vasomotor 
spasm  are  less  easy  to  locate.  It  is  found  associated  with  prolonged 
convulsive  seizures,  and  in  angina  pectoris  at  the  beginning  of  the  attack, 
as  if  caused  by  irritation  of  the  sympathetic  ganglia  in  the  heart. 

That  trophic  or  nutritive  phenomena  are  closely  allied  to  vasomotor 
phenomena  is  commonly  admitted.  That  they  are  under  the  control 
of  the  same  nerves  is  doubtful,  although  the  proof  of  the  existence  of 
separate  trophic  nerves  is  still  wanting.  Vesicular  eruptions  in  the  area 
of  distribution  of  nerves,  such  as  herpes  zoster,  certain  atrophic  skin 
diseases,  pigmentations  and  depigmentations,  such  as  morphea,  Addison's 
disease  and  vitiligo,  scleroderma,  and  the  glossy  skin  which  succeeds  cer- 
tain injuries  to  nerve  trunks  are  illustrations  of  trophic  influences.  Similar 
are  the  changes  in  the  skin,  hair,  and  nails,  as  the  result  of  which  the 
first  becomes  dry,  the  second  is  lost  or  becomes  rapidly  gray,  and  the 
last  grow  brittle,  thicken,  or  drop  off.  The  latter  events  occtor  in  con- 
nection with  spinal  and  even  cerebral  lesions.  The  circumscribed  edema 
known  as  acute  angioneurotic  edema  and  the  more  permanent  condition 
of  myxedema  are  also  probably  trophic.  So,  also,  are  the  atrophies  which 
resiilt  from  disease  of  the  cells  of  the  anterior  horns  of  the  gray  matter 
of  the  cord,  or  from  injuries  to  nerves  by  which  they  are  essentially  cut 
off  from  the  trophic  cells;  also  unilateral  facial  atrophy  including  even 
atrophy  of  bone,  and  the  still  more  remarkable  spinal  arthropathies  of 
Charcot,  as  the  result  of  which  the  joints  enlarge  or  become  the  seat  of 
effusions. 

Finally,  there  is  the  acute  bed-sore  or  eschar,  so  well  described  by 
Charcot,  1  beginning  in  an  erythematous  patch  on  which  bullae  and  blebs 
are  rapidly  developed,  quickly  succeeded  by  gangrene.  While  pressure 
or  irritation  may  be  necessary  to  the  production  of  these  sores  as  excit- 
ing causes,  they  are  more  easily  invited  in  spinal  paralyses  than  in  non- 
paralytic conditions.  Such  restilts  follow  cerebral  lesions  and  lesions  in 
the  medulla  oblongata,  spinal  cord,  and  sympathetic  nerves. 

It  is  well  known  that  the  vasomotor  nerves  surrounding  the  various 
blood-vessels  are  derived  from  the  sympathetic  trunks,  which,  in  turn, 
receive  their  vasomotor  filaments  from  the  roots  of  the  spinal  nerves. 

IV.  Mental  Phenomena. — Under  this  head  come  the  phenomena 
of  consciousness  or  unconsciousness,  coma,  the  state  of  the  will,  the  vari- 
ous perversions  of  mental  processes,  including  delirium,  hallucinations, 
delusions,  illusions,  and  insane  acts.  Hallucinations  axe  deceptions  of 
the  special  senses  which  appear  to  the  individual  as  real.  They  have  no 
external  cause.  The  victim  of  delirium  tremens  who  imagines  that  he  is 
pursued  by  monsters  of  various  sorts  is  the  subject  of  hallucination.  A 
delusion  is  a  false  belief  which  cannot  be  corrected  by  argument  or  ex- 
perience. The  deluded  person  imagines  that  he  is  the  happy  possessor  of 
milHons  when  he  is  actually  a  pauper,  or  complains  of  poverty  although 
affluent.  An  illusion  is  based  upon  an  actual  perception,  but  an  erroneous 
impression  arises  therefrom.  In  a  hallucination  no  object  is  actually  seen; 
there  is  no  sensory  impression.  The  idea  of  relief  obtained  on  looking  at 
a  picture  in  the  stereoscope  is  an  illusion. 

1  "Lectures  on  Diseases  of  the  Nervous  System,"  Philadelphia,  1879. 


860  DISEASES  OF  THE  NERVOUS  SYSTEM 

Delirium  is  the  more  or  less  acute  manifestation  of  one  or  all  these 
perA^ersions  of  mental  process,  associated  with  muttering  or  active  speech 
suggested  by  them  or  with  action  growing  out  of  them.  Thus  consti- 
tuted, delirium  may  be  the  result  of  toxic  states  or  acute  disease  other 
than  of  the  brain. 

The  same  prcversions  of  mental  process  continued  and  unaccom- 
panied by  fever  constitute  insanity,  which  is  probably  always  associated 
with  structural  change  in  the  brain  or  its  membranes,  although  such 
may  not  always  be  demonstrable.  Other  symptoms  are  added,  how- 
ever, in  insanity,  such  as  extreme  depression  of  spirits,  while  hallucina- 
tion, delusion,  and  illusion  may  be  present  in  various  degrees.  Special 
insane  acts  should  be  specified  and  modifications  of  normal  sleep  noticed. 

V.  Alterations  in  Vision  and  Hearing. — In  addition  to  the 
ordinary  defects  of  vision,  the  response  of  the  iris  to  light  should  be  no- 
ticed ;  also  its  accommodating  power.  The  former  is  absent  in  three- fourths 
of  all  cases  of  tabes  dorsalis  while  the  latter  remains.  The  iris  thus 
failing  to  respond  to  light,  but  retaining  its  accommodation  to  change 
of  distance,  is  known  as  the  Arg^dl  Robertson  pupil.  Each  eye  should 
be  tested  separately,  the  other  being  covered.  Finally,  the  eye-ground 
should  be  examined  in  every  exhaustive  study  of  a  nervous  case. 

Modifications  in  hearing  are  the  nature  of  increased  and  diminished 
intensity,  and  there  is  that  very  common  symptom  known  as  tinnitus 
aurium,  or  ringing  in  the  ears,  already  alluded  to  as  a  good  instance  of 
a  subjective  sj'mptom.  Hyperacusis  occiu-s  in  association  with  aug- 
mented acuteness  of  the  other  senses  in  acute  affections  of  the  brain  or 
when  there  is  hyperemia  of  the  brain  from  any  cause.  It  is  also  often 
complained  of  in  hysteria.  Deafness,  on  the  other  hand,  is  more  frequently 
the  consequence  of  disease  of  the  ear  itself.  Ringing  in  the  ears  occurs 
in  many  conditions.  Some  more  than  usual  impression  on  the  acoustic 
nerve  is  the  cause  of  tinnitus.  In  addition  to  the  numerous  forms  of 
irritation  due  to  ear  disease,  the  blood  in  an  adjacent  vessel  may  be  thrown 
into  vibration  and  produce  an  audible  murmur.  On  the  other  hand, 
tinnitus  is  sometimes  due  to  intracranial  irritation  either  of  the  nen-e  or  of 
the  auditory  centers. 

VI.  Alterations  in  Breathing  and  Pulse. — Alterations  of  breathing 
are  very  common  in  nervous  diseases.  Respiration  may  be  rapid  or  slow, 
and  labored  and  sighing,  or  irrgeular,  but  especially  peculiar  is  the  Cheyne- 
Stokes  breathing,  in  which,  succeeding  a  long  pause,  so  long  sometimes  that 
it  seems  as  though  the  patient  would  never  breathe  again,  follows  gentle  and 
shallow  respiration,  which  gradual^  grows  deeper  and  more  frequeiit  until 
an  acme  of  dyspnea  breathing  is  reached,  when  it  again  gradually  diminishes 
in  depth  and  frequency  until  the  pause  again  occurs.  It  is  an  arrhythmical 
breathing  of  a  periodic  type.  During  the  pause  the  pupil  often  contracts 
and  the  heart's  action  becomes  less  frequent.  Cheyne-Stokes  breathing 
may  occur  in  various  conditions  of  the  brain,  in  which  the  respiraton,'  center 
is  influenced.  The  period  of  arrest  varies  from  five  to  forty  seconds,  and 
the  duration  of  each  cycle  may  be  from  15  to  75  seconds,  and  may  varj'. 

A  modification  of  Cheyne-Stokes  breathing  is  a  form  in  which  there  are 
periods  of  deep  and  energetic  breathing  which  begin  suddenly,  and  in  which 


NEURITIS  861 

the  respirations  gradually  become  shallower  until  they  cease,  and  after  a 
pause  energetically  recoinmence. 

The  pulse  is  influenced  chiefly  by  diseases  of  the  cranial  contents,  espe- 
cially of  the  medulla  oblongata,  the  cerebrum,  and  the  meninges.  It  is  at 
times  very  slow,  as  in  meningitis  and  apoplexy,  or  when  there  is  intracranial 
pressiu-e  from  any  cause  or  when  there  is  pneumogastric  irritation.  It  may 
be  accelerated  when  there  is  inflammatory  pyrexia  or  irritation  of  the  cardiac 
center.  Again,  it  may  be  irregular,  acting  through  the  nervous  system,  of 
which  opium  poisoning  is  among  the  familiar  causes ;  uremia  is  another  cause, 
rarely  also  is  influenza. 

VII.  Focal  Disease  and  Focal  Symptoms. — The  terms  focal  disease 
and  focal  symptoms  will  be  often  used  in  the  following  pages.  By  Jocal 
disease  in  the  nervous  system  is  meant  a  circumscribed  lesion,  no  reference 
being  made  to  the  nature  of  the  lesion  as  to  whether  it  is  softening,  a  tumor, 
or  clot.  By  focal  symptoms  is  meant  symptoms  caused  by  a  lesion  in  one 
spot  whether  in  the  brain  or  spinal  cord.  Cerebral  syphilis  is  a  diffuse  proc- 
ess, therefore  usually  not  a  focal  disease.  The  general  symptoms  of  a 
tumor  in  the  motor  cortex  are  headache,  vertigo,  choked  disk,  etc.,  the  Jocal 
symptoms  are  paralysis  of  one  or  both  limbs  on  the  opposite  side  of  the  body, 
convulsions  confined  to  these  limbs  or  groups  of  muscles.  Focal  symptoms 
are  localizing  symptoms,  or  symptoms  that  indicate  the  -focus  of  the  disease 
or  the  region  affected. 

AFFECTIONS  OF  THE  PERIPHERAL  NERVES. 

NEURITIS. 

Definition. — Neuritis,  or  inflammation  of  a  nerve,  may  be  confined  to  a 
single  trunk,  whence  it  is  called  localized;  or  it  may  involve  a  large  number 
of  nerves,  when  it  is  known  as  multiple  neuritis  or  polyneuritis . 

Etiology. — Local  neuritis.  Exposixre  to  cold  is  a  frequent  cause  of 
neuritis,  and  the  nerve  most  frequently  affected  is  the  facial.  Trauma  is 
another  cause,  including  compression,  contusions,  or  cuts,  as  with  glass,  or 
stretching  and  laceration  such  as  occur  when  there  are  dislocation,  frac- 
ture, and  other  violent  injuries.  Neuritis  may  also  occur  as  the  result  of 
extension  of  inflammation  from  contiguous  parts,  as  from  caries  in  a  bone 
through  which  the  nerve  passes,  adjacent  joint  inflammation,  pleurisy,  and 
meningitis. 

The  causes  of  multiple  neuritis  are  numerous,  and  by  no  means  easy  of 
classification.     They  include : 

1.  The  commonly  acknowledged  poisons  introduced  from  without:  (a) 
Organic,  including  alcohol,  by  far  the  most  frequent  cause,  ergot,  morphin, 
ether,  carbon  monoxid,  carbon  bisulphid,  benzine  and  its  products,  and 
anilin;  {b)  inorganic,  inclviding  lead,  arsenic,  phosphorus,  and  mercury. 

2.  Endogenous  toxins  generated  in  the  organism  by  chemical  changes. 
Such  is  the  cause  of  the  neuritis  of  diabetes  mellitus,  whether  glucose, 
oxybutyric  acid,  diacetic  acid,  or  acetone,  all  of  which  are  found  in  the  blood 
in  that  disease. 

3.  Toxins  inherent  to  the  infectious  diseases.  Instances  are  malarial 
neuritis,    leprous   neuritis,   beri-beri    or   so-called    endemic    neuritis,    also. 


8G2  DISEASES  OF  THE  NERVOUS  SYSTEM 

probably,  the  neuritis  of  acute  infectious  jaundice  (Weil's  disease).  Of 
neuritis  also  due  to  toxic  products  of  pathogenic  bacteria  are  diphtheritic 
neuritis,  septicemic  neuritis,  the  neuritis  of  smallpox,  typhoid  fever,  tuber- 
culosis, and  possibly  syphilis  are  instances. 

4.  Intrinsic  states  of  the  blood  of  undetermined  nature,  with  which  cold 
may  or  may  not  co-operate  as  an  exciting  cause — viz.,  rheumatism,  gout; 
also  the  puerperal  state,  and  chorea.  Malnutrition,  such  as  characterizes 
cachectic  and  senile  states,  cancer,  tuberculosis,  and  wasting  diseases  gener- 
ally are  also  causes.  It  is  not  impossible  that  cold  alone  may,  by  its  opera- 
tion, generate  a  poison  capable  of  producing  a  polyneuritis,  but  more  prob- 
ably it  acts  by  lowering  the  vitalitj'  of  the  nerves  and  rendering  them 
liable  to  attacks  from  other  agents. 

Age  and  Sex. — Multiple  neuritis  is  a  disease  of  adults.  Diphtheritic 
neuritis  is  the  most  common  form  observed  in  children. 
The  alcoholic  form  is  more  frequent  than  all  others  put  together.  More 
than  one  cause  may  co-operate,  when  one  may  be  the  predisposing  and 
the  other  the  exciting.  Cold  probably  most  frequently  plays  the  latter 
role,  but  there  may  be  others,  such  as  anemia,  and  the  like. 

Morbid  Anatomy. — An  inflamed  ner\'e  is  reddish,  from  hyperemia  of 
the  va^sa  nervorum,  though  the  stage  of  demonstrable  hyperemia  may  have 
passed  away  when  the  nerve  comes  under  observation.  In  perineuritis  and 
interstitial  neuritis  the  primary  change  is  in  the  connective  tissue — in  the 
former,  an  infiltration  of  the  nerve  sheath  with  leukocytes,  and  in  the  latter, 
of  the  interstitial  tissue  with  the  same  cells.  There  may  even  be  minute 
extravasations  of  blood.  These  changes  are  more  likely  to  occur  in  places 
along  the  course  of  the  nerve  where  it  is  exposed  to  special  irritation,  as  in 
passing  through  foramina  or  over  bone.  The  lymphoid  cells  gradually 
become  fusiform  cells,  resulting  in  the  formation  of  true  connective  tissue. 
The  pressure  of  this  new  tissue  gradually  destroys  the  nerv^e  itself,  the 
medullary  sheath  being  gradually  broken  up  into  drops,  which  subsequently 
disappear,  while  the  nuclei  of  the  sheath  of  Schwann  increase;  finally,  the 
axis-cyHnder  also  becomes  granular  and  disappears — all  this  in  varying 
degrees.  The  nerve  fiber  may  be  substituted  by  a  fiber  of  connective  tissue, 
in  which  there  may  be  a  deposit  of  fat,  a  condition  seen  in  the  lipomatous 
neuritis  of  Leyden. 

In  parenchymatous  neuritis  the  primary  change  is  in  the  nerve  fiber 
itself.  Here  the  medullary  sheath  and  the  axis-cylinder  are  the  first  in- 
volved, the  former  breaking  up  into  drops,  as  described,  and  the  latter 
into  granules,  both  ultimately  disappearing,  while  the  interstitial  connective 
tissue  remains  comparatively  unchanged ;  but  the  nuclei  of  the  sheath  of 
Schwann  proliferate  and  become  a  part  of  the  interstitial  connective  tissue. 

The  muscles  connected  ^vith  the  inflamed  nen^e  also  atrophy — in  the 
case  of  the  motor  nerves,  at  least — being  practically  cut  off  from  their 
center  of  nutrition.  The  change  in  the  nerve  is  essentially  the  Wallerian 
change  noticed  in  the  ner\'e  fiber  of  a  cut  ner\-e.  In  some  instances  the 
changes  noticed  in  the  sheath  of  Schwann  extend  over  into  the  interstitial 
tissue  of  the  muscle. 

Symptoms. — Localized  neuritis.  There  is  not  much  constitutional  dis- 
turbance in  localized  neuritis,  though  the  thermometer  may  show  some  rise 


NEURITIS  863 

of  temperature.  Pain,  especially  pain  on  motion,  and  tenderness,  are  the 
salient  symptoms.  The  pain  may  be  confined  to  the  seat  of  the  inflam- 
mation or  may  involve  the  distribution  of  the  nerve,  or  the  whole  limb  may 
be  involved.  It  varies  in  degree  and  also  in  character,  being  sometimes 
burning  and  at  other  times  aching,  boring,  or  shooting.  It  is  likely  to  be 
worse  at  night,  and  when  in  situations  involving  pressiu-e  on  the  nerve  itself. 
The  nerve  may  be  swollen  appreciably,  and  rarely  the  skin  over  it  is 
reddened. 

The  pain  in  the  trunl<  of  an  inflamed  nerve  is  probably  due  to  pressure 
on  the  nervi  nervorum.  Weir  Mitchell  has  especially  called  attention  to 
this.  An  interesting  fact  is  that  the  nerves  composed  almost  purely  of 
motor  fibers  are  less  tender  than  sensory  nerves.  This  would  imply  that 
fewer  sensory  nerves  are  distributed  to  the  motor  nerve  trunks  than  to  sen- 
sory nerves,  or  that  some  pain  is  felt  by  the  sensory  fibers  which  make  up 
the  inflamed  trunk. 

Mitchell  also  describes  elevation  of  surface  temperature  and  trophic 
disturbances,  such  as  sweating,  herpes,  and  effusion  into  neighboring 
joints.  Other  trophic  derangements,  including  muscle  wasting,  associated 
with  peculiar  "glossy  skin"  or  slight  edema,  may  be  present.  Vesicles, 
bullae,  and  herpetic  eruptions  may  occur.  The  nails  become  brittle,  rough, 
and  marked  with  transverse  ridges.  The  bones  in  the  fingers  may  even 
become  atrophied.  There  may  be  thickening  of  the  skin  and  a  condition 
resembling  ichthyosis  may  be  present.  Ultimately  the  hyperesthesia  and 
paresthesia  may  become  anesthesia,  though  usually  limited  to  small  areas. 

Motor  disturbances,  including  twitchings  and  contractions,  may  be 
present. 

The  electrical  condition  of  the  nerves  and  muscles  must  be  studied.  It 
may  be  normal  in  slight  cases.  In  more  severe  cases  there  may  be  the 
reaction  of  degeneration,  with  the  slow,  lazy  contraction  of  the  muscles, 
and  the  reversed  reaction  to  opening  and  closing  currents,  described  on 
page  850. 

The  course  of  the  disease  is  variously  prolonged.  Many  acute  cases 
terminate  favorably  in  a  few  weeks.  More  cases  become  chronic,  extending 
over  months  and  even  years,  after  which  they  may  gradually  subside. 

A  rare  variety  is  "  ascending  neuritis,"  in  which  the  inflammation  extends 
from  smaller  to  larger  branches,  iintil  finally  most  of  the  nerves  of  a  limb 
may  be  involved,  or  possibly  even  the  spinal  cord,  producing  myelitis,  with 
or  without  spinal  meningitis.  Paralysis  may  result  from  such  a  condition. 
This  is  possibly  the  rare  form  of  paralysis  that  succeeds  visceral  disease,  as 
that  of  the  bladder.  Even  the  corresponding  nerves  of  the  other  side  may 
be  involved.  It  is  the  opinion  of  some  of  the  best  neuropathologists  that 
this  ascending  neuritis  occurs  only  from  a  suppurating  wound.  The  theory 
of  an  ascending  neuritis  is  not  universally  accepted. 

The  symptoms  of  multiple  neuritis  are  easily  divided  into  three  classes : 
Motor  weakness,  sensory  derangement,  and  inco-ordination.  The  first  is 
the  result  of  the  involvement  of  motor  nerves,  and  manifests  itself  usually 
first  in  the  extensors  of  the  wrist  and  fingers,  flexors  of  the  ankle,  and  ex- 
tensors of  the  toes.  The  sensory  disturbances  are  tingling,  numbness,  and 
pain,  while  the  inco-ordination  resembles  that  of  tabes.      According  as  one 


864  DISEASES  OF  THE  NERVOUS  SYSTEM 

or  the  other  of  these  sets  of  symptoms  predominates  we  have  a  motor 
form,  a  sensory  foim,  or  an  ataxic  form. 

The  onset  may  be  rapid  or  slow.  In  the  form,  due  to  cold  and  exposure, 
it  is  usually  sudden,  with  chill  and  fever  and  a  temperature  of  103°  or 
104°  F.  (39.5°  to  40°  C),  headache,  and  backache.  The  slow  onset  is  char- 
acteristic of  alcoholic  neuritis,  though  it  may  be  precipitated  by  some  excit- 
ing cause,  as  cold,  exposure,  fatigue,  or  some  other  toxic  state.  Neuritis 
of  slow  onset  is  raiely  febrile.  In  the  initial  stage  sensory  symptoms  an 
numbness  and  tingling  of  the  fingers  and  toes,  palms  of  the  hands  and  soles 
of  the  feet,  and  other  parts  of  the  lower  arms  and  legs;  then  hyperesthesia, 
tenderness,  and  pain,  more  marked  in  the  legs,  sometimes  associated  with 
cramp  in  the  calves.  These  symptoms  may  in  mild  degree  precede  the  onset 
as  premonitory  for  weeks  and  for  months,  especially  in  the  alcoholic  form. 

Very  characteristic  is  the  tenderness  of  the  muscles  themselves,  developed 
as  they  become  weaker,  and  elicited  by  grasping  them,  the  slightest  pressure 
often  causing  the  patient  to  cry  out  with  pain.  This  is  regarded  as  evidence 
that  all  the  nerves  of  the  muscles  are  involved,  the  sensorv'  as  well  as  the 
motor.  The  nerve  trunks  are  also  tender,  although  this  tenderness  is  less 
marked  than  in  simple  neuritis,  because  the  contrast  with  the  hyperesthesia 
of  the  surrounding  skin  is  less  conspicuous. 

The  motor  symptoms,  seldom  absent,  soon  follow  the  sensor>^  phenomena 
just  mentioned.  They  include  palsy  or  inco-ordination  or  both  in  upper 
and  lower  limbs,  but  with  this  characteristic — that  the  involvement  of  the 
limbs  is  symmetrical  and  the  distal  extremities,  as  the  feet  and  hands,  are 
affected,  the  former  more  frequently.  Motor  symptoms  may  exist  in  the 
feet  and  sensory  symptoms  in  the  hands,  the  latter  commonl}-  preceding. 

The  muscles  commonly  involved  are  those  supplied  by  the  peroneal 
nerve  in  the  lower,  and  by  the  posterior  interosseous  branch  of  the  musculo- 
spiral  in  the  upper  extremity.  With  weakness  in  the  legs  comes  loss  of 
knee-jerk  and  ankle-jerk,  quite  frequently,  but  not  invariably,  depending,  of 
course,  on  the  involvement  of  the  nerves  forming  these  reflex  arcs.  The 
muscles  above  the  knee  are  less  frequently  affected,  and  still  less  frequently 
those  which  move  the  hip-joint. 

The  paralysis  of  the  muscles  innerv^ated  bj'  the  peroneal  nerve  gives  rise 
to  a  peculiar  and  distinctive  walk  known  as  the  steppage  gait,  and  occasion- 
ally it  is  unilateral,  when  only  one  peroneal  nerve  is  affected.  It  is  the  gait 
of  polyneuritis  in  which  the  foot  drops,  and  in  order  to  raise  it  from  the 
ground  and  thereby  to  "shorten"  the  limb,  the  thigh  is  drawn  up  unneces- 
sarily high  and  the  knee  is  flexed  excessively  so  that  the  gait  resembles 
that  of  the  "  high-stepping"  horse.  The  extremitj^  of  the  foot  strikes  the 
ground  first,  followed  by  the  heel,  so  that  there  is  often  a  recognized  interval 
of  time  between  the  two  events.  Closing  of  the  eyes  does  not  affect  this 
gait.  Occasionally  the  anterior  tibial  muscle  may  escape  when  the  other 
muscles  of  the  peroneal  distribution  are  paralyzed. 

As  contrasted  with  the  diminisUed  tendon  reflexes,  the  reflex  action  from 
the  skin  may  be  increased,  especially  when  there  is  hyperesthesia,  even  when 
there  is  considerable  motor  paralysis,  the  movement  being  caused  by  the 
muscles  which  escape  involvement.  In  severe  cases,  on  the  other  hand, 
when  there  is  much  loss  of  sensation  and  motion,  the  skin  reflex  is  absent: 


NEURITIS  865 

exceptionally,  it  may  bo  absent  when  sensation  is  perfect.  Myotatic  irri- 
tability is  almost  always  lost,  although  in  the  early  stages  of  the  disease, 
or  in  those  cases  in  which  the  anterior  crural  nerves  escape,  it  may  be 
preserved. 

In  the  arms  it  is  the  extensors  of  the  wrist  and  fingers  which  are  first 
affected,  and  these  symmetrically,  illustrated  by  one  of  the  best  recognized 
toxic  forms  of  neuritis,  lead  palsy.  In  the  latter  there  is  paralysis  of  the 
extensors  while  the  extensor  of  the  metacarpal  bone  of  the  thumb  and  the 
supinator  longus  usually  escape,  although  in  some  cases  of  lead  palsy  these 
muscles  are  aflected.  After  the  extensors,  the  flexors  of  the  wrist  and 
fingers  are  'involved,  then  the  interosseous  muscles,  and,  finally,  the  thenar 
and  hypothenar  muscles  are  attacked,  always  to  a  less  degree  than  the  exten- 
sors.    The  muscles  above  the  elbow  are  less  affected. 

Occasionally  the  fibers  of  the  pneumo gastric  are  involved,  causing  fre- 
quent pulse-rate  and  paralysis  of  the  vocal  cords,  cardiac  failure,  and  death. 
Still  more  rarely  the  diaphragm  and  muscles  of  the  thorax  and  abdomen  are 
involved.  The  facial  and  motor  oculi  nerves  are  possible  seats.  Neuritis 
confined  to  the  cranial  nerves  has  been  described.  The  sphincters  are  also 
rarely  affected. 

The  muscles  exhibit  the  reaction  of  degeneration,  faradic  irritability  being 
lost,  while  galvanic  irritability  may  be  increased,  but  is  not  always  altered 
in  quality.  In  the  nerves,  irritability  to  both  currents  diminishes  and  ulti- 
mately disappears,  although  in  the  very  first  stage  there  may  be  increased 
galvanic  irritability.  In  severe  cases  total  loss  of  excitabilitj^  may  occur 
at  once  because  of  a  corresponding  destruction  of  muscular  substance,  in- 
stead of  being  preceded  by  an  intermediate  state  of  increased  excitability. 

Wasting  of  the  muscles  is  sooner  or  later  inevitable,  unless  the  disease  is 
of  short  duration,  although  it  may  be  obscured  by  a  temporary  oedema  or  a 
condition  of  fatty  infiltration,  in  which  the  fat  accumulates  between  the 
wasting  fasciculi,  keeping  up  for  a  time  the  bulk  of  the  muscle.  The  less 
affected  muscles  are  likely  to  undergo  shortening  and  contracture  because 
of  maintaining  so  long  a  fixed  position,  either  from  being  given  over  to 
gravitation  or  as  a  result,  of  an  effort  to  relieve  pain.  This  alteration 
occurs  most  frequently  in  the  lower  extremity,  •  contributing  to  intensify 
the  "foot-drop"  at  the  ankle,  and  more  rarely  to  produce  flexure  at  the 
knee-joint  and  to  a  less  degree  even  at  the  hip,  both  of  the  latter  being 
the  result  of  posture.  The  foot-drop  may  be  increased  by  the  pressure 
of  the  bed-clothes  upon  the  foot. 

The  sensory  and  motor  phenomena  are  commonly  associated  pari  passu, 
the  latter  extending  from  the  hands  and  feet  up  the  outside  of  the  arm  and 
leg.     Very  rarely  either  set  of  symptoms  may  occur  alone. 

Tremor  is  a  marked  symptom  in  some  alcoholic  cases  and  may  precede 
loss  of  power. 

Ataxic  phenomena  are  usually  associated  with  the  sensory  and  motor 
symptoms.  They  are  manifested  by  difficulty  in  balancing  while  standing, 
or  by  inability  to  execute  finer  movements  with  the  fingers.  Indeed,  these 
may  be  the  first  symptoms,  and  may  lead  when  studied  to  the  knowledge 
of  some  defect  in  extending  the  wrist  and  fingers,  or  in  raising  the  toes,  or 
foot,  from  the  ground  while  walking.     The  ataxia  is  more  marked  in  the 


866  DISEASES  OF  THE  XERVOUS  SYSTEM 

lower  extremities,  and  is  believed  to  depend  chiefly  upon  sensor}-  ner\^e 
involvement,  since  these  nerves  are  supposed  to  have  most  to  do  with  co-or- 
dination. Involvement  of  the  motor  nerves  may  possibly  also  cause  ataxia. 
Because  of  the  associated  absence  of  the  knee-jerk,  the  term  peripheral 
pseudo-tabes  has  been  applied  to  the  ataxic  variety.  The  symptoms  may 
closely  resemble  those  of  tabes,  but  the  phenomena  always  fall  short  of 
those  of  true  tabes.  It  may  be  said,  too,  of  the  ataxic  form  that  the  sensory 
disturbances  are  sometimes  less  severe  than  in  other  typical  cases.  Absence 
of  the  Argyll-Robertson  pupil  and  of  vesical  disturbance,  rapid  development 
of  the  disease,  a  history  of  the  case  suggesting  a  cause  for  neuritis,  and, 
finally,  recovery,  are  diagnostic  points  in  favor  of  the  ataxic  form  of  neuritis 
as  distinguished  from  tabes. 

Trophic  changes  may  occur  in  prolonged  cases,  including  mainly  glossy 
skin,  arthritic  adhesions,  and  thickening;  also  vasomotor  derangement, 
shown  by  edema,  especially  about  the  ankles  and  the  dorsum  of  the  foot; 
also  pallor  of  the  fingers  and  changes  in  the  nails  and  hair. 

Mental  symptoms  are  found  more  particularly  in  connection  with  the 
alcoholic  form  of  neuritis.  Besides  irritability  and  general  ill  temper,  more 
active  symptoms  are  at  times  present.  Hystena  and  skilful  duplicity  in 
obtaining  alcohol  are  characteristic.  The  phenomena  may  be  those  of 
delirium  tremens  or  simple  hallucination  with  extravagant  ideas.  Espe- 
cially peculiar  is  the  condition  described  by  Wilks,  and  especially  by  Korssa- 
kow,  in  which  there  is  a  loss  of  appreciation  of  time  and  place,  the  patient 
describing  with  minute  detail  impossible  journeys  recently  taken  and  persons 
whom  he  imagines  he  has  seen.  Convulsions  and  optic  neuritis  are  rarely 
present;  if  present,  they  are  probably  due  to  meningeal  inflammation.  A 
simple  mild  delirium  may  occur  in  toxemic  cases  from  the  action  of  the 
poisons  on  the  brain  cells.  Mental  symptoms  are  not  usually  present  in 
multiple  neuritis  from  other  causes. 

The  number  and  variety  of  the  symptoms  varj^  greatly  in  different  forms, 
being  most  widespread  in  those  cases  due  to  alcoholism,  to  cold,  or  to 
combined  causes,  and  limited  in  the  cases  due  to  metallic  poisons,  as  lead. 
The  more  acute  the  case,  the  more  widespread  are  the  sj-mptoms. 

Diagnosis. — Localized  neuritis.  The  disease  is  chiefly  to  be  differentiated 
from  neuralgia.  This  depends  upon  pain  and  tenderness  in  the  course  of 
the  nerve  and  upon  the  limitation  of  the  symptoms  to  its  distribution. 
Neuralgia  is  more  intermittent,  and  is  relieved  rather  than  aggravated  by 
pressure.  The  presence  of  the  paresthesia  points  to  neuritis  and  the  diag- 
nosis is  confirmed  if  there  is  ultimately  lessened  sensibility.  In  neuralgia, 
nerve  and  muscle  reactions  remain  normal.  It  is  possible,  however,  that 
neuralgia  maj'  result  in  neuritis.  The  distal  pain  of  central  spinal  disease 
must  be  differentiated.  In  brachial  neuritis  the  pain  may  radiate  to  the 
left  side,  suggesting  angina  pectoris,  and  there  may  even  be  a  tendency 
to  cardiac  distress,  but  there  is  no  tenderness  in  the  course  of  the  nerves  in 
angina. 

Special  Variety  of  Localized  Neuritis — Sciatica. 

Definition. — This  term  is  applied  to  all  painful  affections  in  the  dis- 
tribution of  the  sciatic  nerve,  some  of  which  may  be  neiu^algic,  but  the  vast 


NEURITIS  867 

majority  are  inflammatory  and  perineviritic,  as  it  is  the  sheath  of  the  nen^e 
that  is  usually  involved. 

Etiology. — Sciatica  is  far  more  common  in  men  than  in  women,  in  the 
ratio  of  about  four  to  one,  while  brachial  neuritis  affects  both  sexes  about 
equally.  It  is  also  a  disease  of  adults,  being  unknown  in  children  and  very- 
rare  in  the  second  decade.  It  is  most  frequent  between  forty  and  fifty, 
next  between  fifty  and  sixty,  and  next  between  thirty  and  forty. 

Very  rarely  syphilis  may  be  a  predisposing  cause.  Exposure  to  cold  is 
the  most  frequent  exciting  cause,  especially  after  severe  muscular  exertion; 
while  standing  in  water,  sitting  or  lying  on  the  cold  ground,  and  the  like  are 
frequent  causes.  Pressure  by  mechanical  agents  and  possibly  muscular 
contraction  may  be  a  cause;  also  pressue  by  tumors  and  other  new  forma- 
tions within  the  pelvis.  In  bilateral  sciatica  the  possibility  of  intrapelvic 
tumor  should  be  carefully  considered.  In  addition  to  the  intrapelvic  causes 
referred  to,  secondary  sciaticas  may  be  caused  by  bone  disease  and  other 
foci  of  suppuration  external  to  the  pelvis.  A  commonly  overlooked  cause 
is  a  movable  sacroiliac  joint. 

Symptoms. — The  leading  symptom,  is,  of  course,  pain  in  the  course  of 
the  nerve.  Felt  first  in  the  back  of  the  thigh,  it  also  travels  above  the  hip- 
joint,  into  the  sciatic  notch,  behind  the  knee,  below  the  head  of  the  fibula, 
behind  the  internal  malleolus,  and  on  the  dorsum  of  the  foot.  It  may  be 
more  diffuse,  but  the  course  of  the  main  trunk  of  the  nerve  is  often  indicated 
by  it,  and  the  points  previously  named,  especially  the  back  of  the  middle 
of  the  thigh  and  the  sciatic  notch,  will  often  be  pointed  out  by  the  patient 
as  seats  of  special  tenderness.  It  usually  begins  gradualty,  but  it  maj^  start 
suddenly,  especially  in  cases  of  rheumatic  origin.  Motion,  particularly  in 
walking,  and  positions  in  which  the  nerve  is  put  in  a  state  of  tension  or  is 
compressed,  aggravate  it.  A  valuable  sign  of  sciatica  is  pain  produced  by 
passive  flexion  of  the  thigh  upon  the  pelvis  with  the  knee  extended  (Lasegue's 
sign);  by  this  means  the  sciatic  nerve  is  stretched,  and  pain  is  readily 
produced  if  the  nerve  is  inflamed.  The  characteristics  of  the  pain  are  those 
already  described  under  neuritis.  The  other  more  unusual  symptoms  of 
neuritis  may  also  be  present,  as  herpes,  edema,  and  wasting,  but  the  reaction 
of  degeneration  is  seldom  present.  The  loss  of  the  tendo  Achillis  jerk  is  an 
important  sign. 

Diagnosis. — This  is  not  difficult,  although  a  careful  study  should  be 
made  of  each  case  with  a  view  to  determining  its  primary  or  secondary 
origin.  Pelvic  tumors,  especially  in  women,  and  rectal  accumulations  should 
be  sought  for.  Lumbago,  hip-disease,  and  sacroiliac  disease  are  all  to  be 
recalled.  Pain  felt  only  in  the  outer  side  of  the  thigh  is  not  sciatica.  Some 
writers  attribute  all  sciatica  to  joint  diseases,  but  this  view  is  not  tenable. 
The  rare  cases  of  sciatic  neuralgia  are  not  characterized  by  tenderness. 
They  occur  in  persons  subject  to  neuralgia,  and  the  pain  is  not  influenced 
by  position  and  motion,  but  is  purely  spontaneous.  Disease  of  the  vertebrcB, 
of  the  Cauda  equina,  and  even  of  the  spinal  cord  may  produce  sciatic  pain; 
but  here,  again,  tenderness  is  not  so  common  in  the  course  of  the  nerve,  the 
pain  is  more  likely  to  be  bilateral,  and  changes  in  objective  sensation  may  be 
distinct.  Inflammation  of  the  roots  of  the  sciatic  nerve,  however,  may 
extend  downward.     Bilateral  pain  may  be  indicative  of  disease  of  the  nerve 


868  DISEASES  OF  THE  .\EK VOL'S  SYSTEM 

roots,  although  bilateral  sciatica  from  other  causes  does  occasionally  occur. 
The  shooting  pains  of  tabes  dorsalis  are  like  those  of  sciatica,  but  the  other 
symptoms  of  the  former  disease  are  present. 

Prognosis. — Cases  of  sciatica,  however  obstinate,  usually  sooner  or  later 
get  well,  although  they  may  persist  for  months.  A  case  came  under  Tyson's 
obseni-ation  which  lasted  seven  years,  but  recovery  final!}'  was  complete. 

Treatment. — Here,  as  elsewhere,  if  a  cause  is  discoverable,  it  should  be 
removed.  Exposure  to  cold  and  dampness  should  be  avoided,  pressure  by 
cicatricial  tissue  or  dislocated  bones  should  be  relieved,  and  constitutional 
states  favoring  neuritis,  such  as  gout  and  syphilis,  should  be  corrected. 

Of  curative  measures,  rest  is  the  most  important.  When  a  limb  can  be 
splinted,  this  should  be  done,  pressure  by  muscular  contraction  being  thus 
prevented.  Fixation  of  the  hip-joint  by  a  plaster  cast  ma}'  be  of  great 
service  and  permit  the  patient  to  get  about.  Cold  may  be  a  useful  applica- 
tion, as  by  an  ice  bag.  In  other  instances  heat,  now  dry  and  again  moist, 
subsen,'es  a  useful  purpose.  A  blister  or  blisters  may  be  applied  over  the 
tender  nerve.  Especially  convenient  is  the  Paquelin  cautery,  which  should 
be  used  earlier  than  it  commonly  is;  its  application  takes  but  a  second,  and 
may  be  rendered  painless  by  previously  applying,  for  a  few  minutes,  a  mix- 
ture of  ice  and  salt  to  the  spot  to  be  burned,  although  this  has  been  largely 
superseded  of  late  by  the  more  convenient  ethyl  chlorid.  Alorphin  is 
sometimes  indispensable,  and  the  hypodermic  method  of  application  is 
best — 1/6  to  1/4  grain  (o.oii  to  0.0165  grn)  for  s-n.  adult.  But  the  morphin 
habit  is  easily  acquired,  and  the  patient  should  not  be  allowed  to  use  the 
syringe  himself.  Cocain  may  be  similarly  used — i/io  to  1/3  grain  (0.0066 
to  0.022  gm.) — and  Gowers  recommends  it  highly,  more  particularly  for  its 
power  in  arresting  local  transmission  of  the  impulses  that  cause  pain. 
Eucain  is  even  better.  Here,  too,  the  injection  should  be  made  at  the  seat 
of  the  pain  by  the  physician  or  a  trusted  attendant.  Gowers,  whose  large 
experience  always  bespeaks  respect,  considers  mercury  also  a  most  efficient 
agent,  in  the  shape  of  a  blue  pill,  i  grain  (0.066  gm.)  once  or  twice  a  day, 
associated,  if  necessary,  with  morphin,  the  constipating  effect  of  which  it 
counteracts.  Salicylate  of  sodium  and  aspirin  are,  undoubtedly  sometimes 
useful,  as  is  also  more  rarely  iodid  of  potassium.  Strj'chnin  is  also  of 
ser\'ice.  Injection  of  a  considerable  amount  of  normal  salt  solution  into 
the  buttock  near  the  seat  of  pain  has  been  recommended. 

In  the  chronic  form  also  Paquelin's  cautery  should  be  repeatedly  used, 
or  if  not  at  hand,  blistering  may  be  substituted.  Electricity  here  comes  into 
play,  and  galvanism  is  the  form  to  be  used,  the  positive  electrode  being 
placed  over  the  nerve  or  seat  of  pain,  and  the  negative  indifferently  placed. 
A  weak  current  is  best,  but  its  strength  may  be  increased  if  such  current  be 
inefficient.  The  application  should  continue  for  about  ten  minutes.  The 
wasted  muscles  recover  as  the  inflammation  subsides,  but  massage  and  gal- 
vanic electricity  help  them.  Faradism  is  less  favorably  regarded,  especially 
in  the  active  stage. 

Every  case  of  sciatica  should  be  at  once  ordered  to  rest,  and  the  more 
complete  the  rest,  the  sooner  the  recovery.  Splinting  of  the  limb  as  recom- 
mended by  Weir  Mitchell. 

For  the  relief  of  mild  degrees  of  pain  phenacetin  and  antifebrin,  and 


NEURITIS  869 

especially  a  combination  of  phenacetin  and  caft'cin  citrate,  say  lo  grains 
(0.66  gm.)  of  the  former  and  3  grains  (0.2  gm.)  of  the  latter  every  two 
hours  is  often  efficient.  Acupuncture  over  the  course  of  the  nerv-e  is  of 
service  for  the  same  purpose — relief  of  pain  rather  than  cure.  Anodyne 
liniments  may  be  used,  and  although  not  curative,  do  give  some  comfort 
and  meet  the  wishes  of  the  patient  that  something  should  be  done. 

In  chronic  cases  change  of  scene  is  often  of  advantage,  and  if  associated 
with  thermal  bath  treatment  may  accomplish  a  cure  in  otherwise  obstinate 
cases.  The  mud-bath  is  a  measure  of  treatment  applied  in  Europe  with  some 
success.  In  the  chronic  stage  electricity  also  meets  the  demands  of  patients 
and  friends  and  may  do  some  good.  The  galvanic  current  should  be 
employed.  Massage  is  less  efficient  than  in  muscular  rheumatism,  though 
it  should  be  tried.  Nerve  stretching  is  a  very  dubious  expedient,  it  may 
cause  serious  consequences. 

Multiple  Neuritis. — The  diagnosis  of  alcoholic  cases  is  usually  easy  from 
the  history,  although  sometimes  skilfid  deception,  especially  in  women,  de- 
prives the  physician  of  this  assistance.  The  distinctive  features  of  the 
disease  are  the  symmetrical  localizations  of  the  sensory  and  motor  symp- 
toms, first  and  mainly  in  the  extremities,  and  the  tenderness  of  the  skin, 
nerve  trunks  and  muscles.  There  are,  however,  great  variations  in  dif- 
ferent cases,  even  in  those  dependent  on  the  same  cause,  some  cases  being 
very  acute  and  general  and  even  rapidly  fatal,  others  slow  with  limitation  to 
groups  of  muscles ;  some  mainly  motor,  others  sensory  and  ataxic  (pseudo- 
tabes). 

The  possible  sources  of  confusion  are  rheumatism,  acute  and  chronic; 
neuralgia,  tabes  dorsalis,  poliomyelitis,  acute  and  subacute;  pachymeningitis 
damaging  the  nerve-roots,  acute  ascending  paralysis,  and  hysterical  palsy. 

In  rheumatism  the  tingling  characteristics  of  neuritis  is  not  present,  and 
although  the  tenderness  of  a  nerve  passing  in  the  neighborhood  of  a  joint, 
especially  likely  to  be  aggravated  in  motion,  may  be  mistaken  for  joint  pain, 
careful  examination  will  elicit  its  true  nature.  Neuritis  differs  from 
neuralgia  in  the  bilateral  symmetry  of  the  pain,  and  in  the  persistence  of 
tenderness  and  hyperesthesia  as  contrasted  with  the  spontaneous  pain  of 
neuralgia. 

The  ataxic  form  of  the  disease,  especially  the  form  called  neuro-tabes 
(peripheral  pseudo-tabes),  sometimes  resembles  tabes  dorsalis  very  closely. 
In  neurotabes  the  lesion  consists  only  of  the  nerve  degeneration,  while  the 
spinal  cord  is  free,  its  claim  to  the  title  being  the  fact  that  the  loss  of  motor 
power  may  be  slight  in  neuro-tabes,  as  in  most  cases  of  true  tabes.  The 
diagnosis  from  tabes  may  generally  be  easily  made.  The  association  of 
absolute  paralysis  or  distinct  weakness  of  extensors  with  inco-ordination 
would  indicate  neuritis.  The  "lightning  pains"  of  tabes  are  seldom  found 
in  neuritis,  nor  are  waist  constriction  nor  pupillary  symptoms,  while  the 
muscular  tenderness  is  not  found  in  tabes.  Rapid  onset  of  the  disease  and 
ultimate  recovery  occur  in  pseudo-tabes.  The  extreme  hyperesthesia,  so 
distinctive  a  symptom  of  neuritis,  may  be  less  valuable  in  diagnosis,  because 
it  is  often  absent  in  the  ataxic  form.  Girdle  pains,  paralysis  of  the  sphincters 
of  bladder  and  rectum,  are  much  more  common  in  cord  involvement,  even 
in  alcoholic  cases,  but  may  occur  in  multiple  neuritis. 


870  DISEASES  OF  THE  NERVOUS  SYSTEM 

Poliomyelitis — inflammation,  acute  or  subacute,  of  the  gray  matter  of 
the  cord — resembles  the  rheumatic  and  toxemic  forms  of  neuritis,  which 
have,  like  it,  a  febrile  onset,  initial  rheumatic  pains,  and  muscular  wasting 
with  the  reaction  of  degeneration.  But,  again,  we  contrast  the  symmetrical 
distribution  of  the  palsy  of  neuritis  and  its  limitation  to  nerve  distribution 
with  the  random  distribution  of  poliomyelitis.  Pain  on  pressure  and  sub- 
jective sensory  disturbances  are  not  prominent  in  poliomj^elitis,  but  some- 
times the  symptoms  are  suggestive  of  the  association  of  multiple  neuritis 
with  poliomyelitis. 

In  pachymeningitis  which  involves  the  nerve-roots,  producing  paralysis, 
wasting,  and  anesthesia,  the  legs  do  not  suffer  early  in  the  disease,  as  a  rule ; 
and  while  the  upper  parts  of  the  arms  and  trunk  may  be  anesthetic,  there 
is  no  tenderness  of  the  nerve  trunks,  unless  these  also  are  inflamed. 

Acute  ascending  paralysis  (Landry's)  resembles  the  most  rapid  form  of 
multiple  neuritis  in  some  of  its  symptoms,  but  the  paralysis  usually  ascends 
the  trunk  from  the  legs  to  the  arms,  and  does  not  begin  in  the  hands  and 
feet  at  the  same  time,  nor  does  it  affect  the  trunk  last,  as  in  neuritis.  There 
is,  moreover,  no  anesthesia  in  typical  ascending  paralysis.  There  are, 
however,  transitional  cases  between  multiple  neuritis  and  Landry's  paralysis, 
and  the  term  Landry's  paralysis  is  somewhat  in  disfavor. 

Some  assistance  in  diagnosis  may  be  had  from  the  etiological  standpoint ; 
the  history  of  metallic  poisoning,  of  alcoholic  excesses,  or  of  exposure  to 
infectious  diseases,  or  the  presence  of  diabetes  being  suggestive. 

Prognosis. — Localised  neuritis.  The  prognosis  varies  greatly,  being 
favorable  in  mild  and  in  most  traumatic  cases.  Those  consequent  upon 
local  suppuration  are  the  gravest.  In  ordinary  cases  from  cold  or  contu- 
sion recovery  usually  ensues  sooner  or  later,  although  some  last  a  long  time 
and  recurrences  are  not  unusual,  especially  in  neuropathic  dispositions,  in 
which,  too,  recovery  is  slower. 

Multiple  Neuritis. — A  large  number  of  patients  with  multiple  neuritis 
get  well,  though  slowly,  especially  if  thecauso  be  discovered  and  removed. 
Especially  is  this  true  of  the  alcoholic  cases,  although  improvement  does 
not  always  begin  immediately  on  withdrawing  the  cause — indeed,  the  disease 
may  even  progress  for  a  long  time,  and  improvement  may  not  be  obser%-ed 
for  several  months.  Hence  the  prognosis  should  be  guarded.  The  acute 
and  widespread  cases  are  the  most  dangerous  to  life,  and  in  such  the  prog- 
nosis should  always  be  guarded.  The  involvement  of  the  heart  and  of  the 
muscles  of  respiration,  including  the  diaphragm,  is  most  to  be  feared.  Pain 
in  the  trunk  muscles  is  a  grave  symptom  if  the  motor  power  of  the  limbs  has 
diminished  much.  Paralysis  of  the  diaphragm  may  be  insidious  and  un- 
noticed until  that  of  the  intercostals  is  added,  when  there  may  be  accumula- 
tion of  mucus,  bronchitis  and  death  by  suffocation.  Involvement  of  the 
vagus  ner\'^es  is  manifested  by  frequency  of  pulse.  Superadded  involve- 
ment of  the  spinal  cord  increases  the  danger.  At  best,  months  are  required 
for  recover^^  and  even  years  may  be  necessary.  Extensive  involvement 
of  the  spinal  cord  precludes  total  recovery.  The  return  of  faradic  irritability 
in  ner\^e  and  muscle  is  favorable.  To  sum  up  with  Gowers :  "The  prognosis 
is  better  in  the  sensory  than  in  the  motor  form,  better  when  the  arm  escapes 
than  when  aU  the  limbs  are  involved,  better  in  cases  of  chronic  than  acute 


ADIPOSIS  DOLOROSA  871 

onset,  and  better  if  a  case  of  apparently  acute  onset  is  really  such,  than  if  it 
succeeds  slight  symptoms  of  longer  duration." 

Treatment. — The  removal  of  the  cause,  if  possible,  is  a  primary  step  in 
treatment.  Along  with  this,  rest  is  most  important,  and  the  rest  should  be 
complete — in  bed,  and  this  should  be  enforced  in  the  earlier  stages;  later 
the  pain  and  loss  of  motor  power  make  rest  obligatory.  Care  should  be 
taken  to  avoid  any  pressure  of  the  bed-clothes  upon  the  feet,  which  might  aid 
in  the  contracture  of  the  muscles  in  the  position  of  foot-drop.  There  should 
be  no  compromise  with  alcohol,  although  in  some  cases  of  great  debility, 
when  the  cardiac  action  is  feeble,  gradual  withdrawal  may  be  justifiable. 
The  patient  should,  on  the  other  hand,  be  fed  on  the  most  nutritious  food. 
Local  anodyne  applications  may  be  resorted  to  to  relieve  the  pain,  and  may 
be  varied  according  to  effect.  Dry  heat,  moist  heat,  applications  of  lead- 
water  and  laudanum,  and  ointments  of  aconite  and  veratrum  are  some 
of  those  which  may  be  employed.  Wrapping  in  cotton  or  wool  is  sometimes 
beneficial.     Warm  baths  are  soothing;  sometimes  very  hot  ones  give  relief. 

Postures  assumed  because  of  the  relief  they  give  to  pain  should  not  be 
too  long  permitted  lest  deformity  result  by  contraction  and  adhesion, 
difficult  or  impossible  to  overcome.  Dropping  of  the  feet  should  be  pre- 
vented by  splints  or  by  support  with  sand-bags.  The  same  is  true  of  flexion 
at  the  knee  and  hip. 

As  to  drugs,  they  are  of  little  use;  the  salicylates,  phenacetin,  antifebrin, 
and  antipyrin  may  be  useful  in  mild  cases,  and  should  be  tried  in  doses  of 
from  5  to  15  grains  (0.3  to  i  gm.),  but  their  action  should  be  watched  if 
the  heart  be  affected.  ■  They  are  more  particularly  useful  in  cases  due  to 
cold.  Extreme  pain  may  demand  the  cautious  use  of  morphin  hypoder- 
mically  in  doses  of  from  1/6  to  1/3  grain  (o.oii  to  0.022  gm.)  combined 
with  1/150  grain  (0.00044  gm.)  of  atrophin,  which  modifies  and  improves 
the  action  of  morphin  most  happily.  For  the  mental  symptoms  the  hydro- 
bromate  of  hyoscin  in  doses  of  from  1/200  to  i/ioo  graia  (0.00033  to 
0.00066  gm.)  hypodermically,  or  hyoscin  in  doses  of  from  1/400  to  1/150 
grain  (0.00016  to  0.00044  gm.)  may  be  tried.  Mercurials,  so  highly  approved 
by  Gowers  in  simple  neuritis,  are  useless  here.  The  iodids  are  sometimes 
beneficial  in  chronic  cases  and  in  cases  due  to  lead  absorption. 

Roborant  medicines,  such  as  iron  and  cod-liver  oU,  are  indicated  to 
buUd  up  the  patient,  who  is  generally  broken  down.  Electricity,  massage 
and  strychnin  are  very  useful  after  convalescence  has  set  in. 


ADIPOSIS  DOLOROSA. 

Synonym. — Dercum's  Disease. 

Definition. — A  condition  first  described  by  Dercum,  in  18S8,  in  which 
there  are  irregular  deposits  of  fat  in  different  parts  of  the  body  which  are 
the  seats  of  pain  or  tenderness  or  have  been  preceded  by  it. 

Etiology  and  Pathology. — The  subjects  are  almost  always  women.  A 
neuropathic  family  predisposition,  the  alcoholic  habit  and  syphilis,  have 
been  generally  present.  Sclerosis  with  diminution  in  size  of  the  thyroid 
gland  has  been  found  and  in  a  case  of  Burr  there  was  a  tumor  of  the  pituitary 


872  DISEASES  OF  THE  XERVOUS  SYSTEM 

body.  There  is  sometimes  neuritis  and  later  degeneration  of  smaller  ner\-e 
branches,  the  main  trunks  being  intact.  The  disease  is  probably  a  neuritis 
associated  with  peculiar  fat  formation  and  in  relation  with  the  ductless 
glands.  Attention  has  already  been  called  to  the  probable  relation  of  this 
disease  to  disease  of  the  hypophysis. 

Symptoms. — Sometimes,  after  middle  life,  the  patient,  usually  a  woman, 
acquires  irregular  deposits  or  bunches  of  fat  in  various  parts  of  the  body. 
These  gradually  become  the  seat  of  burning,  scalding,  shooting  pain  and 
paresthesias.  The  masses  of  fat  grow  larger  and  become  soft  and  pultace- 
ous,  but  do  not  pit  on  pressure.  There  remain  areas  of  the  body  quite 
uninvolved,  especially  the  peripheral  parts  of  the  limbs.  Hyperesthesias 
may  alternate  with  anesthesia  elsewhere  than  in  the  fatty  masses.  At  times 
there  is  mental  weakness,  even  dementia.  As  the  accumulations  grow 
there  succeeds  muscular  weakness,  at  times  extreme ;  the  skin  appears  nor- 
mal, the  hands  and  feet  remain  normal.  The  skin  is  at  times  normal,  at 
others  it   is   pigmented  or  atrophied. 

Diagnosis. — The  disease  differs  from  simple  obesity  iii  the  lumpiness 
as  contrasted  with  the  uniform  distribution  of  fat,  and  by  the  painfulness 
and  tenderness.  From  myxedema  it  differs  in  the  absence  of  the  peculiar 
facies  and  other  symptoms  which  attend  myxedema. 

Treatment  is  without  effect.  Local  anodynes  may  palliate.  Thyroid 
extract  should  be  tried.  Coal-tar  derivatives  may  be  employed,  especially 
aspirin  and  phenacetin.     Morphin  should  be  put  oR  as  long  as  possible. 

NEURALGIA. 

Definition. — Strictly  speaking,  the  term  neuralgia  should  be  restricted 
to  such  varieties  of  nerve  pain  as  are  unattended  with  structural  changes  in 
the  nerve.  Formerly,  much  that  is  now  regarded  as  neuritis  was  called 
neuralgia,  and  it  is  probable  that,  as  our  knowledge  grows,  other  so-called 
neuralgias  will  be  eliminated.  Finally,  the  border-line  existing  between 
neuralgia  and  neuritis  cannot  be  drawn  sharply,  but  as  far  as  possible,  the 
term  neuralgia  should  be  restricted  to  nerve  pain  without  organic  change. 

Etiology. — Neuralgia  is  a  disease  of  adults.  It  rarely  occurs  before 
puberty,  and  is  relatively  rare  in  old  age.  It  is  more  common  in  women 
than  in  men,  although  not  so  very  rare  in  old  men.  Heredity  is  responsible 
for  a  tendency  to  neuralgia.  According  to  Anstie,  fully  one-fourth  of  all 
cases  are  the  result  of  heredity.  It  is  frequent  in  so-called  neurotic  families 
and  in  the  so-called  "nervous"  person — i.  e.,  one  who  is  excitable,  an.xious, 
and  fretful  in  disposition.  In  this  category,  too,  are  the  hysterical  neural- 
gias. The  debilitated,  anemic,  and  poorly  fed  are  liable  to  it.  So  are  they 
who  are  overworked  and  worried. 

The  most  frequent  exciting  cause  is  cold.  Malaria  is  one  of  the  most 
common  causes,  producing,  especially,  hemicrania,  while  the  malarial 
cachexia  also  predisposes  to  neuralgia.  The  pain  of  carious  teeth  is  not 
regarded  as  neuralgic,  but  when  such  pain  causes  irritation  of  the  peripheral 
branches  of  the  fifth  nerve,  a  neuralgia  may  be  produced  in  the  distal 
distribution. 

Symptoms. — Pain  is  the  leading  symptom.     "Spontaneous  pain,"  by 


NEURALGIA  873 

which  is  meant  pain  independent  of  neuritis  or  irritation  of  the  nerve, 
and  the  modifications  to  which  it  is  subject  in  severity  and  distribution, 
constitute,  in  fact,  the  disease. .  This  pain  is  irregularly  paroxysmal, 
shooting,  darting,  or  burning  in  character,  not  usually  increased  by  motion 
and  if  not  relieved  by  pressure,  may  be  by  gentle  friction.  The  more  the 
pain  is  increased  by  motion  and  the  more  there  is  pain  over  the  nerve  trunks 
on  pressure,  the  more  is  it  a  neuritis  and  the  less  a  neuralgia.  Yet  we  cannot 
literally  adhere  to  this,  as  evidenced  by  the  "tender  points"  of  Valleix, 
which  will  be  further  referred  to  under  the  different  varieties  of  neuralgia. 
Multiple  dartings  and  shootings,  separated  by  seconds  or  minutes  of  freedom 
from  pain,  are  characteristic. 

The  absence  of  primary  tenderness  is  also  characteristic;  but  after  the 
pain  has  continued  for  some  time  there  often  succeed  tenderness  of  the  skin 
and  even  a  redness  and  swelling,  the  absence  of  any  unnatural  degree  of 
which  at  the  beginning  is  considered  distinctive.  These  phenomena, 
including  edematous  swellings,  are  regarded  as  vasomotor  in  origin.  Other 
vasomotor  symptoms  are  hyperidrosis,  increased  secretion  of  saliva  and 
tears,  and  elevation  of  temperature.  Trophic  effects  are  seen  in  shedding 
of  the  hair  and  its  rapid  blanching,  and  other  sj^mptoms  to  be  referred  to. 
Muscular  twitchings  are  also  not  uncommon  at  the  seat  of  the  pain,  and  some- 
times even  muscular  spasm. 

The  duration  of  an  attack  of  neuralgia  varies  from  an  hour  or  even 
less  to  many  hours.  Sooner  or  later,  if  not  relieved,  it  subsides  spontane- 
ously, though  with  a  greater  tendency  to  recur  than  when  relieved  by 
treatment. 

Varieties  Depending  upon  Nerves  Involved. 

Neuralgias  are  variously  named  in  accordance  with  the  nerves  affected, 
whence  we  have  the  following  varieties : 

I.  Trifacial  Neuralgia  {Neuralgia  of  the  Fifth  Pair;  Tic  douloureux; 
Prosopalgia) . — This  form  involves  one  or  more  of  the  branches  of  the  fifth 
pair,  rarely  all.  It  is  more  common  than  all  other  varieties  of  neuralgia 
combined.  Here,  doubtless,  we  have  sometimes  to  do  with  a  neuritis  not 
always  easily  separable.  One  or  more  numerous  tender  points  are  usually 
demonstrable,  of  which  those  at  the  supra-orbital  and  infra-orbital  foramina 
are  the  most  conspicuous. 

Of  the  branches  of  the  fifth,  the  ophthalmic,  or  the  first  division  through 
its  supra-orbital  branch,  is  that  most  frequently  affected,  giving  rise  to 
the  well-known  supra-orbital  neuralgia.  The  pain  radiates  from  the 
"tender  point"  at  the  supra-orbital  notch  over  the  anterior  half  of  the  head 
sometimes  to  the  eye  itself,  the  eyelid,  and  half  of  the  nose.  There  may  be 
injection  of  the  eye  and  suffusion.  There  is  sometimes  pain  in  the  occipital 
protuberance  and  cervical  spines.  This  supra-orbital  form  must  most 
frequently  be  distinguished  from  catarrh  of  the  frontal  sinuses,  but  the  latter 
is  more  likely  to  be  symmetrical,  and  while  the  pain  is  severe,  it  is  duller, 
less  shooting,  and  is  accompanied  by  coryza;  it  terminates  suddenly  with  a 
free  discharge  of  purulent  matter,  sometimes  offensive. 

When  the  distribution  of  the  infra-orbital,  or  second  branch  is  involved. 


874  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  pain  occupies  the  superior  maxillary  area  between  the  orbit  and  the 
mouth,  over  the  cheek  to  the  ala  of  the  nose.  The  "tender  points"  are 
at  the  emergence  of  the  nerve  below  the  orbit,  at  the  side  of  the  nose,  over 
the  most  prominent  part  of  the  malar  bone,  and  along  the  gingival  line  in 
the  upper  jaw,  rarely  in  the  upper  lip. 

When  there  is  involvement  of  the  third,  or  inferior  maxillary,  division, 
less  common  as  an  isolated  form — except  as  to  its  inferior  dental  branch — 
there  is  a  much  more  extensive  area  of  pain,  including  the  parietal  eminence, 
the  temple,  the  ear,  the  lower  jaw,  and  the  tongue.  The  "tender  points" 
are  in  front  of  the  ear  where  the  auriculotemporal  crosses  the  zygomatic 
arch,  where  there  is  often  burning  pain,  and  at  the  mental  foramen  on  the 
chin.  The  movements  of  mastication  and  speaking  may  be  painful,  and 
there  may  be  salivation.  A  herpetic  eruption  about  the  eyes  or  lips  occa- 
sionally present  points  to  neuritis.  Atrophy  and  induration  of  the  skin 
have  been  included  in  the  symptoms,  but  these  are  ascribable  also  to  a 
neuritis. 

There  is  a  pure  ocular  neuralgia  involving  the  eyeball  only.  It  may  or 
may  not  be  due  to  errors  of  refraction.  Of  these,  hypermetropia,  or  far 
sightedness,  is  the  most  common  cause.  Either  one  or  both  eyes  may  be 
affected.     It  may  be  accompanied  by  dimness  of  vision. 

A  form  of  trigeminal  neuralgia,  called  by  Trousseau  "epileptiform," 
consists  in  sudden,  severe,  and  frequent  attacks  of  pain,  lasting  from  a  few 
seconds  to  a  few  minutes,  many  times  repeated  during  the  da^'. 

2.  Cervico-occipital  Neuralgia. — This  affects  the  area  of  the  neck  sup- 
plied by  the  posterior  branches  of  the  first  four  cervical  nerves,  and  the 
posterior  part  of  the  head  supplied  by  the  great  occipital  branch  of  the 
posterior  division  of  the  second  cervical  nerve,  at  the  exit  of  which  there  is  a 
tender  point  about  half  way  between  the  mastoid  process  and  the  first 
cervical  vertebra.  Two  other  tender  points  are  just  above  the  parietal 
eminence,  and  between  the  stemomastoid  and  trapezius  muscles.  The  pain 
may  extend  over  the  greater  part  of  the  neck  and  head,  as  far  fonvard  as  the 
parietal  eminence  and  the  ear. 

Exposure  to  cold  or  a  draft  of  air  is  the  most  common  cause  of  this  form. 
Nephritis  has  been  alleged  to  be  a  cause. 

3.  Cervico-brachial  and  Brachial  Neuralgia. — This  involves  the  area 
supplied  by  the  four  lower  cervical  and  the  first  thoracic  nen,-es,  the  area  of 
sensory  distribution  of  the  brachial  plexus. 

The  tender  points  are  the  axillary,  the  circumflex  at  the  posterior  part 
of  the  deltoid,  the  superior  ulnar  behind  the  elbow,  and  the  inferior  ulnar  in 
front  of  the  wrist.  This  form  is  often  confounded  with  neuritis  due  to 
rheumatic  affections  of  the  joints  or  injury. 

4.  Neuralgia  of  the  Phrenic  Nerve. — This  is  rare,  the  pain  in  its  area 
during  pleurisy  and  pericarditis  being  rather  a  neuritis.  The  pain  is  at  the 
lower  part  of  the  thorax,  at  the  attachment  of  the  diaphragm.  Breathing 
is  shallow,  because  pain  is  caused  by  the  breathing  movements.  Coughing 
and  even  deglutition  cause  pain. 

5.  Trunk  Neuralgia. — This  naturally  divides  itself  into  two  subvarieties: 
dorso-intercostal  and  lumbo-abdominal. 

(a)  Dorso-intercostal  neuralgia  covers  the  area  supplied  by  the  inter- 


NEURALGIA  875 

costal  nerves  from  the  third  to  the  ninth,  and  is  characterized  by  pain  along 
the  intercostal  spaces  or  in  parts  of  them.  It  is  sometimes  bilateral.  There 
is  usually  a  constant  dull  pain  with  or  without  acute  stabbing  exacerbations, 
or  the  latter  may  be  excited  by  deep  breathing  or  motion.  There  may  be 
special  tenderness  at  the  points  of  emergence  of  the  three  branches  of  the 
intercostal  nerve — viz.,  posteriorly  near  the  vertebrae,  anteriorly  near  the 
median  line,  and  midway  between  these  two  points  in  the  midaxillary  line. 

The  term  pleurodynia  has  been  used  with  a  good  deal  of  vagueness. 
Strictly  speaking,  it  should  be  limited,  as  it  is  by  Gowers,  to  neuralgia  of  the 
pleural  nerves.  Consistently  with  this  it  should  not  be  applied  to  pain 
localized  in  the  course  or  point  of  exit  of  an  intercostal  nerve.  It  is  very 
acute  in  character  and  excited  by  expansion  of  the  thorax  rather  than  by 
lateral  movements  of  the  trunk.  The  pain  of  herpes  zoster  is  not  a  neuralgia, 
but  a  neuritis. 

Another  variety  in  this  locality  is  the  inframammary  neuralgia  of 
anemic  women. 

(6)  Lumbo-ahdominal  neuralgia  involves  the  posterior  branches  of 
the  lumbar  nerves,  especially  the  ilioscrotal  branch.  The  area  of  the  pain 
is  the  region  of  the  iliac  crest,  along  the  inguinal  canal  and  the  spermatic 
cord  in  the  scrotum,  or  round  ligament  in  the  labium  majus.  The  pain  is 
often  bilateral,  sometimes  resembling  the  constricting  girdle  pains  of  spinal 
cord  disease,  from  which  it  differs,  however,  by  its  changing  place.  It  is 
especially  frequent  in  connection  with  the  diseases  of  pelvic  organs,  particu- 
larly in  women.     The  testes  and  penis  are  the  seat  of  neuralgic  pains. 

6.  Neuralgia  of  the  spinal  column  is  the  more  modem  term  for  the 
"spinal  tenderness"  of  the  older  authors.  It  is  common  in  feeble  and  hys- 
terical women,  and  a  sequel  of  the  modern  railway  accident  under  the  name 
of  "spinal  congestion."  The  pain  in  most  cases  is  felt  along  a  considerable 
vertical  extent  of  the  spine,  but  is  more  intense  in  certain  spots.  The 
thoracic  region  is  the  most  common  seat,  next  the  lower  cervical,  and 
least  frequently  the  lumbar  Region.  The  pain  in  some  cases  is  purely 
hysterical. 

7.  Sacral  neuralgia  and  coccygodynia  are  defined  by  their  names.  These 
affections  reside  in  the  nerves  between  the  bone  and  the  skin,  and  are  often 
exceedingly  difficult  to  cure.  The  pain  may  really  be  due  to  organic  lesions 
in  the  part. 

8.  Neuralgia  of  the  feet  includes  painful  heel,  plantar  neuralgia,  and 
erythromelalgia.  In  the  latter,  first  described  by  Weir  Mitchell,  vascular 
changes,  including  either  acute  hyperemia  or  cyanosis — probably  of  vaso- 
motor origin — are  associated  with  severe  pain  in  the  heel  or  sole  of  the  foot. 
It  is  probably  a  neuritis  in  some  cases.  In  some  others  it  is  caused  by 
disease  of  the  vessels.     It  is  often  mistaken  for  flat  foot. 

9.  Visceral  neuralgia  means  neuralgia  affecting  the  gastro-intestinal 
tract,  the  kidneys,  ovaries,  and  other  pelvic  organs.  Idiopathic  nephralgia, 
or  neuralgia  of  the  kidney,  probably  does  not  exist.  It  and  testicular  neu- 
ralgia are  more  frequently  secondary  to  inflammation  of  adjacent  urinary 
passages,  but  idiopathic  testicular  neuralgia  is  less  rare  then  nephralgia. 

Neuralgias  are  further  classified  according  to  character  and  cause. 
Thus,  in  addition  to  the  epileptiform  variety  alluded  to,  there  are  reflex  or 


876  DISEASES  OF  THE  XERVOUS  SYSTEM 

symptomatic  neuralgias,  traumatic  neuralgias,  herpetic  neuralgias  accom- 
panying herpes,  hysterical,  rheumatic,  gouty,  diabetic,  anemic,  malarial, 
syphilitic,  and  degenerative  neuralgias.  Many  of  these  terms  are  loosely 
applied.  The  term  rheumatic  neuralgia  is  often  erroneously  applied  to 
myositis.     It  should  not  be  used. 

Very  interesting  and  important  is  the  subject  of  reflex  neuralgias  and 
referred  pains  which  have  been  especially  studied  by  the  late  Dr.  Anstie  and 
by  Henry  Head  in  England  and  Charles  L.  Dana  in  this  country.  Reflex 
neuralgias  are  due  to  disease  in  organs  distant  from  the  actual  seat  of  the 
neuralgia.  The  fifth  nen'e  is  a  favorite  seat  of  such  neuralgias.  Thus,  an 
irritation  of  the  distribution  of  one  branch  of  this  nerve  by  a  carious  tooth 
may  excite  a  neuralgia  in  another  distribution  of  the  same  nerve.  Illus- 
trations of  referred  pain  are  the  "pain  in  the  back"  or  spinal  cord  pain  in 
ulcer  of  the  stomach,  the  left  scapular  pain  in  diseases  of  the  liver,  the  sacral 
pain  in  uterine  disease,  and  the  testicular  pain  in  renal  colic. 

Diagnosis. — Neuralgia  is  chiefly  to  be  distinguished  from  neuritis  and 
the  effects  of  pressure  on  nerves;  and  also  rheumatism.  From  neuritis  it  is 
separated,  by  its  imilateral  distribution  as  contrasted  with  the  more  frequent 
symmetrical  distribution  of  neuritis,  although  neuritis  is  not  infrequently 
unilateral;  also  by  its  numerous  remissions  and  intermissions,  and  the  shift- 
ing of  the  pain  from  one  spot  to  another.  The  fixed  neuralgias  are  more 
difficult  of  separation  from  neuritis,  especially  mild  cases.  The  severe  forms 
of  neuritis  are  soon  recognized  by  the  anesthesia  which  succeeds  upon  the 
hyperesthesia  in  the  cases  of  sensory  nerves,  and  muscular  wasting  with 
changes  in  the  electrical  irritability  in  mixed  nerves.  In  the  case  of  com- 
pression of  nerves  the  pain  is  continuous,  while  the  symptoms  and  conse- 
quences of  neuritis  will,  sooner  or  later,  show  themselves.  Nevertheless, 
doubt  and  error  must  not  infrequently  occur. 

Myalgia  differs  in  its  localization  in  muscles  or  groups  of  muscles  such 
as  the  lumbar  or  shoulder  muscles,  its  continuousness  and  pain  increased 
by  motion. 

Prognosis. — The  prognosis  in  neuralgia  is  usuall^^  ultimately  favorable, 
although  some  forms  and  cases  are  very  stubborn.  Especially  true  is  this 
of  neuralgia  of  the  fifth  pair.  The  more  frequent  the  recurrence  and  the 
wider  the  distribution,  the  more  difficult  is  the  cure.  On  the  other  hand,  the 
severity  of  the  pain  is  not,  in  my  experience,  a  measure  of  obstinacy  to  cure, 
some  of  the  severest  cases  being  easiest  relieved.  Hereditary  cases  are  the 
more  obstinate.  The  same  is  true  of  cases  occurring  in  the  decline  of  life. 
Epileptiform  neuralgia  is  said  to  be  incurable. 

Treatment. — The  treatment  of  neuralgia  is  divided  into  that  of  the 
condition  predisposing  to  it  and  of  the  paroxysm.  The  anemias- — especially 
chlorosis — malaria,  and  other  predisposing  causes  should  be  corrected  by 
quinin,  iron,  and  arsenic.  Good  nourishing  food  is  important.  Change  of 
scene  and  residence  is  often  necessary.  Reflex  causes  should  be  carefully 
sought  for  and  removed.  Until  these  predisposing  causes  are  removed,  the 
treatment  of  the  paroxysm  affords  but  temporary  relief. 

For  the  paroxysm  quinin  is  by  far  the  most  efficient  remedj-,  and  will 
cure  many  cases.  Two  or  3  grains  (0.12  to  0.194  gm.)  should  be  given 
hourly  until  the  paroxysm  is  relieved  or  decided  cinchonism  is  produced. 


NEURALGIA  877 

The  salicylate  of  cinchonidia  is  a  valuable  preparation.  Some  cases  are 
relieved  by  phenacetin  or  antifebrin  (acetanilid)  in  from  lo  to  15  grain 
(0.66  to  I  gm.)  doses.  A  combination  of  phenacetin  and  cafifein,  3  grains 
(0.33  gm.)  of  the  former  and  i  (o.ii  gm.)  of  the  latter  each,  in  hourly  doses; 
is  often  efficient.  Some  cases  can  only  be  relieved  by  sulphate  of  morphin. 
The  hypodermic  injection  is  the  promptest  and  surest  remedy,  in  doses  of 
from  1/8  to  1/4  grain  (0.008  to  0.016  gm.),  but  morphin  is  a  drug  to  be 
avoided  in  neuralgia,  if  possible,  as  the  danger  of  acquiring  the  morphin 
habit  is  extremely  great.  The  patient  should  never  be  allowed  to  use  the 
hypodermic  s^-ringe  himself.  The  use  of  anodynes  is  sometimes  more  than 
palliative,  the  repeated  removal  of  the  pain  tending  to  prevent  its  recur- 
rence. The  combination  of  atrophin  with  morphin  undoubtedly  modifies 
the  unpleasant  effect  of  the  latter  drug  and  increases  its  efficiency. 

Belladonna,  and  its  active  principle,  atropin,  are  remedies  which  have 
long  enjoyed  reputation  in  the  treatment  of  neuralgia,  when  imcombined 
'with  other  drugs,  but  in  our  hands  they  have  been  feeble  remedies.  The 
doses  recommended  are  from  1/6  to  1/2  grain  (o.oii  to  0.03  gm).  of  the 
extract  and  from  1/120  to  1/60  grain  (0.0005  to  o.ooii  gm.)  of  atropin. 
Aconite  and  gelsemium  have  also  some  reputation,  especially  in  neuralgia 
of  the  fifth  ner\^e.  Gelsemium  may  be  given  in  doses  of  15  minims  (0.92 
c.c.)  of  the  tincture,  frequently  repeated.  Gelsemia  may  be  given  hypoder- 
mically  in  doses  of  from  1/60  to  1/30  grain  (o.ooii  to  0.0022  gm.),  and 
aconitin  in  doses  of  from  1/250  to  i/ioo  grain  (0.00027  to  0.00066  gm.), 
but  the  latter  is  a  remedy  so  dangerous  that  it  should  be  rarely  employed. 
Cannabis  indica  is  also  sometimes  useful  in  doses  of  1/4  grain  (0.016  gm.) 
three  times  a  day  or  oftener,  but  the  drug  varies  so  much  in  strength  that 
it  cannot  be  relied  upon. 

Local  applications  are  sometimes  very  usefiil.  Pressure  relieves  many 
mild  cases,  especially  when  associated  with  gentle  friction.  Local  anes- 
thetics, such  as  menthol,  the  ointments  of  veratria  and  aconitia,  are  simi- 
larly useful;  so  is  the  tincture  of  aconite  painted  over  the  involved  area. 
The  local  use  of  opiates,  at  least  without  first  removing  the  epidermis,  and 
of  atropin  (five  per  cent,  strength),  is,  however,  comm.ended.  The  extract 
of  belladonna,  diluted  with  glycerin  so  as  to  admit  its  being  smeared  on,  is 
sometimes  useful.  Frequent  renewals  of  all  these  local  applications  should 
be  made  in  the  course  of  the  day.  Counterirritation  by  blisters  or  sinapisms, 
by  chloroform  either  pure  or  variously  diluted,  and  by  camphor  may  be  used. 
The  last  two  may  be  applied  on  lint  and  covered  with  oiled  silk;  Both  will 
blister  if  left  on  too  long. 

Acupuncture  and  aquapuncture  are  employed,  the  latter  consisting  of 
injecting  water  under  the  skin.  For  their  local  effect,  also,  chloroform,  car- 
bolic acid,  and  osmic  acid  have  been  injected  hypodermically .  From  15 
to  20  minims  (0.92  c.c.  to  1.23  c.c.)  of  the  first  may  be  used,  from  5  to  10 
minims  (0.31  c.c.  to  0.62  c.c.)  of  the  second,  and  i  or  2  drops  of  a  one  per 
cent,  solution  of  osmic  acid  in  water  and  glycerin.  Chloroform  should  be 
cautiously  used  in  this  manner,  as  it  may  occasion  uglj'  sloughing.  It  is 
more  especially  in  sciatica  that  these  measures  have  been  employed.  Local 
applications  of  heat  and  cold  have  been  fovmd  useful — cold  by  freezing  or 
by  the  ethyl  chloride  spray;  heat  by  the  hot-water  bag,  or  in  the  case  of  a 


878  DISEASES  OF  THE  NERVOUS  SYSTEM 

supraorbital  neuralgia,  by  the  nasal  douche.  Heat  is  usually  more  efficient 
than  cold;  indeed,  the  latter  sometimes  aggravates  neuralgia. 

Electricity  is  of  uncertain  value  in  neuralgia,  but  is  sometimes  very  use- 
■ful.  The  constant  current  is  the  form  most  frequently  used,  but  faradism 
may  also  be  employed.  It  is  used  in  two  ways :  a  strong  current  is  applied 
at  once  with  a  view  to  removing  the  neuralgia  promptly  (this  is  scarcely  to 
be  recommended);  in  the  second  method  a  sedative  effect  is  sought  by  a 
weak  current,  preferably  of  galvanism,  just  sufficient  to  produce  a  tingling 
or  burning  sensation.  Experience  goes  to  show  that  the  direction  of  the 
current  may  be  ignored,  but  it  is  commonly  recommended  to  apply  the 
positive  pole  to  the  painfiol  part,  the  sponge  being  well  wet  with  warm  water, 
and  if  faradism  is  used,  it  shotild  be  with  rapid  interruptions. 

The  surgical  treatment  of  neuralgia  has  been  followed  by  brilliant  results, 
and  has  met  signal  failures.  The  most  common  procedure  is  division  of  a 
nerve,  or,  better,  the  exsection  of  a  portion  of  the  nerve.  It  has  been  most 
frequently  done  in  the  case  of  the  fifth  nerve,  and  is  almost  always  followed 
by  temporary  relief,  but,  sooner  or  later,  an  operation  on  the  Gasserian 
ganglion  or  sensory  root  usually  becomes  necessary.  Operation  is  to  be 
recommended  in  intractable  cases,  and  should  be  done  at  a  point  as  near 
the  origin  of  the  nerve  as  possible,  as  second  operations  are  not  infrequently 
necessary  on  account  of  the  recurrence  of  the  pain.  Injection  of  alcohol 
into  the  nerve  has  become  a  common  method  of  treatment.  The  injection 
has  even  been  made  into  the  Gasserian  ganglion. 

Nerve  stretching  is  also  performed  with  a  measure  of  relief  less  thorough 
than  exsection,  but  in  view  of  the  fact  that  its  disadvantages  are  less  lasting, 
it  is  the  better  operation  to  do  first  in  the  case  of  certain  nerves.  It  is 
important  to  remember  that  relief  does  not  always  immediately  follow  the 
operation.  The  sciatic  is  the  nerve  most  frequently  stretched,  but  the 
procedure  is  not  to  be  recommended.  The  intercostals  and  branches  of 
the  fifth,  including  the  lingual,  have  been  similarly  treated  mth  satisfactory 
restilts. 

TUMORS  OF  NERVES. 

Definition  and  Morbid  Anatomy. — Strictly  speaking,  the  term  neuroma 
shotdd  be  restricted  to  tiunors  composed  purely  of  nervous  tissue,  which 
are  to  be  distinguished  from  fibrous  tumors  or  fibromata,  often  seated  on 
nerves  and  known  as  false  neuromata.  Some,  however,  dispute  the  exist- 
ence of  true  neuromata,  and  they  are  certainly  very  uncommon.  Another 
form  of  false  neuroma  is  a  variety  of  the  small,  subcutaneous,  painful  tumor 
— tubercula  dolorosa — occurring  in  nerves  of  the  skin  in  the  neighborhood 
of  the  joints,  on  the  face  and  on  the  breast.  Myxomata,  sarcomata,  and 
even  carcinoma ta  are  found  in  coimection  with  nen-es.  The  latter  are 
commonly  the  result  of  extension  by  contiguity,  infiltrating  the  cormective 
tissue  between  the  fibers.  The  nervous  tissue  represented  in  the  true  neu- 
roma is  usually  fibrous,  but  very  rarely  ganglionic  nen,-e  cells  are  found,  and 
in  such  event  the  tumor  may  be  regarded  either  as  dislocated  nerve  tissue 
or  as  a  glioma  the  cells  of  which  closely  resemble  true  nerve  cells.  The 
nervous  tissue  may  be  of  the  meduUated  or  nonmedullated  variety — i.  e., 


TUMORS  OF  NERVES  879 

myelinic  or  nonmyelinic.  Connective  tissue  varying  in  quantity  is  asso- 
ciated with  both,  producing  various  degrees  of  hardness,  which  is  most 
striking  in  the  multiple  fibroneuroma. 

An  interesting  variety  is  the  plexijorin  neuroma,  nodular  and  tortuous 
in'  appearance  to  the  naked  eye,  the  internal  structure  of  which  is  composed 
also  of  interlacing  nodular  and  tortuous  nervous  cords  made  up  of  con- 
nective tissue  and  nerve  fibers.  It  is-  seen  in  connection  with  any  of  the 
spinal  and  even  symjiathetic  nerves.  The  tumors  may  be  extremely  nu- 
merous. In  a  case  lately  presented  by  Weisenberg  they  were  hundreds  in 
number.     It  grows  slowly,  and  probably  begins  in  fetal  life. 

Fibromata  of  nerves  are  usually  small,  but  may  be  three  or  four  inches 
(7.5  to  10  cm)  in  diameter  and  even  larger.  They  are  usually  foimd 
seated  in  nerve  trunks,  or  at  their  ends,  are  often  multiple,  and  their 
number  is  sometimes  large. 

Etiology. — Nerve  tumors  which  are  not  congenital  maj'  be  traumatic. 
More  than  one  member  of  a  family  has  been  found  affected.  Their  growth 
seems  stimulated  by  perversion  in  the  healing  process,  since  they  are  found 
on  the  ends  of  nerves  in  cicatrices  after .  amputation.  Growths  of  this 
character  are  truly  neuro-fibromata,  the  others  are  usually  fibromata. 

Symptoms. — Neuromata  may  be  totally  -without  symptoms.  At  other 
times  they  are  very  painful,  the  pain  being  aggravated  by  pressure.  There 
may  be  numbness  and  formication  and  even  loss  oj  sensation  on  the  one 
hand,  muscular  twitching  and  paralysis  on  the  other,  the  latter  especially 
when  the  ttmior  is  in  the  course  of  the  ner\re. 

Neuromata  of  the  cauda  equina  may  cause  paraplegia.  Refiex  spasm 
in  adjacent  or  distant  muscles,  and  even  epileptiform  convulsions,  are  occa- 
sionally present.  A  neuroma  may  give  rise  to  visible  swelling,  or  it  may  be  • 
beneath  the  surface  out  of  sight  and  touch. 

Diagnosis. — Except  in  the  case  of  plexiform  neuroma,  which  has  a 
characteristic  form  described,  the  exact  diagnosis  of  the  variety  of  nerve 
tumor  can  for  the  most  part  be  made  only  by  microscopic  examination 
after  removal,  since  all  the  symptoms  occasioned  by  true  neuroma  may  be 
caused  by  pressure  on  nerves  by  any  form  of  morbid  growth.  Multiple 
neuromata  are  usually  false  neuromata. 

Prognosis. — Nerve  tumors  rarely  cause  death,  though  they  sometimes 
undergo  malignant  change,  and  in  this  way  cause  a  fatal  termination. 
The  extreme  pain  which  is  so  characteristic  may  in  time  exhaust  a  patient, 
but  the  course  of  the  disease  is  always  prolonged. 

Treatment. — Excision  is  the  proper  treatment  for  neuromata  and  all 
other  forms  of  tumors  connected  with  nerves,  if  they  can  be  reached,  and  if 
the  symptoms  demand  active  treatment.  Often  such  treatment  is  not  de- 
manded. If  syphilitic  origin  be  suspected,  syphilitic  treatment  should  be 
adopted.  In  operations  involving  section  of  a  nerve  trunk  the  possibility 
of  loss  of  function  is  to  be  remembered. 

Local  anodyne  applications  may  be  used  to  palliate  in  mild  cases,  but 
they  are  useless  in  severe  ones.  Cocain  in  doses  of  from  1/6  to  1/2  grain 
(o.oii  to  0.033  gm.)  may  be  injected  hypodermically,  but  morphin  should 
not  be  used,  as  the  conditions  are  especially  favorable  to  the  production  of 
morphinism. 


880 


DISEASES  OF  THE  XERVOUS  SYSTEM 


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TUMORS  OF  NERVES  881 

The  muscular  sense  "or  sense  of  position"  is  probably  conducted  on 
the  same  side  of  the  cord  in  the  posterior  columns,  to  cross  in  the  medulla 
oblongata,  and  we  have  evidence  that  the  tactile  fibers  ascend  in  the 
posterior  and  lateral  columns.  Thermal  and  pain  impulses  probably  cross 
to  the  anterolateral  columns  of  the  other  side  ver>'  soon  after  entering  the 
cord,  and  possibly  ascend  in  or  near  Gowers'  tract. 

Spinal  Cord  Localization. — The  areas  of  distribution  of  spinal  nerves, 
sensory  and  motor,  are  not  sharply  defined  for  each  nerve  as  it  emanates 
from  the  spinal  cord,  while  the  regions  supplied  by  these  nerves  overlap.  At 
the  same  time  physiologists  and  clinicians  have  been  able  to  map  out  ^^^th  ap- 
proximate accuracy  the  motor  and  sensory  areas  corresponding  to  the  distri- 
bution of  each  pair  of  nerves  emanating  from  different  segments  of  the  cord. 
Among  those  who  have  especially  devoted  themselves  to  this  subject  are 
M.  Allen  Starr,  Charles  K.  Mills,  and  Charles  L.  Dana  in  America,  William 
Thorbum  and  Henry  Head  in  England,  and  Sano,  Bruns,  Kocher,  Stroh- 
meyer  and  Seiffer  on  the  Continent. 

The  results  of  various  observers  differ  in  detail,  but  agree  in  essentials. 
The  appended  table  compiled  by  E  dinger  is  from  that  originally  compiled 
by  Starr,  further  modified  by  C.  L.  Dana  and  C.  K.  Mills.  When  stood  on 
end  in  front  of  the  reader  it  will  be  found  to  correspond  in  outline  to  one- 
half  of  the  body. 

It  must  not  be  forgotten  that  these  areas  of  distribution  correspond 
to  a  nerve  constituted  as  it  is  when  it  emanates  from  a  corresponding  segment 
of  the  cord,  and  not  to  a  nerve  as  it  is  constituted  immediately  before  it 
begins  to  spread. 

The  preceding  table  includes  only  the  distribution  of  spinal  nerves. 

The  following  table  includes  the  distribution  of  nerves  starting  from  the 
nuclei  in  the  pons  and  medulla  oblongata,  so  far  as  these  are  concerned 
with  motion: 

Nuclei.  Muscles. 

f  Sphincter  iris.     Ciliary  muscle. 

III  Cranial.      \  Levator  palpebree  superioris.     Rectus  internus  in  convergence. 

[  Superior  rectus.     Inferior  rectus. 
[  Obliquus  inferioris. 

IV  Cranial,      -j  Obliquus  superioris. 

L  (Upper  facial  group.) 

VI  Cranial.      f  Rectus   externus.     Rectus   internus   of   opposite    side   in   lateral 
\  movements. 

V  Cranial.      [  Associated  movement  of  levator  palpebrae. 
Muscles  of  the  lower  jaw. 


VII  Cranial.      -|  Facial  muscles. 

XII  Cranial.      (  Lower  facial  group.      ■ 

[  Muscles  of  tongue. 
IX  Cranial.      f  Muscles  of  pharynx. 
X  Cranial.      \  Muscles  of  esophagus. 
XI  Cranial.      [  Muscles  of  larynx. 

The  study  of  the  sensory  areas  is  facilitated  by  the  use  of  diagrams  in 
which  the  areas  are  mapped  out  and  indicated  by  color  or  a  shading  which 
will  permit  their  easy  separation,  like  those  annexed,  in  which,  too,  the  areas 
corresponding  to  each  spinal  segment  are  indicated  by  suitable  lettering. 

Interpreting  by  the  data  contained  in  tables  and  diagrams  such  motor 
or  sensory  derangements  as  may  be  present,  one  may  deduce  with  more  or 


882 


DISEASES  OF  THE  NERVOUS  SYSTEM 


less  accuracy  the  scat  of  the  lesions  in  the  cord  producing  them.  It  has 
been  mentioned  that  motor  localization,  being  more  definite,  its  arrangement 
permits  more  exact  inference  than  sensory  derangements. 

The  union  of  both  adds  further  facility.  Results  vary  also  according  as 
a  lesion  involves  only  one-half  or  a  complete  section  of  the  cord.  It  is 
evident  that  an  injury  involving  the  entire  transverse  section  of  the  cord 
must  produce,  first,  motor  paralysis  in  all  parts  supplied  with  nerv'es  emana- 
ting from  segments  below  it.  In  less  complete  lesions  correspondingly 
limited  degree  and  extent  of  motor  paralysis  succeed.     Such  paralysis  may 


Fig.  144. — Diagram  of  Lesion  Showing  Brown- 
Sequard's  Paralysis — {after  Slarr). 

L.  Lesion  in  left  half  of  cord  cuts  off  motor  im- 
pulses to  left  leg,  sensory  impulses  from  right  leg, 
and  sensory  impulses  from  eleventh  dorsal  nerve. 


Fig.  145. — Schema  Showing  Chief 
Symptoms  in  Left  Unilateral  Lesion 
of  the  Dorsal  Cord — [after  Erb). 

Oblique  shading  at  a  signifies  motor 
and  vasomotor  paralysis;  vertical 
shading  cutaneous  anesthesia  at  b 
and  d\  dots  on  a  cutaneous  hyper- 
esthesia, b.  Small  anesthetic  zone. 
c.  Small  hyperesthetic  zone. 


extend  to  the  bladder  and  rectum.  After  complete  or  nearl}'  complete 
section  the  muscles  are  usually  flaccid  and  the  deep  reflexes  absent.  There 
is  no  rapidly  developing  atrophy,  and  the  muscles  respond  normally  to 
electricity.  No  satisfactory  explanation  has  as  yet  been  offered  of  the 
abolition  of  the  deep  reflexes  in  complete  or  nearly  complete  transverse 
lesion  of  the  cord  above  the  level  of  the  reflex  arcs ;  although  neuritis  is 
supposed  by  some  to  be  the  cause  of  this  loss  of  the  deep  reflexes,  it  is 
probably  not  the  cause  in  all  cases.  Second,  there  is  impaired  sensibility 
in  the  parts  supplied  by  sensory  ner\'es  associated  with  corresponding 
segments  below  the   lesion.     Anesthesia   does  not,    however,  reach   quite 


TUMORS  OF  NERVES  883 

to  the  level  of  the  lesion,  because  of  the  overlapping  of  sensory  areas 
by  nerves  which  enter  the  cord  above  the  section.  Thus,  if  the  section 
be  in  the  segment  of  the  sixth  thoracic,  the  anesthesia  may  extend  only  as 
high  as  the  area  supplied  by  the  seventh.  Moreover,  above  the  anesthetic 
area  there  is  also  at  times  an  area  of  increased  sensibility — the  effect  of  the 
section  possibly  being  to  increase  the  sensitiveness  of  the  cord  above  it  by 
increasing  its  vascularity — due  to  section  of  vasomotor  nerves  by  the  lesion. 
By  means  of  these  facts  we  may  be  enabled  to  ascertain  the  level  of  the 
disease. 

Muscular  sense  or  sense  of  position  is  lost.  Reflex  excitability,  at  first 
slightly  impaired,  may  subsequently  be  increased  when  the  lesion  is  not 
complete  and  is  above  the  reflex  arcs,  but  may  remain  impaired  in  complete 
transverse  lesions  of  the  cord  or  in  those  portions  of  the  body  whose  reflex 
arcs  are  situated  in  the  damaged  region  of  the  cord. 

The  phenomena  are  modified  if  the  lesion  be  a  /-zewn'-lesion  of  the  cord. 
In  such  an  event  there  is,  first,  motor  paralysis  in  the  portion  of  the  body 
on  the  same  side  supplied  by  nerves  whose  cells  of  origin  are  below  the 
lesion  (Figs.  144  and  145),  varying,  however,  with  the  seat  of  the  lesion.  If 
the  lesion  is  in  the  cervical  part  of  the  cord,  the  motor  paralysis  is  of  the 
arm  and  leg  on  the  same  side,  while  if  in  the  lumbar  part  of  the  cord  there  is 
loss  of  motion  in  the  leg  only  of  the  same  side.  There  is  diminished  sensi- 
bility in  the  arm  and  leg  of  the  opposite  side.  The  anesthesia  may  be  to 
pain  and  to  thermic  sense  only,  the  tactile  sense  being  unimpaired.  Such 
anesthesia  exists  on  the  opposite  side,  because  of  the  fact,  already  mentioned, 
that  one  of  the  many  routes  of  sensory  impressions  crosses  the  cord  soon 
after  it  enters  it  from  the  periphery. 

More  than  this:  the  sensibility  on  the  same  side,  below  the  segment  of 
the  lesion,  so  far  from  being  diminished  as  to  touch,  pain,  and  temperature, 
may  even  be  slightly  increased,  possibly  owing  to  the  vasomotor  paralysis 
caused  by  the  lesion,  in  consequence  of  which,  too,  there  may  be  a  slight 
rise  of  temperature  on  the  same  side.  Slight  pricks  may  be  painful,  and  the 
soles  of  the  feet  may  be  unusually  sensitive.  In  the  area  corresponding 
exactly  to  the  segment  involved  on  the  same  side  there  is  anesthesia,  while 
just  above  it  on  the  same  side,  again,  there  is  a  small  zone  of  hyperesthesia. 
The  anesthesia  is  due  to  the  fact  that  the  sensory  nerves  coming  from  the 
same  side  are  cut  just  as  they  enter  the  cord.  It  begins  somewhat  lower 
down  than  the  exact  seat  of  the  lesion,  because  of  the  overlapping  of  the 
upper  sensory  area.  The  hyperesthesia  in  the  lower  portions  of  the  body 
on  the  side  of  the  lesion  has  been  said  to  be  inexplicable,  but  may  it  not 
depend  on  hyperemia  due  to  section  of  vasoconstrictor  nerves  ?  It  may  be 
for  this  reason  also  that  the  temperature  is'  higher  on  the  side  of  the  lesion — ■ 
from  1°  to  2°  F.  (0.5  to  1°  C).  The  upper  hyperesthetic  zone  above  the 
anesthetic  area  on  the  side  of  the  lesion  may  be  explained  as  the  result  of 
irritation  of  sensory  nerve  fibers  entering  just  above  the  lesion.  The  mus- 
cular sense  or  sense  of  position  on  the  same  side  is  impaired,  a  condition 
ascribed  by  Brown-Sequard  to  the  fact  that  the  fibers  of  this  sense  run  on 
the  same  side  uncrossed,  and  probably  in  the  posterior  columns,  until  the 
medulla  oblongata  is  reached.  Reflex  excitability,  at  first  diminished  on 
the  side  of  lesion,  is  subsequently  increased  and  there  is  often  a  good  ankle 


884 


DISEASES  OF  THE  XERVOUS  SYSTEM 


CJT 


C.VZ. 


Fig.  146.— Diagram  of  Skin  Areas  Corresponding  to  Different  Spinal  Segments— (c/ne/y 

ajlcr  Starr.     Trunk  areas  from  Head). 

Roman  numerals  refer  to  nerves. 


TUMORS  OF  NERVES 


885 


CT7 


Fig.  147. — Diagram  of  Skin  Areas  Corresponding  to  Different  Spinal  Segments — {chiefly 

after  Starr.     Trunk  areas  from  Head). 

Arabic  numerals  refer  to  vertebra,  Roman  to  nerves. 


886  DISEASES  OF  THE  NERVOUS  SYSTEM 

clonus,  explainable  by  the  interruption  of  the  inhibiting  influence  from 
above. 

The  phenomena  detailed  in  the  foregoing  paragraph  are  those  of  the 
so-called  Brown-Sequard' s  paralysis,  due  to  unilateral  lesion  of  the  spinal 
cord,  caused  by  knife-cuts,  stabs,  by  pressure  from  tumors  or  inflammatory 
products,  especially  syphilitic. 

On  the  opposite  side  muscular  power  is  intact,  sensibility  is  impaired, 
and  the  derangement  may  include  the  senses  of  pain,  touch,  and  temperature, 
or  any  one  or  two,  touch  usually  escaping;  there  is  no  elevation  of  tempera- 
tiu-e,  the  muscular  sense  is  intact,  and  reflex  action  is  normal. 

All  these  results,  as  described,  may  be  produced  by  the  experiments  on 
the  spinal  cord  originally  suggested  by  Brown-Sdquard,  which  included  also 
section  along  the  median  line  of  the  spinal  cord,  which  impaired  sensation 
on  both  sides,  leaving  motion  intact.  So  far  as  completed,  minute  ana- 
tomical studies  ftirnish  results  quite  consistent  with  the  derangements  of 
motion  produced  by  diseased  states,  and,  to  less  extent,  also  with  the  morbid 
phenomena  of  sensation  as  illustrated  by  disease.  Thus,  anatomy,  experi- 
ment and  pathology  contribute  to  the  same  conclusion.  It  shoidd  be 
mentioned,  however,  that  the  explanation  of  the  Brown-Sequard  type  of 
paralysis  here  given  has  not  been  fiilly  accepted. 

More  circumscribed  lesions  produce  more  limited  results.  Thus,  a 
local  lesion  may  produce  paralysis  in  only  a  few  groups  of  muscles.  Destruc- 
tive lesions  of  the  anterior  cornua  produces  lower  segment  paralysis  in  the 
parts  innervated  by  nerves  arising  in  the  injured  cornua,  with  secondary' 
degeneration  and  muscular  atrophy,  the  reaction  of  degeneration,  diminished 
reflexes,  and  diminished  muscular  tension. 

Irritative  lesions  in  the  central  motor  tract  cause  spastic  conditions, 
including  exaggerated  tendon  reflexes,  all  of  which  have  been  described. 
More  commonly  such  symptoms  are  the  result  of  diminished  inhibition  of 
the  brain. 

It  is  also  a  matter  of  importance  to  know  whether  a  lesion  lies  in  a  nerve 
or  in  the  cord  itself.  Frequently  this  is  at  once  apparent.  At  other  times 
it  is  more  difficult  to  settle.  It  has  already  been  said  that  hemiplegias  are 
almost  invariably  cerebral  in  their  origin,  while  paraplegias  are  usuaU}^  of 
nerve  origin  or  spinal.  It  is  chiefly  with  localized  palsies  that  diffictdties  in 
diagnosis  arise.  Etiology  aids  us  somewhat.  Thus,  localized  palsies 
succeeding  localized  exposiu-e  to  cold  are  likely  to  be  peripheral.  Some 
assistance  is  rendered  if  there  be  an  associated  anesthesia.  Thus,  if  a  part 
be  anesthejtic  and  palsied  as  to  motion,  and  if  the  same  ner\^e  supplies 
sensory  and  motor  fibers  to  the  muscles,  the  lesion  is  in  that  nerve.  If, 
on  the  other  hand,  the  muscles  are  supplied  by  several  ner\^es  from  a  given 
segment  of  the  cord,  and  the  anesthesia  corresponds  to  the  area  of  distri- 
bution of  ner\^es  from  the  same  segment  of  the  cord,  the  lesion  is  probably  in 
the  cord  or  in  the  nerves  at  their  origin  from  it. 

Affections  of  the  Membranes  of  the  Cord. 

As  in  the  case  of  the  brain,  the  diu-a  mater  and  pia  arachnoid  may  be 
separate  seats  of  disease,  chiefly  inflammaton,',  not  quite  so  well  understood 
nor  quite  so  definitely  separated  in  their  chnical  features.     As  in  the  case 


SPINAL  PACHYMENINGiriS  887 

of  the  brain,  too,  we  call  inflammation  of  the  dura  mater  pachymeningitis; 
of  the  pia  mater,  leptomeningitis. 

SPINAL  PACHYMENINGITIS. 

The  dura  mater  is  separated  by  loose  connective  tissue  from  the  bony 
canal  which  stirrounds  it,  and  an  inflammation  may  invade  this  outer  or 
the  inner  layer,  affording  a  pachymeningitis  externa  or  interna,  though  it  is 
not  easy  to  separate  these  two  conditions  symptomatically  or  even  always 
anatomically  as  the  external  form  may  extend  to  the  inner  layer  and  even 
the  pia  mater,  but  usually  the  dura  offers  an  effectual  resistance  to  processes 
which  begin  on  its  outer  siu^face. 

External  Pachymeningitis. — -This  is  usually  secondary  to  disease  of 
the  vertebrae  or  similar  morbid  processes  or  to  trauma  or  aneurysmal  erosion. 
While  an  acute  condition  may  thus  supervene,  it  is  much  more  commonly 
chronic. 

Etiology  and  Morbid  Anatomy. — Perhaps  its  most  frequent  cause  is 
tuberculosis  of  the  spine,  with  its  pathological  cheesy  product  and  its  trau- 
matic result — the  spinal  curvature  known  as  Pott's  disease.  It  may  be  con- 
fined to  a  limited  area,  corresponding  to  the  primary  seat  of  the  disease,  or 
it  may  extend  over  a  large  area  of  the  meninges,  corresponding  to  six  or 
eight  vertebrae.  Such  inflammations  seldom  spread  to  the  inner  layer  and 
pia. 

Symptoms. — The^se  are  those  of  the  vertebral  lesion,  together  with  those 
of  the  internal  form  detailed  below. 

Internal  Pachymeningitis. — This  occurs  in  two  forms,  first  as  an 
inflammation  of  the  internal  layer  of  the  dura,  usually  confined,  primarily, 
at  least,  to  the  cervical  part  of  the  cord.  It  was  first  fully  described  by 
Charcot  in  187 1,  and  later  by  his  pupil  Joffroy,  under  the  name  of  "pachy- 
meningitis cermcalis  hypertrophica" ;  second,  as  a  pachymeningitis  interna 
hemorrhagica,  in  every  way  anatomically  identical  with  the  same  disease  to 
be  described  in  connection  with  the  dura  of  the  brain. 

Etiology  and  Morbid  Anatomy. — Cervical  hypertrophic  pachymenin- 
gitis, ascribed  to  exposure  to  cold,  to  the  abuse  of  alcohol,  and  to  syphilis,  is 
a  chronic  process,  consisting  in  an  accumulation  on  the  inner  surface  of  the 
dura  of  concentric  layers  of  a  firm,  fibrinous  growth,  covering  either  a  small 
extent  or  a  considerable  portion  of  the  cervical  enlargement,  and  sometimes 
causing  adhesions  of  the  dtira  to  the  pia. 

Symptoms. — To  the  subjective  symptoms  of  the  inflammation  itself  are 
naturally  added  compression  symptoms,  which,  in  fact,  overshadow  the 
former.  The  former  include  pain,  not  merely  at  the  seat  of  inflammation 
in  the  back,  but  also  in  the  area  of  distribution  of  the  spinal  nerves,  the 
roots  of  which  are  involved  in  the  process. 

The  compression  of  the  cord  and  of  the  nerve  roots  which  are  involved 
produces  symptoms  divisible  into  three  stages: 

I.  The  Painful  Stage. — In  this  there  is  pain  in  the  region  supplied  by 
the  nerves  whose  roots  arethus  compressed — viz.,  that  of  the  arms,  cervical 
region,  and  occiput — pain  at  times  of  great  severity.  In  addition  are 
observed  paresthesia,  numbness,  and  tingling,  rarely  herpes. 


888  DISEASES  OF  THE  NERVOUS  SYSTEM 

2.  The  Stage  of  Paralysis  oj  the  Upper  Extremities. — After  two  or  three 
months  the  second  period,  or  stage  of  paralysis,  sets  in — an  atrophic  paraly- 
sis in  which  there  is  weakness  of  the  arms,  resulting  from  prcssirre  on 
the  anterior  nerve  roots.  The  wasting  affects  certain  muscular  groups, 
as  the  flexors  of  the  hands,  supplied  by  the  ulnar  and  median  nerves,  while 
the  distribution  of  the  posterior  interosseous  nerve  to  the  antagonistic 
extensors  may  remain  free.  The  result  is  the  very  striking  claw-hand,  or 
main  en  griffe.  In  extreme  cases  the  atrophy  of  the  arms  and  shoulders 
becomes  very  great.  There  may  be  anesthesia  of  the  skin  an  this 
stage. 

3.  The  Stage  oj  Spastic  Paralysis  in  the  Lower  Extremities. — If  the 
compression  of  the  cord  continues,  we  reach  the  third  stage  of  the  disease. 
The  motor  fibers  to  the  lower  extremities  which  pass  through  the  cervical 
cord  become  involved,  and  the  result  is  a  spastic  paralysis  of  the  lower 
extremities — a  paresis  with  increased  reflexes,  and  without  wasting  of  the 
muscle,  because  the  trophic  centers  for  the  muscles  of  the  lower  extremities 
in  the  anterior  cornua  of  the  lumbar  cord  remain  intact.  In  cases  of 
long  duration,  however,  the  compression  of  the  cervical  cord  may  lead 
to  anesthesia  of  the  lower  extremities,  paralysis  of  the  bladder,  and 
bed-sores. 

The  symptoms  of  the  internal  hemorrhagic  pachymeningitis  are  not 
essentially  different  from  those  detailed,  but  are  commonly  superadded  to 
those  of  hematoma  of  the  dura  mater  of  the  brain,  with,  which  it  is  usually 
concurrent.  It  has  generally  been  observed  in  the  same  class  of  persons, 
general  paralytics  and  drunkards.  It  may  occur  at  any  part  of  the 
cord,  or  it  may  be  limited  to  the  cer\acal  region,  producing  corresponding 
symptoms,  but  it  is  rarel}^  recognized  before  death  and  is  an  extremely 
rare  finding. 

Diagnosis. — The  superaddition  to  the  symptoms  of  spinal  caries  of 
those'  detailed  as  characteristic  of  spinal  pressure  determines  at  once  the 
condition.  The  forms  arising  in  other  ways  are  to  be  distinguished  from 
amyotrophic  lateral  sclerosis,  syringomyelia,  and  tumors.  From  the  first  it 
can  be  differentiated  by  the  presence  of  the  characteristic  severe  pain  in  the 
neck  and  arms,  and  by  the  absence  of  bulbar  symptoms;  from  syringomyelia, 
by  the  absence  of  the  sensory  changes  peculiar  to  that  disease;  but  from 
tumors  in  the  same  locality  it  is  often  distinguished  with  difficulty  because 
the  pressvire  symptoms  in  both  are  the  same. 

Prognosis. — Cases  are  described  in  which  decided  improvement  has 
taken  ]5lace,  but  recovery  or  much  improvement  is  improbable,  when  the 
process  is  internal  as  well  as  external. 

Treatment. — The  usual  methods  of  treating  spinal  caries  b}-  exten- 
sion or  operation  constitute  the  treatment  of  the  external  forms  thus  arising. 
The  symptoms  are  to  be  relieved  by  appropriate  measures.  Baths,  iodid 
of  potassium,  counterirritation,  and  electricity  have  been  recommended. 

The  first  three  are  reasonable;  the  last  is  of  doubtful  value.  Iodid  of 
potassium  is  indicated  in  cases  of  syphilitic  origin.  JofEroy  recommends 
the  application  of  the  hot  iron  to  the  neck.  Paquelin's  cautery  woxild 
answer  the  purpose  as  well. 


SPINAL  LEPTOMEMNGITIS  889 

SPINAL  LEPTOMENINGITIS. 

Acute  Spinal  Leptomeningitis. 

Etiology. — As  a  disease  separate  and  distinct  from  epidemic  cerebro- 
spinal meningitis,  described  under  infectious  diseases,  acute  spinal  leptomen- 
ingitis may  occur: 

1.  As  the  result  of  tuberculosis,  its  most  common  cause.  When  thus 
occurring,  it  is  as  a  tuberculosis  infection  separate  and  independent  of  the 
tuberculosis  extension  in  Pott's  disease. 

2.  From  localization  of  the  poison  of  the  infectious  diseases,  as  syphilis 
and  typhoid  fever. 

3.  As  the  result  of  extension  by  contiguity. 

Morbid  Anatomy. — The  pathological  changes  are  similar  to  those  of 
epidemic  cerebrospinal  meningitis.  Injection,  accumulation  of  fluid  in  the 
piaarachnoid  space,  either  a  serofibrinous  or  a  ptirulent  exudate,  round- 
cell  infiltration,  and  finallj'-  thickening  of  the  membrane,  all  are  more  or 
less  in  evidence.  As  determined  by  the  position  of  the  body,  the  fluid 
exudate  tends  to  gravitate  downward  or  toward  the  posterior  aspect.  Not 
infrequently  the  morbid  process  more  or  less  extensively  invades  the  cord, 
especially  at  its  peripheral  portions,  producing  a  meniigomyelitis. 

Symptoms. — The  symptoms  are  those  of  the  disease  with  which  the 
meningitis  is  associated,  in  addition  to  fever  and  such  other  symptoms  as 
are  the  result  of  vascular  derangement  and  mechanical  interference.  These 
have  already  been  detailed  under  cerebrospinal  meningitis,  including  pain 
in  the  hack  of  varying  severity,  stiffness,  sensitiveness  of  the  spine,  symptoms 
of  irritation  of  nerve  trunks,  and  disturbances  of  sensation.  The  reflexes 
may  be  increased.  Kemig's  sign  of  "flexion  contraction"  at  the  knee- 
joint,  described  in  connection  with  cerebrospinal  fever,  shoidd  be  looked 
for.  Examination  of  the  fluid  obtained  by  lumbar  puncture  is  of  diag- 
nostic value. 

Paralytic  symptoms  are  a  late  and  also  a  rare  development.  At  such 
time  the  reflexes  are  sometimes  diminished  or  abolished  on  account  of  the 
destructive  involvement  of  nerve-roots  or  of  the  spinal  cord.  The  urinary 
and  bowel  functions  are  sometimes  deranged. 

Diagnosis. — The  diagnosis  of  simple  acute  meningitis  in  association 
with  the  infectious  diseases  should  not  be  too  hastily  made,  because  of  its 
simulation  by  these  diseases.  Such  simulation  is,  however,  less  common 
with  spinal  meningitis  than  with  cerebral.  Here,  as  in  cerebral  meningitis, 
the  etiological  factor  may  help  us  out;  while,  on  the  other  hand,  given  the 
disease,  the  special  variety  present  cannot  always  be  told.  The  tubercu- 
lous form  is  most  easily  recognized,  because  of  possible  pre-existing  symptoms 
of  the  disease.  Stiffness  and  pain  in  the  back  are  not  so  distinctive  as 
hyperesthesia  and  pain  in  distant  parts  supplied  by  nerves  from  the  seat 
of  special  spinal  involvement.  Again,  cases  of  spinal  meningitis  have  been 
found  on  the  autopsy  table  in  which  no  symptoms  were  recognized  during 
life. 

Prognosis. — This  is  generally  unfavorable  in  all  forms..  Recovery  may 
occur  in  the  cerebrospinal  form  if  Flexner's  serum  is  used  early,  especially 
when  the  disease  is  secondary  to  the  infectious  diseases. 


890  DISEASES  OF  THE  NERVOUS  SYSTEM 

Treatment. — This  is  mainly  symptomatic,  and  the  details  are  those 
given  under  the  head  of  cerebrospinal  meningitis. 

Chronic  Spinal  Leptomeningitis. 

Etiology. — So  rare  is  primary  chronic  meningitis  that  its  existence  as 
a  separate  disease  may  be  doubted.  It  may,  however,  remain  as  a  remnant 
of  an  acute  inflammation,  especially  of  epidemic  meningitis.  The  possibilit}^ 
of  its  occurrence  secondary  to  chronic  disease  of  the,  cord,  such  as  tabes 
dorsalis,  is  admitted,  but  it  then  almost  never  gives  rise  to  symptoms.  It 
is  a  possible  consequence  of  syphilis  and  alcoholism. 

Morbid  Anatomy. — The  distinctive  morbid  change  would  be  a  thicken- 
ing and  opacit}^  of  the  membrane,  and  adhesions  between  the  dura,  and 
arachnoid,  localized  or  general.  Certain  white  cartilaginous  plates  some- 
times found  on  the  posterior  surface  of  the  spinal  arachnoid  are  not  to  be 
regarded  as  inflammatory. 

Symptoms. — The  symptoms  would  be  those  described  in  connection 
with  the  acute  form,  milder  in  degree  and  less  definite.  In  fact,  the  diag- 
nosis is  rarely  made.  A  long-continued,  otherwise  inexplicable  stiffness  in 
the  trunk  and  extremities  would  justify  suspicion. 

Treatment. — This  is  symptomatic.  Counterirritation  would  natiu-ally 
be  indicated  if  the  diagnosis  be  made;  Paquelin's  cautery  is  the  best  in- 
striunent  for  the  purpose.  Antisyphilitic  treatment  should  be  used  if 
syphilis  be  suspected. 

HEMORRHAGE  INTO  THE  SPINAL  MEMBRANES. 

Synonyms. — Hematorrhachis;  Meningeal  Apoplexy. 

Hemorrhage  may  take  place  between  the  dura  mater  and  its  bony 
column,  extrameningeal,  or  mthin  the  dura  mater,  intrameningeal.  A 
third  variety  of  spinal  hemorrhage,  medullary,  into  the  substance  of  the 
cord,  is  described  elsewhere. 

Etiology. — Extrameningeal  hemorrhage  is  almost  invariably  the  result 
of  trauma,  such  as  concussion  or  fracture  of  the  spinal  column,  puncture, 
or  gunshot  wound.  The  blood  comes  from  the  rich  plexus  of  veins  that 
surrounds  the  dura.  A  considerable  amount  of  blood  may  be  thus  effused 
without  compressing  the  cord.  An  aneiu-j'sm  may  burst  into  the  spinal 
canal  with  fatal  consequences. 

Intrameningeal  hemorrhage  is  rare,  and  is  naturally  more  limited,  as 
are  the  sources  of  the  hemorrhage.  Punctiform  heraorrhages,  such  as  occur 
in  cerebrospinal  meningitis,  are  possibh'  of  little  significance.  Intramenin- 
geal hemorrhages  occur  sometimes  in  connection  with  the  infectious  dis- 
eases, and  William  Osier  observed  two  such  cases  in  malignant  smallpox, 
while  they  have  been  found  after  death  from  con\Tilsive  diseases,  such  as 
epilepsy,  tetanus,  and  str\-chnin  poisoning.  So,  also,  in  ventricular  apo- 
plexy blood  in  transit  from  the  fourth  ventricle  into  the  meninges  is  not  a 
ven.-  rare  finding.  Aneurj'sm  of  the  basilar  or  vertebral  arteries  is,  however, 
the  most  frequent  cause  of  this  form  of  hemorrhage. 

Symptoms. — The  symptoms  in  both  varieties  are  those  of  pressure  on 


AFFECTIONS  OF  CORD  891 

the  cord,  and  may  be  slight  and  scarcely  recognizable,  or  decided,  with 
resulting  paralysis  and  pain  on  the  one  hand,  or  anesthesia  on  the  other. 
The  symptoms  are  as  sudden  as  is  usually  the  event  which  causes  them. 
Sometimes,  however,  the  extravasation  is  slower  and  the  symptoms  are'  cor- 
respondingly gradual  in  their  appearance.  The  absence  of  all  cerebral 
symptoms  from  a  complex  including  the  above  points  to  spinal  rather  than 
cerebral  hemorrhage. 

The  extent  of  the  paralysis  and  the  other  nervous  symptoms  depends  on 
the  seat  of  the  hemorrhage.  If  in  the  lumbar  region,  the  legs  are  alone 
involved,  the  lower  deep  reflexes  may  be  absent,  and  the  functions  of  bladder 
and  rectum  are  impaired.  If  in  the  thoracic,  there  may  be  complete  para- 
plegia, while  the  reflexes  are  retained,  and  there  may  be  girdle  pains. 
Herpes  may  be  present.  If  in  the  cervical  region,  arms  or  legs  may  be 
paralyzed,  and  there  may  be  pain  or  anesthesia  in  the  upper  extremities 
and  neck.  Embarrassed  breathing,  stiffness  of  the  muscles  of  the  neck, 
and  even  pupillary  symptoms  may  be  added  when  the  hemorrhage  is  thus 
situated. 

Diagnosis. — The  diagnosis  is  based  on  the  absence  of  brain  symptoms 
in  connection  with  the  suddenness  of  the  symptoms  due  to  the  disease  and 
the  history  of  possible  cause. 

Prognosis. — In  certain  cases  in  which  the  hemorrhage  is  small,  con- 
traction and  absorption  of  the  clot  may  take  place,  and  the  symptoms  may 
pass  away.  In  others  the  hemorrhage  is  fulminating  and  death  foUows 
early  from  involvement  of  the  medulla  oblongata  in  the  pressure.  In 
intermediate  states  there  is  corresponding  improvement. 

Treatment. — Conditions  favoring  the  arrest  of  hemorrhage  and  the 
absorption  of  blood  should  be  secured.  Absolute  rest  is  most  important. 
If  symptoms  remain  permanent,  without  aggravation,  iodid  of  potassium 
may  be. used  to  promote  absorption,  and  the  usual  measures  intended  to 
restore  muscular  and  nervous  power,  such  as  massage,  baths,  and  electricity, 
should  b©  employed. 


AFFECTIONS  OP  THE  SUBSTANCE  OF  THE  CORD. 

General  Considerations. 

Two  separate  sets  of  pathological  changes  occur  in  the  substance  of  the 
spinal  cord.  In  one  they  are  confined  with  marked  constancy  to  certain 
definite  areas  which  have  precise  functions  residing  in  "systems  of  fibers," 
so  that  the  clinical  phenomena  of  the  disease  are  exactly  defined.  These 
affections  are  called  systemic  diseases.  They  include  such  as  tabes  dorsalis, 
an  affection  of  the  posterior  column;  amyotrophic  lateral  sclerosis,  a  disease 
of  the  lateral  columns  and  anterior  horns.  Why  certain  definite  areas  of 
the  cord  are  especially  involved,  and  why  this  peculiar  selective  systemic 
implication,  we  do  not  know  any  more  than  we  know  why  certain  poisons, 
such  as  curare,  strychnin,  and  lead,  select  certain  tissues  for  their  operation. 

In  the  second  group  there  is  no  such  limitation  of  area  invaded,  but  the 
cord  in  its  entire  transverse  section  is  involved  in  one  large  focus,  or  it  is 
involved  in  several  foci  separated  by  areas  of  sound  tissue.     In  this  group 


892  DISEASES  OF  THE  NERVOUS  SYSTEM 

arc  included  acute  and  chronic  diffuse  inflammations,  the  hemorrhages 
and  traumatic  lesions,  multiple  sclerosis,  etc.  These  are  the  non-systemic 
diseases.  Since,  in  the  diffuse  affections,  all  the  parts  involved  in  the 
systemic  lesions  are  also  affected,  the  symptoms  of  the  latter  are  found 
associated  with  those  growing  out  of  the  diffuse  lesion.  The  diagnosis 
arrived  at  by  a  study  of  these  symptoms  is  still,  however,  mainly  a  "topical " 
one,  for  it  is  an  important  fact  growing  out  of  the  functions  of  the  cord 
that  all  diseases  involving  certain  areas  jjroduce  the  same  symptoms,  whence 
we  infer  the  seat  of  the  lesion  rather  than  its  nature  or  exact  cause.  This 
may,  however,  be  determined  with  a  varying  degree  of  certainty  from  other 
symptoms. 

A  ftirther  peculiarity  of  all  diseases  of  the  substance  of  the  cord  is  that 
its  symptoms  are  commonly  bilateral.  This  depends  upon  two  causes: 
first,  the  fact  that  the  two  halves  of  the  cord  are  in  such  close  proximity  that 
almost  any  cause  of  a  violent  kind,  such  as  hemorrhage,  aff'ecting  one  half, 
must  also  extend  its  influence  to  the  other;  and,  second,  the  cause  of  system 
diseases  commonly  select  corresponding  parts  in  two  halves  of  the  cord  for 
their  operation. 

Again,  symptoms  vary  according  as  the  lesion  affects  the  conducting 
path  in  the  substance  of  the  cord,  to  and  from  the  brain,  or  a  portion  of  the 
peripheral  system  of  fibers  within  or  without  the  spinal  canal.  The  symp- 
toms are  accordingly  known  as  "central,"  and  as  "root"  symptoms. 

SECONDARY  SYSTEMIC  DEGENERATIONS  OF  THE 
SPINAL  CORD. 

Very  important  in  connection  ^^dth  ner^'ous  diseases  is  the  subject  of 
secondary  degenerations.  These  succeed  cerebral  lesions  and  lesions  in 
the  spinal  cord  itself.  They  depend  upon  the  fact,  several  times  referred 
to,  that  a  trophic  influence  is  exerted  by  ganglion  cells  upon  the  fibers 
originating  from  them,  so  that  the  latter  degenerate  when  the  conduction 
of  the  trophic  influence  is  interrupted  or  when  the  trophic  ganglion  cells  are 
destroj'cd.  For  motor  fibers  such  ganglion  cells  exist  in  two  situations — 
in  the  motor  areas  of  the  cortex  cerebri  and  in  the  anterior  comua  of  the 
spinal  cord.  The  former  exert  on  the  motor  fibers  arising  from  them  a 
trophic  influence  which  extends  down  the  cord  as  far  as  the  latter.  For 
sensory  fibers  in  the  cord  the  trophic  infiuence  resides  in  cells,  probably  on 
the  posterior  spinal  root  ganglia,  and  also  ganglion  cells  in  the  posterior 
gray  matter.  The  fibers  of  the  lateral  cerebellar  column  in  the  periphery 
of  the  cord  arise  in  the  cells  of  the  column  of  Clarke,  or  posterior  vesicular 
column — the  group  of  cells  in  the  inner  part  of  the  neck  of  the  posterior  horn. 

Secondary  Degeneration  in  the  Spinal  Cord  after  Cerebral  Lesions. — 
If  there  be  disease  in  the  motor  area  of  the  cortex  or  in  any  part  of  the 
motor  tract  in  the  brain — that  is,  in  the  motor  fibers  of  the  corona  radiata, 
the  internal  capsule,  the  crus,  or  the  pons — interrupting  conduction,  a 
secondary  degeneration  of  the  motor  fibers  takes  place  below  in  the  related 
pyramidal  tracts,  anterior  on  the  same  side  of  the  cord,  lateral  on  the  oppo- 
site side,  as  far  as  the  anterior  cornua  of  the  gray  matter.  In  many  cases 
there  is  slight  degeneration  in  the  lateral  tract  on  the  same  side  as  far  as  the 


DEGENERATIONS  OF  THE  SPINAL  CORD 


893 


lumbar  region,  showing  that  some  fibers  of  each  anterior  pyramid  find  their 
way  to  the  lateral  tract  on  the  same  side.  The  relative  proportion  of  the 
crossed  lateral  fibers  and  the  anterior  fibers  that  remain  uncrossed  varies 
wdthin  limits.  In  cases  in  which  no  anterior  pyramidal  tracts  exist — that 
is,  where  all  the  fibers  pass  over  to  the  lateral  column  of  the  opposite  side — 
there  is  no  descending  degeneration  of  the  anterior  column. 

Secondary  Degeneration  of  the  Spinal  Cord  after  Transverse  Lesion  of 
the  Cord  Itself. — If  a  lesion  be  seated  in  any  part  of  the  cord  afifecting  more 
or  less  its  transverse  section,  the  interruption  of  conduction  in  these  fibers 
is  also  followed  by  secondary  degeneration,  which  may  be  traced  in  two 
directions  upward  and  downward,  ascending  and  descending.  Such  lesions 
may  be  transverse  myelitis,  compression  of  the  spinal  cord,  and  tumors — 
any  lesion,  in  fact,  involving  the  whole  of  the  cord. 


Fig.  148. — Secondary  Descending  Degeneration  of  the  Pyramidal  Tracts  in  a  Primary  Lesion 

of  the  Left  Half  of  the  Cerebrum — {after  Erb.) 

The  lateral  pyramid  tract  of  right  half  is  degenerated  down  to  the  lowest  part  of  the  lumbar 

region.     1-8.    The  anterior  pyramid  tract  of  left  liaU  is  degenerated  to  beginning  of  lumbar 

enlargement. 


The  descending  degeneration  of  the  pyramidal  tract  is  like  the  descend- 
ing degeneration  after  cerebral  lesions,  except  that  after  spinal  lesions  the 
degeneration  of  the  pyramidal  tract  is  usually  more  extensive;  as  the  trans- 
verse disease  affects  the  pyramidal  tract  on  the  two  sides,  the  secondary 
descending  degeneration  will  affect  both  lateral  pyramidal  tracts  below  the 
seat  of  lesion.  The  ascending  secondary  degeneration  developing  upward 
from  the  seat  of  lesion  affects  the  columns  of  Goll — i.  e.,  the  posterior 
median  columns — and  the  columns  of  Burdach — i.  e.,  the  posterior  lateral 
columns  and  the  lateral  cerebellar  tracts  on  the  periphery  of  the  lateral 
columns,  because  the  conduction  in  those  parts  which  receive  their  trophic 
influence  from  lower  cells  is  interrupted.  The  ganglionic  cells  which  act 
trophically  on  the  fibers  of  Goll  are  probably  in  the  gangha  on  the  posterior 
roots.     The  lateral  cerebellar  tracts  share  in  the  ascending  degeneration. 


894 


DISEASES  OF  THE  NERVOUS  SYSTEM 


because  they  are  cut  off  from  the  cells  of  the  column  of  Clarke,  and  when  this 
occurs  or  these  cells  are  destroyed,  such  degeneration  may  be  traced  up- 
ward into  the  restiform  bodies.  Fig.  149  shows  secondary  ascending  and 
descending  degeneration  of  the  cord  as  occurring  after  transverse  section 
in  the  upper  thoracic  region. 

Clinical  Effect  of  the  Secondary  Degenerations. — This  is  disputed,  Charcot 
and  some  of  the  French  clinicians  ascribing  to  them  the  contractures  and 
increase  of  the  tendon  reflexes  in  the  paralyzed  limbs  of  hemiplegia,  while 
Strumpell  and  others  thinly  they  have  no  clinical  import.     It  is  more  prob- 


FiG.  149. — Diagram  of  Descending 
Degeneration  of  the  Pyramidal 
Tracts  Due  to  a  Lesion  in  the  left 
Internal  Capsule — (after  Edingcr). 


Burdach—  --<--i-^,^ GoU 


Fig.  150. — Secondary  Ascending 
and  Descending  Degeneration  in  a 
Transverse  Section  of  the  Upper 
Dorsal  Region — [after  Slriimpell). 

The  columns  of  GoU  and  the  direct 
cerebellar  tracts  are  degenerated  up- 
ward, shown  in  i  and  2,  the  anterior 
and  lateral  pyramidal  tracts  down- 
ward, as  in  3  and  4. 


able  that  the  symptoms  are  caused  by  an  interruption  of  the  nerve-fibers 
and  that  the  sclerotic  tissue  in  the  degenerated  tracts  produces  no  clinical 
signs  of  disease. 

Secondary  Degeneration  in  the  Spinal  Cord  after  Injuries  of  the  Cauda 
Equina. — After  fractures,  caries,  or  other  injtuies  to  the  lower  lumbar 
vertebras  or  sacrtun  producing  injtuy  to  the  cauda  equina,  or  as  the  result 
of  new-growths  in  this  region,  a  secondary  ascending  degeneration  takes 
place  in  the  cord  after  the  rupttue  of  continuity.  Tlus  is  due  to  involvement 
of  the  posterior  nerve-roots;  whence  the  degeneration  is  confined  to  the  poste- 
rior columns  of  the  spincil  cord,  and  in  its  distribution  it  resembles  closely  the 
state  of  the  cord  in  tabes  dorsalis.  In  the  lumbar  cord  all  the  posterior 
columns  are  degenerated  except  a  small  mediaii  zone  and  the  most  anterior 
portion.  The  ascending  degeneration  grows  smaller  as  we  ascend,  and 
finally  is  confined  in  the  cer\'ical  cord  to  the  regions  of  the  columns  of  GoU, 


DISTURBANCES  OF  THE  CIRCULATION  OF  SPINAL  CORD         895 

which  Include,  in  part  at  least,  the  prolongation  of  the  fibers  from  the  root 
zones  of  the  lumbar  and  sacral  cord. 

Acute  Affections  of  the  Spinal  Cord. 

DISTURBANCES  OF  THE  CIRCULATION  OF  THE  SPINAL 
CORD. 

Congestion. — From  the  standpoint  either  of  chnical  observation  or 
postmortem  examination  but  little  is  known  of  the  phenomena  of  con- 
gestion of  the  cord  as  differentiated  from  inflammation.  It  is  a  well- 
known  fact  that  active  hyperemia  may  partly  disappear  after  death.  Con- 
gestion of  the  vessels  is  found  under  so  many  conditions  that  a  diagnosis 
of  inflammation  based  on  this  finding  alone  would  not  be  justifiable. 

Anemia  of  the  cord  has  been  studied  clinically  and  experimentally. 
The  phenomena  of  paraplegia  which  succeed  profuse  hemorrhages  as  of 
the  uterus  postpartum,  and  from  the  stomach,  are  fairly  ascribable  to  anemia 
of  the  cord. 

This  is  confirmed  by  some  experiments  of  Stenson,  who  compressed 
the  abdominal  aorta  of  an  animal  with  the  effect  of  causing  almost  imme- 
diate paralysis  of  the  extremities;  and  of  C.  A.  Herter,  at  Johns  Hopkins 
Hospital,  in  which  paraplegia  supervened  a  few  minutes  after  the  appli- 
cation of  a  ligature  to  the  aorta,  followed  more  slowly  by  paralysis  of  the 
sphincters.i  Wthin  36  hours  there  were  marked  changes  in  the  ganglion 
cells  of  the  anterior  horns  in  the  lumbar  segment,  and,  later,  signs  of  soft- 
ening. Within  14  days  contracture  of  the  limbs  set  in  with  atrophy  of  the 
muscles  and  with  fibrillar  twitchings.  Similar  results  have  followed  the 
experiments  of  others  on  animals.  Obstruction  of  the  aorta  by  thrombi 
and  emboli  has  been  followed  by  similar  clinical  phenomena.  In  intense 
degrees  of  general  anemia,  such  as  is  found  in  pernicious  anemia,  the  cord 
is  more  frequently  affected.  Observations  showing  that  the  posterior  and 
lateral  columns  are  involved  in  pernicious  anemia  are  numerous. 

Embolism  and  thrombosis  of  the  spinal  arteries  have  been  produced 
experimentally,  with  resulting  choreiform  movements.  Embolism  of  the 
smaller  vessels  possibly  occurs  in  connection  with  endocarditis.  Endarteri- 
tis or  its  results  are  frequently  found  postmortem  in  syphilitic  subjects  as 
a  nodular  periarteritis  or  endarteritis,  sometimes  associated  with  gummatous 
tumors  of  the  meninges;  and  as  an  endarteritis  obliterans  with  thickening 
of  the  intima  and  consequent  narrowing  of  the  lumen,  involving  chiefly 
the  arteries  of  medium  and  larger  size.  Sudden  paralysis  of  spinal  origin 
is  likely  to  be  from  thrombosis  of  the  vessels  of  the  cord.  Miliary  aneurysm 
and  aneurysm  of  the  larger  vessels  of  the  spinal  cord  are  very  rare. 

Hemorrhage  into  the  Substance  of  the  Cord. 

Etiology. — Hematomyelia  is  a  rare  event.  That  it  ever  occurs  primarily 
independent  of  disease  is  reasonably  questioned.  Its  possibility  must, 
however,  be  admitted,  at  least,  as  the  result  of  traumatic  casues,  such  as 


896  DISEASES  OF  THE  NERVOUS  SYSTEM 

falls.  Great  xjhysical  exertion  is  another  possible  i)rimar\-  cause;  so  are 
cold  and  exposure  and  tetanic  and  other  convulsions.  Repeated  coitus 
is  mentioned  by  Gowers  as  having  been  followed  Ijy  hemorrhage  in  the  gray 
substance  at  the  top  of  the  bvdbar  enlargement,  and  this  cause  may  have 
operated  in  a  patient  of  Tyson's  who  was  suddenly  seized  with  a  para- 
plegia during  one  of  a  number  of  closely  repeated  acts  of  coition  and  while 
in  vigorous  health.     Secondary  hemorrhage  is  more  frequent. 

Morbid  Anatomy. — The  cord  may  be  distended,  infiltrated,  or  lacer- 
ated by  the  hemorrhage  escaping  into  the  meninges;  if  not  too  copious, 
the  bleeding  may  be  limited  to  the  gray  matter  and  may  extend  up  and 
down  the  cord  to  a  considerable  extent.  The  blood  undergoes  the  usual 
changes  after  effusion,  i.  e.,  coagulates,  becomes  darker  hued,  then  yellow, 
and,  finally,  at  times,  the  seat  of  the  hemorrhage  is  occupied  by  a  cyst 
while  numerous  hematoidin  crystals  will  be  found  in  the  residue.  The 
blood  may  remain  liquid  for  a  long  time. 

Symptoms. — If  the  hemorrhage  is  in  the  lumbar  enlargement  or  the 
thoracic  region  of  the  spinal  cord,  the  effect  is,  as  a  rule,  sudden  paraplegia. 
If  the  cervical  part  of  the  cord  is  the  seat  of  the  hemorrhage,  the  arms  as 
well  as  the  legs  are  involved,  and  there  may  be  embarrassed  respiration, 
and  possibly  sharp  pain  in  the  extremities  supplied  by  the  nerx^es  passing 
to  the  cord  at  the  seat  of  the  effusion.  Loss  of  sensation  follows  later, 
while  the  reflexes  also  disappear.  Softening  often  develops  as  a  con- 
sequence of  the  irritative  presence  of  the  clot,  and  then  follow  its  usual 
symptoms,  including  trophic  changes  a.nd  fever. 

Diagnosis. — This  is  based  upon  the  suddenness  of  the  consequent 
events — acute  pain  and  paraplegia — under  the  etiological  conditions 
described,  viz.,  trauma,  and  other  causes.  Hemorrhage  into  the  spinal 
meninges  is,  of  course,  equally  sudden  or  nearly  so,  but  the  symptoms 
of  injury  to  the  cord  are  less  prominent,  and  there  is  little  or  no  fever. 
In  meningeal  hemorrhage  the  pain  is  more  severe  and  symptoms  of  irrita- 
tion are  more  likely  to  precede  the  paralysis,  while  the  paralytic  symptoms 
are  less  persistent. 

Prognosis. — The  accident  is  rapidly  fatal  in  the  severest  cases.  In 
others  paralysis  may  exist  for  a  long  time  or  may  be  permanent.  In 
others  there  is  slow  but  persistent  improvement,  and  the  patient  may 
even  recover.  Hemorrhage  into  the  cervical  region  of  the  cord  is  more 
serious  because  the  center  of  the  phrenic  nerve  which  innervates  the  dia- 
phragm is  likely  to  be  invaded.  The  presence  of  trophic  changes  renders 
the  prognosis  as  to  recovery  more  unfavorable. 

Treatment. — This  is  identical  with  that  for  hemorrhage  into  the  mem- 
branes. Absolute  rest  is  the  primary  essential  condition.  Ice  may  be 
applied  to  the  spine  over  the  seat  of  the  hemorrhage,  and  leeches  or  wet- 
cups  in  the  same  locality,  although  the  benefit  obtained  by  these  measures 
is  somewhat  doubtful. 

If  the  case  is  not  immediately  fatal,  improvement  is  likely  to  follow 
the  contraction  of  the  clot,  as  in  cerebral  hemorrhage.  Morphin  to  keep 
the  patient  quiet  is  indicated.  Later  muscular  nutrition  should  be  kept 
up  by  massage  and  electricity. 


DIFFUSE  MYELITIS  897 

DIFFUSE    MYELITLS    (Acute    and    Chronic). 

Synonyms. — Myelitis;  Transverse  Myelitis. 

Definitions. — The  line  of  demarcation  symptomatically  between 
acute,  subacute,  and  clironic  myelitis  is  not  sharp,  but  the  term  acute 
is  applied  to  that  form  of  inflammation  in  which  the  symptoms  come  on 
suddenly.  When  requiring  from  two  to  six  weeks  for  their  development, 
it  is  called  subacute.  When  a  still  longer  time  elapses  before  the  symp- 
toms reach  a  decided  degree  of  intensity,  it  is  chronic.  At  the  same  time 
it  is  plain  that  no  very  sharp  line  of  demarcation  can  be  drawn  between 
these  forms.  When  the  whole  thickness  of  the  cord  is  involved  to  a  small 
vertical  extent — a  common  form — it  is  said  to  be  transverse;  if  an  ex- 
tensive area,  diffuse;  when  one  small  area,  focal;  when  many  foci,  con- 
tiguous or  distant,  it  is  disseminated.  Inflammation  of  the  gray  matter 
around  the  central  canal,  extending  into  the  intermediate  gray  substance, 
is  called  central  myelitis,  which  may  be  parenchymatous  and  interstitial. 

Etiology. — ^The  cause  is  often  undiscoverable.  There  is  an  occasional 
hereditary  tendency  to  it.  It  may  occur  at  any  age,  but  is  more  common 
in  adult  males.     It  may  result : 

1.  From  repeated  exposure  to  wet  and  cold,  or  from  overexertion, 
or  from  both  combined. 

2.  Rarely  from  the  acute  infectious  diseases,  as  smallpox,  typhoid 
fever,  or  puerperal  fever. 

3.  From  syphilis,  either  as  the  direct  result  of  primay  infection, 
or  secondarily  from  invasion  of  the  cord  by  syphilitic  tumors;  the  former 
appears  within  a  few  months  or  several  years  after  the  primary  inoculation, 
the  latter  as  a  late  manifestation,  but  a  macroscopic  gumma  of  the  spinal 
cord  is  a  very  rare  finding. 

4.  From  tumors  other  than  syphilitic. 

5.  From  injuries  to  the  spinal  column,  especially  fractures,  and  from 
caries  of  the  vertebrae.  It  is  extremely  difficult,  nay,  often  impossible, 
to  distinguish  the  inflammatory  results  of  tumors  and  caries  from  those 
of  compression;  and,  indeed,  the  symptoms  due  to  tumors  and  caries  are 
chiefly  the  result  of  pressure. 

Morbid  Anatomy. — The  seat  of  invasion  varies,  the  upper  half  of  the 
thoracic  cord  being  most  frequently  involved,  but  there  may  be  cervical 
myelitis  or  lumbar  myelitis.  There'may  be  a  central  focus  and  numerous 
small  foci  in  the  vicinity.  The  extent  of  the  involvement  varies  at  different 
levels.  The  softer  reddish  conditions  indicate  the  more  acute  stage;  the 
harder,  grayer,  and  more  contracted,  the  chronic  stage — sclerosis. 

Considerable  experience  is  necessary  to  be  able  to  recognize  the  changes 
in  many  cases  of  myelitis.  The  separation  of  the  process  into  different 
stages  is  difficult  or  impossible.  To  the  untrained  naked  eye  the  cord 
often  appears  quite  normal.  The  expert  examiner  may  recognize  by 
touch  that  over  a  certain  extent  the  cord  may  be  either  softer  or  harder 
and  firmer.  On  section,  the  substance  of  the  cord  rises  up  more  than 
in  the  normal  state,  the  contour  of  the  gray  matter  is  less  distinct,  and 
sometimes  has  a  hyperemic,  reddish  coloring,  while  the  white  matter  is 
reddish-gray.     There  may  be  minute  hemorrhages.     The  consistence  may 


898  DISEASES  OF  TUE  NERVOUS  SYSTEM 

be  diffluent,  constituting  red  softening.  These  foci  of  hemorrhage  ma\' 
give  place  to  cavities.  The  gray  matter  may  be  involved  throughout 
considerable  extent.  The  meninges  may  be  involved,  producing  myelo- 
meningitis. 

These  changes  become  much  more  evident  if  the  cord  is  allowed  to 
remain  in  hardening  fluid,  and  only  after  hardening  can  the  lesions  be 
satisfactorily  studied. 

Microscopic  examination  of  the  fresh  cord  reveals  nvunerous  granular 
fatty  cells.  Blood-disks  and  leukocytes  may  be  present,  the  latter  rarely 
in  quantity  to  justify  the  name  of  pus  or  abscess.  Thin  sections  stained 
by  carmine  give  a  very  different  picture  even  to  the  naked  eye,  the  dis- 
eased tissues  taking  on  the  darker  staining  because  of  their  greater  rich- 
ness in  neuroglia.  By  the  microscope  it  is  found  that  in  these  portions 
the  normal  nerve  tissue  has  partly  or  almost  wholly  disappeared.  In 
some  places  axis-cylinders  remain,  possibly  much  swollen,  and  having 
lost  only  their  medullary  sheaths;  in  others  the  nerve  tissue  has  disap- 
peared. The  changes  in  the  ganglion  cells  are  also  definite;  they  have 
lost  their  processes  and  are  rounder,  or  are  entirelj'  destroyed,  while  the 
increase  of  neuroglia  goes  on  pari  passu  with  the  destruction  of  the  proper 
nervous  matter.  The  neurogha  occupies  the  enlarged  meshes  caused 
by  the  disappearance  of  the  nervous  elements.  The  cells  of  the  neuroglia 
increase,  and  Deiters'  spider  cells  may  be  numerous.  The  granular  fatty 
cells  may  also  be  recognized,  especially  by  osmic  acid,  provided  no  al- 
cohol has  been  used  in  hardening.  The  blood-vessels  are  dilated  and 
distended,  and  their  walls  are  hyaline.  The  sum  of  these  changes  con- 
stitutes sclerosis. 

In  localized  acute  myelitis  affecting  the  white  and  gray  matter  after 
injury  the  cord  is  swollen,  the  pia  injected  and  soft,  and  on  cutting  the 
membrane  an  almost  diffluent  fluid  may  escape.  In  less  degree  the  ap- 
pearances first  described  are  present.  It  is  these  cases  which  arise  par- 
ticularly b}^  invasion  from  without  or  from  compression  in  which  the 
white  matter  is  involved. 

Localized  areas  of  softening  with  blood  accumulation  constitute  red 
softening.  Abscess  of  the  substance  of  the  cord  may  occur,  and  at 
least  nine  or  ten  cases  have  been  reported.  Pus  forms  in  the  cord  in  con- 
siderable quantity  only  in  purulent  meningitis. 

Symptoms. — The  distinctive  symptoms  of  myelitis  may  be  preceded  by 
constitutional  distiu-bance,  including  headache  and  general  malaise,  and  even 
chill,  fever,  and  delirium.  A  temperature  of  107°  to  108°  F.  (41.7°  to  42.2° 
C.)  has  been  noticed.     These  symptoms  are,  however,  imusual. 

The  characteristic  symptoms  vary  greatly  with  the  part  of  the  cord 
involved,  and  no  picture  can  be  drawn  to  suit  such  difl'erences  of  locality. 
Striimpell,  therefore,  will  be  followed  to  describe  the  symptoms  more  or 
less  common  to  all  localities,  and,  after  this,  such  modifications  or  peculiar- 
ities of  these  as  enable  us  to  locate  more  precisely  the  process.  The  former 
include: 

I.  Symptoms  of  Motor  Paralysis. — They  are  the  most  conspicuous  and 
commonly  the  first  recognized  sign  of  developing  transverse  myelitis. 
Beginning  with  a  tired  feeling  in  one  or  both  legs,  followed  by  evident 


DIFFUSE  MYELITIS  899 

weakness  and  then  dragging,  the  paresis  continues  to  grow  until  the  patient 
is  totally  unable  to  make  any  active  movement  with  his  legs.  This  implies 
that  the  lateral  columns  of  the  cord,  and  especially  the  posterior  part  of  the 
lateral  columns,  carrying  the  lateral  part  of  the  pyramidal  tract,  are  involved, 
cutting  off  the  motor  impulses.  In  some  instances  this  paralysis  occurs  very 
rapidly,  and  probably  is  from  occlusion  of  the  blood  vessels  of  the  cord.  The 
motor  paraplegia  can  occur  in  every  form  of  myelitis — lumbar,  thoracic,  or 
cervical;  but  in  the  first  two  the  upper  extremities  are  intact.  In  the 
cervical,  paralysis  of  the  upper  extremities  also  takes  place.  If  one  side  of 
the  body  is  involved  more  than  another,  it  implies  that  one  half  of  the  cord 
is  more  intensely  aflected. 

2.  Symptoms  of  Motor  Irritation.- — These  consist  in  spontaneous  twdtch- 
ings  of  the  muscles  of  the  paretic  limbs,  either  rapid  and  short  or  slow  and 
persistent.  They  occiu-  at  the  beginning  and  during  the  course  of  the  dis- 
ease, and  are  variously  severe.  It  is  not  always  easy  to  distinguish  them 
from  increased  reflexes,  hence  their  diagnostic  value  is  not  great.  Ataxia 
and  intention  tremor  may  occur  in  connection  with  involvement  of  the  upper 
extremities  and  in  the  convalescence  of  acute  cases,  but  thej^  are  vezy  rare. 

3.  Disturbances  0}  Sensibility.- — These  occur  in  marked  degree  much 
later  in  the  disease  than  the  motor  phenomena.  At  the  beginning  there 
may  be  numbness,  formication,  tingling,  and  even  girdle  sensations,  but 
severe  pain  is  rarely  present.  When  pain  is  present,  it  is  an  evidence  of 
involvement  of  the  vertebrse  or  meninges.  In  advanced  stages,  in  addition 
to  anesthesia,  there  may  be  paresthesia  and  striking  hyperesthesia.  The 
involvement  of  sensibility  probably  means  that  the  whole  transverse  area 
of  the  spinal  cord  is  intensely  affected. 

Disturbances  of  sensibility  are  useful  in  determining  the  segment  of  the 
cord  involved  because  the  lesion  corresponds  very  nearly,  or  sufficiently 
so  for  practical  purposes,  to  the  level  of  the  seat  of  the  modified  sensibility. 
Thus,  in  myelitis  of  the  lumbar  region  the  altered  sensation  extends  nearly 
to  the  umbilicus,  in  the  lower  thoracic  to  the  ensiform  cartilage,  in  the 
upper  thoracic  to  the  level  of  the  axiUffi,  while  in  the  cervical  the  sensi- 
bility of  the  upper  extremities  is  impaired.  Total  anesthesia  is  very  rare, 
but  is  present  when  the  transverse  lesion  is  complete. 

4.  The  Reflexes. — The  effect  of  myelitis  on  the  reflexes  varies  greatly 
with  the  seat  of  the  disease  and  the  degree  and  extent  of  the  lesion.  In 
the  very  incipiency  of  an  inflammation  of  the  cord  we  may  expect  aU  the 
reflexes,  cutaneous  and  tendon,  centering  in  the  part  involved  to  be  in- 
creased, but  with  the  progress  of  the  disease  the  effect  varies  greatly  and 
must  be  discussed  in  detail. 

(a)  Skin  Reflexes. — The  reflex  arcs  of  the  cutaneous  reflexes  are  not 
definitely  determined.  Their  connection  with  reflex  inhibitory  fibers  from 
above  is  to  be  remembered,  irritation  of  which  fibers  possibly  diminishes, 
and  interruption  of  which  possibly  increases,  the  sensitiveness  of  the  re- 
action. In  extensive  lumbar  myelitis  the  reflex  path  is  broken  and  the 
cutaneous  reflexes  of  the  lower  extremities  are  diminished,  running  about 
pari  passu  with  altered  sensibility.  In  thoracic  and  cervical  myelitis  the 
arc  for  the  lumbar  reflexes  is  intact,  and  if  the  reflex  inhibitory  influence 
is  removed,  these  skin  reflexes  may  even  be  increased.     Experience  shows, 


900  DISEASES  OF  THE  NERVOUS  SYSTEM 

however,  that  the  skin  reflexes  in  the  leg  may  be  diminished  even  in  dorsal 
or  cervical  myelitis,  in  which  event  there  must  be  loss  of  irritability  in  the 
fibers.  The  cremaster  reflex  has  its  arc  at  about  the  level  of  the  first  lum- 
bar nerve,  hence  its  loss  means  disease  there.  The  lower  abdominal  re- 
flex corresponds  to  the  lower  thoracic  cord  and  the  upper  to  the  level  of 
the  fourth  to  the  seventh  thoracic  vertebra.  There  is  much  need  for 
careful  study  on  the  behavior  of  the  cutaneous  reflexes,  as  this  subject  is 
far  from  being  fully  understood. 

(6)  Tendon  Reflexes. — The  reflex  arc  of  the  patellar  reflex  lies  at  about 
the  level  of  the  second  to  the  fourth  lumbar  segment  inclusive.  Hence 
the  knee-jerk  fails  in  disease  of  the  lumbar  cord  involving  the  lateral  part 
of  the  posterior  columns  and  the  anterior  comua  of  the  gray  matter.  The 
ankle  clonus  probably  has  its  reflex  arc  at  the  level  of  the  first  sacral  seg- 
ment. It  is  always  absent  in  extensive  disease  of  the  posterior  columns 
and  gray  matter  of  the  sacral  cord  in  this  vicinity.  The  absence  of  deep 
reflexes  of  the  lower  extremities  is,  therefore,  one  of  the  most  valuable  signs  of 
myelitis  of  the  lumbar  cord.  In  almost  all  inflammations  above  the  lumbar 
cord — that  is,  of  the  thoracic  and  cervical  portions — there  is  a  decided  in- 
crease in  the  tendon  reflexes  of  the  lower  extremity,  because  these  lesions 
destroy  the  reflex  inhibitory  influence.  When,  therefore,  alongside  of 
this  it  is  remembered  that  the  fibers  which  influence  the  condition  of  the 
tendon  reflexes  run  chiefly  in  the  lateral  columns  of  the  cord,  we  may  con- 
clude that  the  lateral  columns  are  involved.  In  myelitis  of  the  upper 
cervical  cord  the  tendon  reflexes  of  the  upper  extremities  are  often  in- 
creased. It  should  be  remembered  that  complete  or  nearly  complete 
transverse  lesion  of  the  cord  in  the  thoracic  or  cervical  region  may  cause 
a  loss  of  the  deep  reflexes  of  the  lower  limbs. 

5.  Disturbances  of  the  Bladder  and  Rectum. — These  are  common  in 
myelitis.  There  is,  first,  delay  in  micturition,  finally  accomplished  by 
extra  straining,  but  later  aU  power  to  empty  the  bladder  is  lost — the  de- 
trusor urines  is  paralyzed.  Still  later  the  sphincter  vesicae  is  paralyzed, 
and  then  there  is  incontinence  of  urine.  These  symptoms  occur  in  con- 
nection with  paralysis  in  any  part  of  the  cord.  The  ultimate  effect  is 
almost  invariably  a  cystitis,  the  result  partly  of  decomposition,  induced 
by  germs  introduced  through  repeated  catheterization,  even  when  most 
cautiously  conducted,  partly  by  the  entrance  of  germs  through  the  patu- 
lous sphincter.  Such  cystitis  has  also  been  ascribed  to  trophic  influence. 
To  the  cystitis  may  succeed  pyelitis  and  purulent  pyelonephritis. 

In  myelitis  there  is  at  first  obstinate  constipation,  followed  by  paralysis 
and  incontinence  of  feces.  This  symptom  does  not  give  any  information 
as  to  the  seat  of  the  myelitis.  Defecation  and  micturition  are  sometimes 
reflexly  aroused  in  abnormal  degree  when  there  is  increased  reflex  irrita- 
bility. Sexual  functions,  the  centers  of  which  probably  reside  in  the  sacral 
cord,  are  also  often  deranged  in  myelitis. 

6.  Trophic  Disturbances. — These  are  most  important  symptoms,  and 
valuable  also  in  diagnosis.  In  cervical  and  thoracic  myelitis  the  trophic 
centers  in  the  lumbar  cord  are  intact.  The  paralyzed  muscles,  therefore, 
do  not  atrophy  excessively,  though  the}'  may  be  somewhat  softened  from 
want  of  use.     They  retain  their  normal  electrical  excitability,  or  at  least 


DIFFUSE  MYELITIS 


901 


the  reactions  are  not  qualitatively  altered,  although  they  may  be  quanti- 
tatively. On  the  other  hand,  genuine  atrophy  and  the  presence  of  the  reac- 
tion of  degeneration  show  that  the  anterior  gray  cornua  or  the  fibers  of  the 
anterior  roots  of  the  lumbar  cord  are  involved;  in  the  upper  extremities 
they  show  that  the  same  portions  of  the  cervical  cord  are  involved.  Bed- 
sores are  among  the  trophic  phenomena,  the  possibility  of  the  occurrence 
of  which  should  always  be  vividly  present.  They  are  among  the  most 
unpleasant  and  most  unmanageable  symptoms,  yet  they  may  be  guarded 
against;  for,  although  favored  by  the  deranged  trophic  influence,  they  re- 
quire an  exciting  cause  such  as  pressure,  the  irritation  of  secretions,  or 
foreign  substances  to  originate  them.  They  occur  over  the  sacral  and 
gluteal  regions,  more  rarely  on  the  feet  and  inner  sides  of  the  knees.  The 
total  anesthesia  often  associated  with  advanced  stages  of  the  disease  co- 
operates to  permit  the  action  of  the  exciting  causes. 

Other  trophic  effects  often  met  are  drying  and  hardening  of  the  skin; 
glossy  skin,  also  thick  and  brittle  nails.  Vasomotor  disturbances  also  occur, 
producing  congestion  and  mottling,  and  there  may  be  slight  edema  of  the 
paralyzed  parts;  also  sweating,  which  may  be  localized.  The  temperature 
of  the  affected  limbs  may  be  lowered,  and  multiple  arthritis  may  occur. 

7.  Disturbances  in  the  area  of  distribution  of  the  cranial  nerves  seldom 
occur,  though  bulbar  symptoms  are  met  in  rare  cases  of  cervical  myelitis, 
when  the  process  has  extended  to  the  medtdla  oblongata.  Optic  neuritis 
and  pupillary  changes,  vomiting,  hiccough,  slow  pulse-rate  diminishing 
to  20  or  30,  dysphagia,  dyspnea,  and  syncope,  have  been"  obser\'ed  in 
cervical  myelitis. 

By  uniting  the  symptoms  detailed  and  their  mode  of  manifestation 
we  may  draw  conclusions  with  a  certain  degree  of  positiveness  as  to  the 
portion  of  the  cord  involved.  The  following  table  by  Morton  Prince  in 
Dercum's  **Text-book"  will  be  helpful: 


Lumbar  myelitis 


Cervical  m.yelitis 


Electrical  reaction. 


Bowels. 


Reflexes,  superficial. , 

Reflexes,  deep 

Priapism 


Pains  inlegs,  or  girdle  pains 
around  loins;  hyperesth& 
tic  zone  around  loins;  an^ 
esthesia  of  legs,  complett 
or  uneven  distribution. 

Of  legs 


Reaction  of  degeneration 
in  atrophied  muscles;  or, 
in  mild  cases,  quantita- 
tive diminution. 

Incontinence  from  paraly- 
sis of  sphincter. 


Incontinence  from  paraly- 
sis of  sphincter,  disguised 
by  constipation. 

Lost 


I.  Dorsal,  abdominal,  and 
intercostal  muscles,  ac- 
cording to  height  of  lesion. 
2.  Leg. 

Girdle  pain  and  hyperes- 
thetic  zone  between  ensi- 
form  cartilage  and  pubes. 


Of  dorsal  and  abdominal 
(and  intercostal  muscles, 
not  subject  to 
tion)  corresponding 
height  of  lesion;  sc 
times  mild  and  slow  ot  \ 
legs. 

R.  d.  in  dorsal  and  abdom- 
inal muscles;   slight  quan- 

'titative  changes  only  in 
legs  when  wasted. 

Retention,  or  intermittent 
incontinence  from  reflex 
action;  later  from  over- 
flow.     Cystitis    common. 

Involuntary  evacuation 
from  reflex  spasm,  or  con- 
stipation. 

Temporary  loss,  then  rapid 


Temporary  loss,  then  slow 
Often  present 


Hyperesthesia  and  pains  in 
certain  nerve  distributions 
of  arms;  below  this,  anes- 
thesia of  arms,  body,  and 
legs. 

Atrophy  of  neck  muscles 
(rare)  or  more  commonly 
of  arms. 


R.  d.  in  atrophied  muscles. 


;  as  in  dorsal  myelitis. 


Same  as  in  dorsal  myelitis. 
Same  as  in  dorsal  myelitis. 
Often  present. 


902  DISEASES  OF  THE  NERVOUS  SYSTEM 

Diagnosis. — The  difficulty  of  diagnosis  is  sometimes  very  great,  be- 
cause identical  symptoms  may  be  produced  by  other  diseases,  especially 
pressure  diseases  of  the  cord,  such  as  are  caused  by  tumors  or  hemorrhages, 
possible  conditions  which  must  be  carefully  sought. 

Landry's  acute  ascending  paralysis  and  multiple  neuritis  present  some 
striking  resemblances,  and  in  some  cases  Landry's  paralysis  is  due  to 
myelitis.  Both  Landry's  paralysis  and  multiple  neuritis  present  rapidly 
progressive  motor  paralysis,  but  though  sensor}'-  derangement  may  be  a 
late  development  in  myelitis,  it  is  still  a  symptom  belonging  to  it  rather 
than  to  Landry's  paralysis,  which  is  a  motor  affection,  while  the  trophic 
symptoms,  the  paralysis  of  the  bladder  and  rectum,  rapid  wasting,  elec- 
trical disturbances,  and  fever,  pertain  to  myelitis.  The  resemblance  to 
multiple  neuritis  is  closer.  In  this,  however,  anesthesia  is  less  complete, 
the  wasting  less  rapid,  and  bladder  and  rectum  involvement  seldom  present, 
and  the  parts  affected  are  in  nerve  distributions. 

Prognosis. — Almost  all  cases  of  myelitis  are  chronic  after  a  more  or  less 
acute  beginning,  seldom  lasting  less  than  a  year,  often  two  or  three  years 
and  even  longer.  The  term  acute  is  not,  therefore,  applied  in  its  ordinary 
meaning,  implying  rapid  course  and  early  termination,  but  it  is  used  to 
indicate  cases  which  develop  rapidly  to  their  acme  as  contrasted  with  those 
that  are  slow.  Even  these  cases  become  chronic.  There  are  many  who 
doubt  the  existence  of  a  myelitis  which  begins  in  a  chronic  form.  They 
hold  that  all  so-called  chronic  cases  of  myelitis  have  an  acute  commence- 
ment. Rapidl}^  developing  cases  passing  to  a  fatal  termination  in  from 
five  to  ten  days  may  occur,  but  are  rare.  Certain  cases,  after  reaching 
a  given  stage,  remain  as  to  symptoms  in  statuo  quo,  by  which  it  is  under- 
stood that  the  local  lesion  has  healed,  while  function  has  not  been  re- 
gained because  of  the  impossibility  of  restoring  the  normal  structure  of 
the  cord.  Remissions  and  improvements  are  less  infrequent.  Death  is 
usually  the  result  of  exhaustion,  although  it  may  resvilt  from  intercurrent 
disease. 

Treatment. — This  is  for  the  most  part  to  be  directed  to  the  relief  of 
symptoms,  no  curative  means  existing  beyond  what  nature  herself  pro- 
vides. In  cases  with  acute  onset  and  pain,  cups  may  be  applied  to  the 
back.  Even  in  sj'^philis  it  is  thought  by  some  useless  to  give  the  usual 
remedies,  but  it  is  safer  in  cases  of  suspected  disease  to  give  iodid  of  potas- 
sium in  ascending  doses  to  the  extent  permitted  by  the  stomach,  while 
the  mercurial  effect  should  be  brought  about  by  intmctions,  30  grains  (2 
gm.)  to  a  dram  (4  gm.)  of  mercurial  ointment  being  rubbed  in  daily  in 
different  parts  of  the  body,  care  being  taken  to  select  those  parts  having 
less  hair.  Salvarsan  may  be  used.  Tonics,  such  as  iron,  quinin,  and 
strj'chnin,  are  useful  in  this  as  in  other  prolonged  affections.  Hexamethyl- 
enamine  in  five-grain  doses  three  times  a  daj'  must  be  given  to  keep  the 
urine  sterile. 

The  most  painstaking  attention  must  be  given  to  the  skin  by  bathing 
with  alcohol  and  thoroughly  drying  after  all  washing,  in  order  to  prevent 
the  excoriations  which  are  often  the  beginnings  of  bed-sores,  while  the  irri- 
tating effects  of  the  excretions  must  be  carefully  watched,  and  if  cath- 
eterization is  necessary,  it  must  be  practised  with  the  closest  attention  to 


ACUTE  ASCENDING  SPINAL  PARALYSIS  903 

antisepsis.  It  may  even  be  desirable  to  keep  a  soft  catheter  permanently 
in  the  bladder,  to  which  a  long  tube  is  attached  and  the  bladder  thus  kept 
drained.  Should  cystitis  supervene,  the  bladder  is  to  be  washed  out  with 
aseptic  precautions.  When  possible,  the  rectum  should  be  emptied  by 
enema  rather  than  by  purgatives,  which  should  be  cautiously  used. 

Electricity  is  elaborately  directed  by  the  German  authors,  although 
they  admit  that  in  the  majority  of  instances  it  is  principally  a  diversion 
to  the  patient.  In  the  later  stages,  however,  of  the  forms  in  which  there 
is  atrophy  of  the  muscles,  some  advantage  may  be  expected.  The  con- 
stant current  is  most  highly  commended,  by  large  electrodes  placed  over 
the  vertebral  column,  and  a  moderate  stabile  current  or  slowly  labile  cur- 
rent is  passed  for  four  or  five  minutes  through  the  supposed  seat  of  the  dis- 
ease. Peripheral  galvanization  or  faradization  of  the  paralyzed  muscles 
and  nerves  should  also  be  employed.  Massage  is  useful,  perhaps  more  so 
than  electricity.     The  bladder  may  also  be  treated  by  electricity. 

The  bath  treatment  is  carried  out  to  various  degrees  of  elaboration. 
The  simple  tub-bath  with  warm  water  furnishes  the  easiest  form  and  may 
be  quite  useful,  at  a  temperature  of  85°  or  90°  F.  (24°  to  26°  C),  in  the 
cases  with  spastic  symptoms.  The  baths  should  be  at  first  limited  to  10 
or  15  minutes  three  or  four  times  a  week,  and  if  well  borne,  may  be  in- 
creased to  an  hour  daily.  The  water  may  be  impregnated  with  sodium 
chlorid,  using  either  the  sea-salt  or  common  salt,  from  4  to  6  pounds  of  the 
former  or  from  5  to  10  pounds  of  the  latter  to  the  bath.  When  the  patient 
is  able  to  travel  and  avail  himself  of  the  actual  sea-baths  they  may  be  ex- 
pected to  be  beneficial.  The  Hot  Springs  of  Arkansas  and  Virginia  in  this 
country  may  be  resorted  to.  In  Europe  the  thermal  waters  at  Rehme 
and  Nauheim  in  Hesse,  Ragatz,  in  Switzerland,  Teplitz  in  Austria,  Wild- 
bad  in  Wurtemberg,  Gastein  in  Salzburg,  Austria,  and  Wiesbaden  in  Baden 
are  among  those  recommended;  also  the  mud-baths  of  Carlsbad  and 
Marienbad  in  Bohemia  and  Elster  in  southern  Saxony. 


ACUTE  ASCENDING  SPINAL  PARALYSIS. 

Synonym. — Landry's  Paralysis. 

Definition. — A  symptom-complex  first  described  by  Landry,  in  1859, 
characterized  by  an  advancing  paralysis  beginning  in  the  lower  extremities, 
passing  upward  to  the  trunk  and  arms,  and  finally  to  muscles  supplied  from 
the  medulla  oblongata,  including  those  of  respiration;  sensibility  and 
bladder  and  rectum  control  remaining  intact. 

Etiology  and  Pathology .^ — It  is  most  common  in  men  between  20  and 
30,  and  usually  those  who  are  strong  and  healthy.  Cases  have,  however, 
been  seen  in  children  and  old  persons.  No  anatomical  lesions  pathogno- 
monic of  the  disease  have  been  shown  to  he  associated  with  it.  Hence  at- 
tempts have  been  made  to  classify  it  elsewhere,  and  H.  Oppenheim,  James 
Ross,  Neuwerk,  Barth,  and  others  regard  it  as  a  form  of  peripheral  neuritis, 
Ross  having  found  an  interstitial  form  confined  to  nerve  roots,  while 
Neuwerk  and  Barth  described  a  case  confined  to  peripheral  nerves.  Other 
carefully  studied  cases  failed  to  disclose  such  lesion.     In  some  cases  mye- 


904  DISEASES  OF  THE  XERVOUS  SYSTEM 

litis,  especially  poliomyelitis,  is  the  cause.  A  toxic  cause  seems  not  un- 
likely. It  is  quite  consistent  with  such  cause  that  it  should  leav-e  no  local 
lesion,  as  well  as  that  it  should  always  seek  the  same  spot.  Gowers  is 
especially  disposed  to  ascribe  the  disease  to  such  a  cause.  Some  cases  have, 
however,  followed  trauma. 

Symptoms. — The  characteristic  symptoms  are  commonly  preceded 
by  a  prodrome,  in  which  loss  of  appetite,  general  malaise,  moderate  fever, 
headache,  backache,  and  tingling  in  the  extremities  are  conspicuous.  These 
symptoms  vary  in  severity  and  last  from  a  few  days  to  several  weeks, 
when  a  paresis  suddenly  sets  in,  first  of  one  leg  and  then  of  another,  in- 
creasing rapidly,  so  that  in  a  few  days,  sometimes  in  a  few  hours,  an  almost 
total  motor  paraplegia  is  developed.  The  paresis  next  extends  to  the 
trunk;  in  a  few  days  or  even  less  the  arms  are  paralyzed.  The  muscles 
of  the  neck  are  next  involved,  and  ultimately  those  of  respiration,  deglu- 
tition, and  articulation,  producing  bulbar  symptoms.  Finally,  facial 
paralysis  and  other  disturbance  of  facial  muscles  may  ensue.  The  paraly- 
sis is  a  flaccid  one,  and  there  is  no  tendency  to  spasm  or  resistance  to  passive 
motion.  There  is  not  usually  a  change  in  electrical  reaction,  although 
there  is  sometimes  a  rapid  loss  of  faradic  muscular  excitability.  The 
reflexes  are  diminished  or  absent,  but  the  muscles  do  not  waste,  because 
death  usually  occurs  before  atrophy  has  had  time  to  develop. 

There  is  no  definite  loss  of  sensation,  but  in  addition  to  the  primary 
tingling  referred  to  there  is  sometimes  hyperesthesia  and  muscular  tender- 
ness. In  other  characteristic  cases  sensation  is  intact.  More  rarely  there 
is  a  blunted  and  delayed  sensation.  The  special  senses  are  not  affected, 
nor  are  the  bladder  and  rectum.  Sometimes  there  are  vasomotor  edema  and 
sweating.  The  spleen  has  been  found  enlarged  and  slight  albuminuria  has 
been  observed. 

Diagnosis. — This  is  not  always  easy,  the  disease  being  simulated  by 
mtUtiple  neuritis,  acute  anterior  poliomyelitis,  and  ascending  myelitis.  All 
these  may  cause  difficulty,  and  sometimes  a  distinction  clinically  and 
pathologically  is  impossible.  The  rapid  motor  paralysis,  advancing  from 
below,  in  the  feet  and  hands,  instead  of  from  above,  the  absence  of  anes- 
thesia, of  wasting,  and  of  electrical  changes,  are  characteristic  of  Landry's 
paralysis. 

Prognosis. — This  is  grave,  and  the  possibility  of  a  rapidly  fatal  termi- 
nation, even  in  a  few  days,  is  to  be  remembered,  the  danger  being  from 
interference  with  the  cardiac  and  respiratory  functions  of  the  medulla 
oblongata.  Other  cases  terminate  similarly  in  three  or  four  weeks.  If,  on 
the  other  hand,  the  acute  stage  passes  off,  the  s}Tnptoms  of  paralysis  may 
cease  to  extend,  and  recovery  is  possible  and  has  occurred  in  some  cases. 

Treatment. — The  patient  should  be  put  to  bed  immediately,  and  counter- 
irritation  should  be  applied  to  the  back  by  drj'  cups,  and  maintained  by 
gentler  means,  as  by  a  mustard  plaster. 

Of  internal  remedies  the  apparent  results  from  ergotin  and  mercury 
justify  their  further  use.  Gowers  relates  a  remarkable  case  of  recovery 
under  the  use  of  the  former  drug,  20  grains  (1.32  gm.)  having  been  given 
in  the  course  of  a  night  in  divided  hourly  doses.  Likewise  cases  of  syphilitic 
origin  have  been  reported,  in  which  the  iodid  of  mercury  has  seemingly 


SPASTIC  SPINAL  PARALYSIS  905 

proved  of  service.  The  biniodid  may  be  given  in  doses  of  from  1/50  to 
1/30  grain  (0.003  to  0.006  gm.).  The  salicylates  have  been  advised.  Both 
remedies  are  indicated  if  its  toxic  origin  be  admitted.  Perchlorid  of  iron 
is  recommended  in  traumatic  cases,  especially  when  there  is  evidence  of 
septic  poisoning.  It  is  doubtful  whether  any  of  these  remedies  will  be  of 
much  service. 

If  swallowing  is  difficult  the  patient  must  be  nourished  by  the  rectum 
or  through  the  nasal  tube,  and  if  symptoms  of  respiratory  failure  come  on, 
If  the  acute  symptoms  pass  away  and  paralysis  persists,  the  usual  ap- 
plication of  galvanism  and  faradization  may  be  made  for  restoring  muscular 
and  nervous  power. 

Chronic  Affections  of  the  Spinal  Cord. 

SPASTIC  SPINAL  PARALYSIS. 

Synonyms. — Primary  Lateral  Sclerosis;  Spasmodic  Tabes  Dorsalis. 

Definition. — A   chronic   disease   of   the   spinal   cord,    characterized   by 

stiffness  and  weakness  of  limbs  with  greatly  exaggerated  tendon  reflexes, 
but  without  atrophy  or  sensory  or  vesical  derangement. 

Etiology. — The  etiology  is  not  always  apparent,  although  the  causes 
are  probably  many.  The  cases  mostly  begin  between  the  20th  and  40th 
years.  It  may  occur  in  children.  It  has  been  traced  to  syphilis,  several 
times  to  trauma,  to  acute  infectious  fevers  and  the  puerperium ;  the  diagnosis 
in  such  cases  usually  has  been  without  anatomical  confirmation.  Strumpell 
has  called  attention  to  a  hereditary  family  type,  found  in  male  members, 
between  the  20th  and  30th  years,  and  in  some  families  the  symptoms 
are  first  manifested  in  early  childhood.  A  form  closely  related,  but  re- 
sulting from  arrested  development  rather  than  from  atrophy  of  the  central 
motor  tracts,  is  the  spastic  paraplegia  occurring  in  children  bom  prematurely, 
and  sometimes  classed  as  one  type  of  Little's  disease. 

Morbid  Anatomy. — The  lesion  which  would  be  expected  in  spastic 
spinal  paralysis  is  degeneration  of  the  pyramidal  tracts.  In  point  of  fact 
this  condition  is  found,  but  it  is  likely  to  be  part  of  a  mixed  lesion  which 
may  include  that  of  myelitis,  meningomyelitis,  multiple  sclerosis,  or  com- 
pression of  the  cord  by  tumors  or  by  caries  of  the  vertebrae.  In  a  few  cases, 
however,  the  lesion  almost  uncomplicated  has  been  found  by  StriimpeU, 
Dejerine  and  Sottas  and  others. 

Symptoms. — The  conditions  may  begin  with  a  sense  of  fatigue  and 
weariness  in  the  legs,  but  the  two  essential  and  predominating  s^miptoms 
are  increase  of  the  tendon  reflexes  and  motor  paresis.  The  first  is  the  more 
tmmistakable,  constant,  and  characteristic.  In  decided  degrees  of  this 
increase  the  contractions  come  on  even  with  that  amount  of  tension  on 
the  tendons  which  is  produced  by  the  weight  of  the  limbs  or  any  active 
or  passive  movements,  while  the  reflex  muscular  tension  or  rigidity  opposes 
any  attempt  at  motion.  The  muscles  feel  rigid  and  firm,  and  the  legs 
are  found  in  almost  permanent  extension,  while  the  feet  are  in  plantar 
flexion.  Any  attempt,  especially  if  sudden,  to  flex  the  leg  at  the  knee 
or  the  foot  dorsaUy  meets  with  resistance.     Yet  if  slow  effort  is  made, 


906  DISEASES  OF  THE  NERVOUS  SYSTEM 

flexion  may  generally  be  accomplished,  the  leg,  while  undisturbed,  re- 
maining in  the  position  assumed,  whence  the  graphic  term  of  Weir  Mitchell 
"lead-pipe  contraction."  If  the  thigh  be  placed  over  the  edge  of  the  bed, 
the  traction  of  the  leg  on  the  quadriceps  extensor  may  be  sufficient  to  excite 
vigorous  extensor  tetanus  and  a  convulsive  tremor  of  the  whole  leg,  like 
that  of  ankle  clonus.  If  the  patient  is  examined  in  a  bath,  the  spasms 
are  less  violent  because  the  effect  of  the  weight  of  the  legs  is  diminished. 
The  superficial  reflexes  are  also  increased. 

Walking  is  interfered  with  in  two  ways,  first  by  the  stifness  in  the 
legs,  and  second  by  the  paresis.  The  legs  are  only  partially,  if  at  all, 
flexed  at  the  knee,  and  the  foot  is  not  raised,  but  is  pushed  along  the  floor 
in  short,  difficult  steps.  Owing  to  the  contraction  of  the  calf  muscles 
the  toes  are  brought  to  the  ground,  and  thus  the  patient  walks  on  his 
toes;  sometimes  an  ankle  clonus  is  developed  by  contact  of  the  toes  with 
the  ground.  The  legs  are  kept  close  together,  the  knees  touch,  and  in 
certain  cases  adductor  spasm  may  cause  cross-legged  progression.  Stiff- 
ness is  not  always  so  marked.  The  effect  is  the  so-called  spastic  gait. 
In  some  cases  there  is  no  paresis,  and  the  peculiarity  of  the  gait  depends 
purely  on  the  muscular  spasm.  The  effect  is  what  Strumpell  calls  pseudo- 
paresis,  or  spastic  pseudoparesis.  The  absence  of  actual  paresis  is  shown 
by  the  fact  that,  notwithstanding  the  stiffness  in  the  gait,  the  patient 
can  still  walk  some  distance,  even  miles. 

With  all  this,  the  patient  is  well  nourished  and  there  is  no  wasting 
of  muscles,  which  may  even  be  hypertrophied,  and  outside  of  these  symp- 
toms he  may  enjoy  excellent  health.  Nor  is  there  vesical  disturbance. 
There  is  no  sensory  derangement.     Ocular  symptoms  are  rare. 

The  tendency  is  for  the  symptoms  to  become  gradually  worse,  but  very 
gradually;  finally  the  patient  cannot  walk  at  all,  nor  can  he  stand.  Rarely 
the  muscles  of  the  trunk  and  arms  become  involved,  presenting  also  a 
paresis  with  decided  increase  in  the  tendon  reflexes  without  disturbance 
of  sensibility  or  muscular  atrophy.  Such  is  the  picture  of  spastic  palsy, 
rarely,  perhaps,  seen  in  an  uncomplicated  form. 

Diagnosis. — As  stated  at  the  outset,  there  is  absence  of  sensory  and 
trophic  disturbance.  The  onset  may  be  sudden,  but  is  never  so  in  typical 
cases,  with  progressive  loss  of  strength,  but  no  emaciation.  Spastic 
symptoms,  with  increased  knee-jerk,  appear,  followed  by  graduallj-  develop- 
ing paresis.  The  arms  are  often  affected,  but  less  so  than  the  legs,  and 
may  escape.  The  course  of  the  disease  is  slow,  and  mental  symptoms 
similar  to  those  of  dementia  paralytica  may  be  present  at  the  close.  It 
resembles  amyotrophic  lateral  sclerosis,  but  it  differs  in  the  absence  of 
muscular  atrophy. 

Hysterical  spastic  paraplegia  may  furnish  in  the  most  striking  manner 
the  symptoms  detailed.  Every  symptom  to  be  mentioned  may  repeat 
itself  more  or  less  identically.  It  is,  therefore,  not  necessary  to  name 
them.  Moderate  wasting  is  sometimes  added.  It  occurs  more  com- 
monly in  women,  and  usually  careful  examination  will  reveal  some  distinct 
stigmata  of  hj'Steria. 

Prognosis. — Spastic  paraplegia  of  all  forms  except  the  hysterical 
is  of  long  duration  with  little  prospect  of  recovery.     The  upper  extremi- 


TABES  DORS  ALTS  907 

ties  are  tolerably  free  from  derangement,  and  the  mind  is  usually  clear. 
Hysterical  spastic  paraplegia  may  end  in  recovery,  if  properly  managed. 
When  the  cause  is  transient,  also,  recovery  may  be  expect^ed  with  removal 
of  pressure,  as  in  caries. 

Treatment. — If  caries  is  present,  mechanical  measures  should  be 
used  to  remove  pressure.  If  syphilis  is  suspected,  treatment  by  iodids  and 
mercurials  or  salvarsan  should  be  employed.  Mercurial  inunction  is  the 
most  ready  way  of  bringing  about  mercurialism.  Galvanism  and  faradiza- 
tion are  less  useful  in  spastic  conditions  of  the  muscle  than  in  those  in  which 
nutritional  changes  are  more  decided,  but  in  hysterical  spastic  disease 
they  are  of  signal  use  for  their  moral  effect.  The  electrical  brush  is  here 
the  most  useful  instrument.  It  should  be  associated  with  massage  and 
passive  motion,  and  early  attempt  at  locomotion  should  be  encouraged  and 
a  positively  favorable  prognosis  made.  These,  at  least,  tend  to  defer 
the  immovable  stage. 

In  any  case  friction,  massage,  and  forcible  flexion  may  be  of  benefit, 
but  should  be  used  cautiously,  as  the  irritation  produced  in  this  way 
may  possibly  hasten  premature  contracture.  Hydrotherapy  is  com- 
mended. The  effect  of  the  prolonged  warm  bath  at  90°  to  95°  F.  (30 . 2°  to 
35°  C.)  is  often  an  amelioration  of  the  spastic  symptoms.  The  bath 
should  be  kept  up  for  half  an  hour  and  manipulation  practised  during  it. 


TABES  DORSALIS. 

Synonyms. — Posterior    Spinal    Sclerosis;    Duchenne's    Disease;    Locomotor 

Ataxia. 

Definition. — ^A  disease  especially  characterized  clinically  by  loss  of 
co-ordinating  power,  and  by  sensory  and  trophic  sjrmptoms;  anatom- 
ically it  is  pre-eminently  a  disease  of  the  posterior  spinal  roots  and  posterior 
columns  of  the  cord,  although  the  brain  does  not  always  escape,  and 
the  optic  nerves  are  commonly  affected. 

Etiology. — The  etiology  of  tabes  dorsalis  is  not  a  satisfactory  chapter 
The  disease  is  more  common  in  cities,  affects  more  men  than  women,  is 
rare  in  the  negro,  and  is  pre-eminently  a  disease  of  middle  life,  about 
one-half  the  cases  beginning  between  30  and  40,  one-fourth  between  40 
and  so,  and  less  than  one-fourth  between  20  and  30.  It  has  begun  as 
late  as  66,  and  occasionally  before  the  age  of  20.  Direct  inheritance,  in- 
dependent of  inherited  syphilis,  is  unknown. 

Of  the  direct  causes,  syphilis  is  believed  to  be  the  most  frequent. 
From  so  to  90  per  cent,  of  cases  have  been  ascribed  to  it  by  different  authors, 
Erb  and  Strtimpell  leading  with  the  latter  figure.  Mobius  even  believed 
that  all  cases  of  tabes  are  due  to  syphilis,  a  view  which  Mott  shares.  Yet 
there  are  difficulties  in  tracing  the  relation  growing  out  of  the  facts,  first, 
that  the  pathological  product  is  not  anatomically  a  syphilitic  one,  and, 
second,  that  it  does  not  respond  to  the  treatment  of  syphilis.  A  reason- 
able explanation  of  these  difficulties  is  one  which  ascribes  tabes  to  a  toxin 
analogous  to  that  of  the  paralysis  which  follows  diphtheria,  acting  especially 


908 


DISEASE.'^  OF  THE  NERVOUS  SYSTEM 


on  the  centripetal  sensor}-  fibers.  Indeed  it  may  well  be  questioned 
whether  tabes  ever  occurs  without  previous  syphilitic  infection. 

The  Wassermann  reaction  has  helped  to  clear  up  the  cause  in  many  cases. 
A  large  percentage  of  the  cases  have  given  a  positive  reaction.  The  re- 
action is  best  made  by  using  the  spinal  fluid  instead  of  the  blood. 

Prolonged  exposure  to  cold  and  wet,  over-exertion,  physical  and  mental, 
especially  sexual  excesses  and  alcoholism  are  possible  contributing  causes. 
Tuezek,  has  shown  that  in  chronic  ergot  poisoning  symptoms  like  those  of 
tabes  develop,  and  with  them  a  lesion  appears  in  the  posterior  columns  of 
the  cord. 


Fig.  151. — Lumbar  Region,  g  g,  degenerated  posterior  roots.  It  It.  normal  anterior  roots. 
/  /,  degenerated  posterior  columns,  c  c,  ventral  fields  of  the  posterior  columns  intact — 
{after  Spilkr). 


Morbid  Anatomy. — Tabes  dorsalis  is  pre-eminently  a  disease  of  the 
posterior  spinal  roots  and  posterior  columns. 

Directing  our  attention  to  the  spinal  cord,  in  which  are  the  most 
manifest  changes,  we  find  that,  at  times,  even  when  inclosed  in  the 
membranes,  it  is  noticeably  small  and  thin,  while  through  the  pia  we 
may  see  the  posterior  columns  distinctly  as  a  gray  band  throughout  the 
length  of  the  cord.  The  pia  is,  however,  commonly  thickened  and 
opaque,  especially  on  the  posterior  surface,  sometimes  more  firmly  ad- 
herent than  is  natural,  while  the  blood-vessels  also  show  signs  of  arterial 
sclerosis.  The  contraction  of  the  posterior  columns  is  more  conspicu- 
ous on  section.  These  columns  are  flattened  instead  of  convex,  while 
their  gray  translucent  appearance  is  also  evident,  being  due  to  the  fact 
that  the  nerve  fibers  have  been  substituted  by  neuroglia  tissue.  Hence, 
also,  the  name  "gray  degeneration."     In  the  cord  hardened  in  Muller's 


TABES  DORS  A  US 


909 


fluid  the  difference  in  hue  is  even  more  striking  than  in  the  fresh  state. 
The  posterior  comua  and  the  posterior  nerve-roots  are  small  and  gray. 

On  minute  examination,  in  transverse  sections  stained  by  carmine 
or  other  staining  fluid,  the  affected  areas  are  more  conspicuous,  because 
of  the  deeper  staining  of  the  sclerosed  tissue,  while  all  parts  of  the  posterior 
columns  are  not  equally  affected.  In  the  lumbar  cord,  which,  with  the 
lower  thoracic  region,  is  usually  the  most  frequently  and  seriously  involved, 
the  change  affects  chiefly  the  middle  and  posterior  parts  of  the  columns, 
while  the  extreme  anterior  portion,  the  so-called  ventral  fields,  remains 
intact.  The  sclerosis  is  commonly  most  intense  in  the  part  adjacent 
to  the  posterior  comua,  into  which  the  posterior  roots  enter,  also  near 


Fig.  152. — Thoracic  Region,  d  d,  degenerated  posterior  roots,  c  c,  degenerated  poste- 
rior columns,  b  b,  degenerated  columns  of  Clarke,  a,  small  group  of  normal  fibers  from  one 
or  more  posterior  roots,  lower  in  the  cord,  which  were  not  entirely  degenerated,  e,  normal 
anterior  root — {after  Spiller). 


the  surface  of  the  cord.  Ascending  into  the  thoracic  cord,  the  intensit^^ 
of  the  disease  in  many  cases  gradually  diminishes  in  the  external  parts  of 
the  posterior  columns,  and  increases  in  their  median  portions.  It  presents 
in  this  way  the  distribution  of  an  ascending  degeneration,  which  in  fact  it 
is,  receding  from  the  commissure  in  the  upper  cervical  region. 

In  the  cervical  cord  the  columns  of  Goll  are  chiefly  affected,  sometimes 
with  the  fibers  in  the  root  zones — that  is,  those  portions  of  the  coltimns 
of  Burdach  in  which  fibers  enter  directly  from  the  posterior  nerve  roots, 
and  from  which  fibers  may  be  traced  further  into  the  gray  matter  of  the 
posterior  comua;  but  two  anterolateral  areas  in  the  columns  of  Burdach 
remain  free  from  disease,  at  least  for  a  long  time. 

Fig.  151  shows  how  the  beginnings  of  the  disease  are  localized  in  the 


910 


DISEASES  OF  THE  NERVOUS  SYSTEM 


posterior  columns.  It  is  in  consequence  of  involvement  of  the  posterior 
roots  that  the  corresponding  posterior  comua  into  which  they  enter  are 
also  affected.  The  same  is  true  of  the  medullated  fibers  of  Clarke's 
columns  (Fig.  152),  which  are  also  direct  processes  of  the  posterior  roots, 
while  the  cells  of  the  columns  remain  normal.  Lissauer's  tract,  a  narrow 
strip  at  the  periphery  of  the  posterior  comu,  is  early  involved. 

In  advanced  cases,  in  the  larger  peripheral  nerve  trunks,  such  as  the 
sciatic,  and  in  the  finer  branches  of  the  sensory  nerves,  many  degenerated 
fibers  can  be  recognized.  .Some  of  these  atrophies  may  be  secondary, 
but  modem  clinicians  are  disposed  to  regard  the  peripheral  degenerations 
of  tabes  as  independent  and  primary,  especially  since,  in  addition  to  these, 
decided  degenerative  processes  sometimes  occur  in  the  trunks  of  cei"tain 


Fig.  153. — Cervical  Region.  The  degeneration  of  the  posterior  columns  is  now  nearly 
limited  to  the  columns  of  Goll,  e  e.  b,  normal  fibers  from  roots  lower  in  the  cord  Figures 
were  not  entirely  degenerated — (after  Spillcr). 

Figures  151,  152  and  153,  from  an  advanced  case  of  tabes. 

cranial  nerves,  such  as  the  optic  and  oculomotor,  and  more  rarely  the 
vagus  and  auditory.  Tliey  will  be  referred  to  in  treating  the  diseases  of 
special  nerves. 

Finally,  there  are  even  changes  in  the  brain  of  various  kinds.  While  the 
spinal  ganglia  on  the  posterior  roots  have  been  found  invaded  in  a  few 
cases  only,  it  is  the  disposition  of  some  observ^ers  to  place  the  initial  changes 
of  the  morbid  process  constituting  tabes  dorsalis  in  these  ganglia,  and 
thence  the  fibers  ascending  into  the  posterior  columns.  Thus  considered, 
tabes  dorsalis  would  be  a  general  disorder  of  the  central  and  peripheral 
nervous  system,  but  limited  mainly  to  sensory  tracts,  though  motor  ganglia 
and  nerves  do  not  altogether  escape. 

Other  investigators  place  the  primary  lesion  at  the  point  where  the 
roots  penetrate  the  dura;  and  still  others  at  the  place  where  the  posterior 
roots  pass  through  the  pia  to  enter  the  posterior  columns  of  the  cord. 

Symptoms. — The  characteristic  symptoms  of  tabes  are  easily  divisible 
into  three  sets:  motor,   sensory,   and  reflex.     In  addition  to  these  there 


TABES  DORSAL! S 


911 


are  others  not  essential,  but  striking,  including  modifications  of  special 
sense  and  certain  visceral  symptoms  characterized  by  pain  and  known  as 
"crises."  The  special  sense  modifications  include  especially  that  of 
vision,  while  of  "crises"  the  gastric  are  most  striking. 

The  motor  phenomena  are  usually  the  most  prominent,  whence  the 
disease  takes  the  name  of  locomotor  ataxia,  but  this  symptom  may  be 
absent  for  years,  and  hence  the  inappropriateness  of  the  term.  The  dis- 
tinctive symptom  is  a  loss  of  co-ordinating  power  in  the  legs,  having  its 
simplest  illustration  in  the  unsteady  gait  of  a  drunken  man.     It  is  in- 


FiG.  154. — ^Lumbar  Region,  h  h,  posteromedian  root  zones  (Flechsig)  only  slightly  de- 
generated, i,  middle  root  zones  (Flechsig)  degenerated,  g,  normal  ventral  fields.  This 
section  represents  the  earUer  lesions  of  tabes. 

Figure  154  should  be  compared  with  Figure  153 — {after  Spiller). 


tensified  when  the  patient  attempts  to  walk  with  his  eyes  closed,  and, 
indeed,  in  its  early  development  does  not  appear  except  when  the  eyes  are 
closed.  It  is  usually  unaccompanied  by  a  loss  of  power  or  muscular  wasting, 
but  the  latter  may  be  extreme.  On  the  other  hand,  inco-ordination  is  by 
no  means  always  the  earliest  symptom  and  it  may,  ind,eed,  never  be  de- 
veloped, while  there  is  usually  a  preataxic  stage  in  most  cases  of  tabes. 
The  inco-ordination  may  be  shown  sometimes,  before  otherwise  evident, 
by  directing  the  patient  to  place  the  heels  and  toes  together  and  then  to 
close  the  eyes,  when  a  swaying  appears,  as  though  the  patient  were  going  to 
fall — Romberg's   sign   or   "tabetic  swaying."      This    symptom   is    classed 


912  DISEASES  OF  THE  NERVOUS  SYSTEM 

by  StrumpcU  among  those  of  impaired  sensibility  in  the  soles  of  the  feet 
and  the  muscles,  "whence  follows  defective  control  of  muscular  movements 
necessary  to  equilibrium.  In  health  a  slight  unsteadiness  under  these  circum- 
stances is  present  which  varies  in  different  persons,  In  tabes  the  "sway" 
may  be  present  even  when  the  eyes  are  open.  Certain  symptoms  often 
exist  for  a  long  time  before  being  recognized  by  the  patient.  Soon  the 
peculiar  gait  is  noticeable.  The  foot  is  thrust  forward  too  far,  and  brought 
down  suddenly,  with  the  heel  first  on  the  ground,  with  a  stamp.  This 
is  the  typical  tabetic  or  "heel"  gait.  The  patient  cannot  walk  in  a  straight 
line,  and  the  staggering  becomes  worse  when  the  ey^es  are  closed,  because 
the  power  of  orientation  through  vision  is  lost.  The  movements  of  the 
lower  limbs  are  excessive  and  imnecessary.  Ultimately,  he  can  walk 
only  with  the  aid  of  a  cane  or  by  keeping  the  eyes  fixed  upon  the  floor. 
He  rises  from  the  sitting  posture  with  difficulty,  often  after  three  or  four 
efforts.  The  loss  of  co-ordinating  power  may  also  be  shown  in  the  recum- 
bent posture  when  the  patient  attempts  to  touch  the  knee  with  his  heel, 
when  he  will  carry  it  around  and  in  front  and  behind  without  accomplishing 
his  purpose.  The  ataxic  gait  is  not  confined  to  tabes,  but  may  occur  in 
disseminated  sclerosis  and  cerebellar  disease.  In  the  latter  closure  of 
the  eyes  may  not  increase  the  ataxia  of  the  gait,  but  frequently  does. 

A  peculiar  symptom  called  by  Frankel  hypotonia  is  noted  in  this 
stage  or  earlier,  viz.,  a  peculiar  muscular  relaxation  which  permits  the 
joints  to  be  placed  in  a  condition  of  hyperextension  and  hyperflexion 
which  may  give  an  appearance  of  backward  cur\-e  to  the  lower  limb.  Sexual 
power  diminishes  or  disappears  early. 

Inco-ordination  also  develops  in  the  hands,  but  much  more  rarely, 
and  late  in  the  disease,  though  it  may  appear  in  them  first.  It  is  shown 
in  connection  with  more  delicate  acts,  such  as  picking  up  a  pin,  button- 
ing, and  writing.  It  may  be  demonstrated  also  by  asking  the  patient 
to  bring  the  ends  of  two  of  his  fingers  together  with  his  eyes  closed,  or 
to  touch  the  end  of  his  nose  with  one,  which  he  may  not  be  able  to  do. 
With  all  this  ataxia  the  muscular  power  remains  intact.  The  patient 
lying  in  bed  can  kick  out  with  great  force,  and  resist  successfully  any 
effort  to  flex  the  extended  leg,  while  the  grip  of  the  hand  is  strong. 

The  sensory  symptoms  are  less  distinctive,  especially  at  first.  The 
most  frequent  of  these — indeed,  among  the  most  frequent  of  all  symp- 
toms— are  pains  of  a  darting,  shooting,  or  stabbing  character,  whence 
they  are  called  lightning- pains.  They  are  said  to  occur  in  nine-tenths  of 
all  cases.  They  resemble  closely  those  of  neuralgia,  lasting  but  a  second  or 
two.  They  are  most  common  in  the  legs,  and  are  often  accompanied  by 
burning  or  tingling,  especially  in  the  feet.  They  may  be  felt  in  the  trunk, 
arms,  and  even  in  the  head.  Commonly  they  do  not  correspond  with. 
nerves  or  affect  joints.  They  are  often  considered  by  the  patient  as  rheu- 
matic pains.  A  sensation  of  cold  is  felt,  also  a  feeling  as  though  the  limb 
were  immersed  in  cold  water.  The  pains  are  induced  by  fatigue  or  ex- 
cesses or  by  temporary  ill  health  from  other  causes,  and  are  likely  to  come 
on  at  night.  They  may  last  hours  or  a  day  or  two.  There  may  be  areas 
of  hyperesthesia  and  anesthesia.  A  very  curious  sensation  is  felt  in  the 
soles  of  the  feet  when  walking,  a  feeling  as  though  soft  carpet  or  cotton 


TABES  DORS  A  LIS  913 

were  interposed  between  them  and  the  floor.  A  painful  sense  of  constric- 
tion about  the  limb  or  waist  or  around  the  entire  trunk — girdle  pain 
— is  regarded  as  characteristic. 

There  are  other  disturbances  of  sensation,  such  as  retardation  of  tac- 
tile, and  more  especially  of  pain  sensation,  wherein  the  prick  of  a  pin,  in- 
stead of  being  instantaneously  felt,  is  delayed  for  several  seconds.  Another 
sensory  sjrmptom  is  difficulty  in  localization,  manifested,  for  example,  in 
referring  a  pin-prick  to  the  right  foot  when  it  is  made  in  the  left — allochiria 
— or  it  may  be  felt  in  both  feet — polyesthesia.  In  advanced  stages  the 
muscular  sense  also  is  impaired,  and  the  patient  is  unable  to  indicate 
correctly  the  position  of  a  limb.  There  may  be  other  perversions  of 
sensibility.  The  sense  of  pain  may  be  lost  or  perverted;  also  the  tem- 
perature sense — that,  too,  without  derangement  of  the  pain-sense  or 
common  sensibility.  All  varieties  of  sensation  may  be  lost  in  the  most 
diverse  parts  of  the  body  and  most  irregularly. 

Viscera  pains,  known  as  tabetic  crises,  among  which  the  gastric  are 
the  most  common,  are  also  among  the  sensory  phenomena.  They  may 
be  laryngeal,  rectal,  nephritic,  urethral,  etc.,  and  are  sometimes  exceed- 
ingly severe.  The  gastric  crises  are  sometimes  accompanied  b}'  vomit- 
ing of  strongly  acid  gastric  secretion.  On  the  other  hand,  the  vomited 
matters  may  be  alkaline,  the  result  of  a  reflux  of  the  intestinal  contents 
into  the  stomach.  Nor  are  gastric  crises  limited  to  tabes.  They  may 
occur  in  other  cerebrospinal  disease,  including  general  paralysis,  multiple 
sclerosis,  and  subacute  or  chronic  central  myelitis.  The  lar\Tigeal 
crises  maj'  be  associated  with  spasm  and  dyspnea,  with  noisy  breathing. 
Death  is  a  possible  termination  from  this  cause.  Rectal  crises  consist 
in  paroxysmal  pain  and  tenesmus,  with  a  sensation  as  of  a  foreign  body 
in  the  rectum. 

The  reflex  symptoms  consist  in  impairment  in  reflexes  both  tendon 
and  cutaneous.  The  loss  of  the  knee-jerk  is  one  of  the  most  frequent  and 
early  of  these,  occurring  sometimes  years  before  ataxia  appears.  Of  itself  it 
is  not  diagnostic,  as  it  may  be  absent  in  healthy  persons,  but  in  association 
with  lighting  pains  and  certain  ocular  symptoms  it  is  almost  conclusive 
evidence  of  the  disease.  In  by  far  the  greater  number  of  tabetics — at  least 
70  per  cent. — the  patellar  reflex  is  wanting,  with  or  without  the  Argyll- 
Robertson  pupil.  The  skin  reflexes  fail  pari  passu  with  the  loss  of  tactile 
sensibility,  and  it  is  doubtful  whether  they  are  ever  present  without  this. 
The  plantar  skin  reflex  is  that  most  frequenth^  impaired,  and  after  this  are 
successively  involved  the  gluteal,  cremasteric,  and  abdominal.  It  happens 
rarely  that  in  the  early  stages  of  the  disease  the  skin  reflex  is  increased, 
sometimes  considerably,  but  even  then  the  knee-jerk  is  absent  or 
diminished. 

Of  the  reraaining  symptoms  the  ocular  are  the  most  important.  They 
include  ptosis  of  one  or  both  eyelids,  producing  a  very  striking  appearance. 
It  may  be  unaccompanied  or  associated  with  external  strabismus  and  double 
vision.  Rarely  there  may  be  paralysis  of  all  the  external  muscles  of  the 
eye,  producing  ophthalmoplegia  externa.  The  most  remarkable  eye  symp- 
tom is,  however,  the  Ayrgll-Robertson  pupil,  in  which  there  is  loss  of  reflex 
contraction  of  the  iris  in  response  to  light,  while  the  contraction  in  accom- 


914  DISEASES  OF  THE  NERVOUS  SYSTEM 

modation  and  convergence  remains.  According  to  Gowers,  the  loss  of  this 
reflex  occurs  in  five-sixths  of  all  cases.  The  contraction  in  accommodation 
is,  however,  not  always  maintained.  Very  rarely  the  reverse  of  the  Ayrgll- 
Robertson  pupil  exists.  Often  the  dilatation  of  the  pupil  which  takes 
place  in  health  when  the  skin  of  the  neck  is  pinched  cannot  be  produced 
and  coincident  with  this  is  often  unnatural  smallness  of  the  pupil — spinal 
myosis. 

Finally,  there  is  sometimes  atrophy  of  the  optic  nerve,  producing  the  amau- 
rotic form  of  blindness.  When  it  occurs,  it  is  often  an  early  symptom,  usually 
commencing  before  inco-ordination ;  and,  what  is  more  singvilar,  the  ataxia 
often  does  not  supervene — that  is,  there  seems  to  be  a  tendency  for  the 
spinal  malady  to  become  stationary  when  the  optic  nerve  is  affected  early, 
but  in  some  cases  the  disease  progresses  notwithstanding  early  optic  atrophy. 
The  failure  of  vision  usually  begins  with  peripheral  limitation  and  pro- 
gresses slowly  to  total  blindness,  sometimes  to  a  considerable  extent  before 
the  patient  notices  it.  Occasionally  it  ceases,  and  there  may  even  be 
slight  impairment. 

Deafness  may  be  present  from  disease  of  the  auditory  nerve;  also, 
more  rarely,  anosmia,  from  atrophy  of  the  olfactory  ner\'e.  Attacks  of 
vertigo  occur  in  some  cases.  Abnormalities  in  function  of  other  cranial 
nerves  may  be  due  to  similar  involvement.  Among  these  may  be  men- 
tioned pain  at  one  time  and  anesthesia  at  another  in  the  area  of  the  fifth 
nerve;  also  unilateral  atrophy  of  the  tongue. 

There  may  be  delayed  micturition  from  weakness  of  the  detrusor  muscle 
of  the  bladder,  or  incontinence  from  paralysis  of  its  sphincter,  with  partial 
evacuation  of  the  bladder,  and  resulting  cystitis.  The  anal  sphincter  is 
less  frequently  affected. 

Vasomotor  and  trophic  phenomena  also  occur,  and  may  be  predomin- 
ating symptoms.  They  include  local  sweating  of  the  palms  and  soles,  or  of 
half  the  head,  edema,  skin  ecchymoses,  herpes,  and  modified  hair  growth, 
loss  of  pigment  from  hair  and  skin,  thickening  of  the  epidermis  of  the  sole, 
succeeded  by  blisters  under  it.  Alteration  in  the  nails,  and  omxhia  with 
ulceration,  may  be  present;  also  decay  of  the  teeth  and  the  so-called  per- 
forating ulcer  of  the  foot,  which  is  almost  peculiar  to  this  disease.  Only 
late  in  the  disease  may  atrophy  of  muscles,  sometimes  associated  with 
neuritis  or  involvement  of  the  anterior  comua,  occur.  Paroxysmal  diarrhea 
occurs,  and  has  been  regarded  as  vasomotor  in  origin. 

The  so-called  arthropathies  are  an  interesting  trophic  symptom  and 
are  directly  the  result  of  the  disease.  The  most  common  is  that  known 
as  Charcot's  joint,  anatomically  similar  to  chronic  affections  in  which  the 
disease  begins  in  the  bone  as  contrasted  with  the  syno\nal  membrane,  re- 
sulting in  atrophy  and  in  the  destruction  of  bone  and  cartilage,  while 
brittlencss  of  bones,  attended  with  spontaneous  fracture  or  luxation,  may 
occur.  If  union  takes  place,  there  is  a  superabundance  of  callus,  with 
ossification  or  calcification  of  adjacent  structures  and  of  any  newly  formed 
inflammatory  tissue.  The  large  joints  are  those  commonly  affected  and 
are  painless  when  the  seat  of  arthropathy.  There  may  be  eflfusion  and 
even  pus  in  the  joints,  but  pus  will  not  form  unless  the  joint  has  b?en 
injured.      The  arthropathies  may  occur   in    the   preataxic   stage.      They 


TABES  DORS  ALTS  915 

may  be  excited  by  injury.  The  joints  may  also  become  greatly  relaxed, 
while  changes  in  the  tarsal  bones  and  articulations  may  cause  the  foot  to 
become  flat,  with  projection  backward  or  inward  of  the  tarsometatarsal 
articulations  and  of  the  tarsal  bones,  producing  the  "tabetic  club-foot." 

Cerebral  symptoms  also  occur,  but  are  rare,  and  may  resemble  those  of 
dementia  paralytica.  It  is  not  always  easy  to  decide  whether  the  dementia 
or  the  tabes  is  primary.  The  final  stage  of  the  disease,  in  which  the  patient 
is  bed-ridden,  is  known  as  the  paralytic  stage. 

Diagnosis. — The  diagnosis,  commonly  easy  when  the  characteristic 
symptoms  are  developed,  may  demand  critical  judgment  in  the  early 
stage.  The  combination  of  lightning  pains,  absence  of  knee-jerk,  early 
ocular  palsies,  including  the  Argyll-Robertson  pupil,  ptosis  or  squint,  and 
ataxia  are  conclusive.  Lightning  pains  and  ocular  palsies  should  always 
stimulate  to  thorough  examination.  The  same  is  true  of  severe  attacks 
of  gastric  crises  in  middle-aged  men. 

Differential  Diagnosis. — Disease  vf  the  vertebral  column  with  resulting 
compression  of  the  spinal  nerves  is  also  associated  with  lancinating  pain 
and  absence  of  the  patellar  reflex,  but  the  later  symptoms  are  widely 
different.  The  same  is  true  of  deep-seated  tumors  impinging  on  the 
spinal  cord. 

Peripheral  alcoholic  neuritis  and  arsenical  neuritis  also  may  be  asso- 
ciated with  diminished  knee-jerk,  a  pseudotabetic  gait,  and  shaqD  pains, 
but  the  gait  differs  from  the  true  tabetic  gait,  the  leg  being  lifted  high  in 
order  that  the  toes  may  clear  the  floor.  The  pain  also  follows  the  course 
of  the  nerves,  which  are  tender  on  pressure  and  there  is  none  of  the  shoot- 
ing character.  Nor  is  there  reflex  immobility  of  the  pupils,  and  seldom 
bladder  disturbance.  The  cases,  too,  are  much  more  acute  in  character. 
Multiple  sclerosis  in  rare  instances  presents  similar  symptoms,  but  defec- 
tive speech,  nystagmus,  mental  weakness,  and  ultimate  apoplectiform 
seizures  serve  to  distinguish  it,  and  the  tendon  reflexes  are  usually  exag- 
gerated. In  diphtheritic  palsy  there  may  be  absence  of  knee-jerk,  but 
the  history  of  the  case,  the  throat  palsy,  and  all  absence  of  pain  are  dis- 
tinctive. Ataxic  paraplegia  also  displays  ataxia,  but  here  symptoms  of 
implication  of  the  pyramidal  tracts  are  present.  In  cerebellar  disease 
there  is  also  loss  of  co-ordination,  and  the  knee-jerk  may  be  absent, 
there  may  be  headache,  optic  neuritis,  and  vomiting,  but  no  lightning 
pains  or  sensory  disturbance.  Occasionally  neuritis  may  present  a  clinical 
picture  closely  resembling  tabes,  known  as  peripheral  pseudotabes.  The 
rapidity  of  development,  the  absence  of  the  Argyll- Robertson  sign,  and 
of  implication  of  the  bladder,  and  in  some  cases  recovery,  are  the  most 
important  differential  features. 

General  paresis  and  tabes  sometimes  m.erge,  the  latter  developing  on 
the  former,  or  the  former  on  the  latter  toward  the  end.  Rapidly  developed 
ataxia  with  mental  symptoms  often  resolves  itself  into  general  paresis'. 
Yet  acute  involvement  of  the  posterior  columns  may  be  possible,  producing 
ataxia. 

Finally,  there  is  the  nicotin  tabes  of  Striimpell,  who  has  twice  met, 
in  men  long  working  in  tobacco  factories,  a  set  of  symptoms  consisting  in 
painful  sensation,  absence  of  patellar  reflex,  contracted  pupil,  with  reflex 


916  DISEASES  OF  THE  NERVOUS  SYSTEM 

immobility  and  uncertain  gait,  differing,  however,  from  tabes  in  the  presence 
of  tremor  and  marked  increase  in  the  skin  reflexes,  especially  in  the  lower 
extremities. 

Course  and  Prognosis. — It  is  generally  conceded  that  in  no  case  of  thor- 
oughly developed  tabes  has  recovery  occurred.  The  disease  may,  however, 
be  arrested.  This  happens  especially  if  optic  nerve  atrophy  has  set  in 
early,  after  which  ataxia  may  not  develop  further,  while  the  other  symp- 
toms may  subside.  In  most  cases  of  the  disease,  however,  the  advance  is 
slow  but  irresistible.  The  duration  of  the  first  stage,  characterized  by 
absence  of  knee-jerk,  and  by  the  presence  of  the  Argyll-Robertson  pupil 
and  of  lancinating  pains,  lasts  from  a  few  months  to  20  years,  or  longer. 
The  second  stage — that  of  ataxia— from  which,  indeed,  the  patient  often 
dates  the  disease  if  the  initial  symptoms  were  slight,  may  then  supervene 
gradually  or  suddenly.  Finally,  the  paralytic  stage  supervenes,  to  be 
soon  followed  by  death.  Tabes  is  believed  by  many  to  assume  a  milder 
type  more  commonly  now  than  was  the  case  20  or  25  years  ago. 

Treatment. — While  recovery  from  tabes  dorsalis  probably  never  occurs, 
much  may  be  accomplished  by  treatment  in  arresting  progress  and  reliev- 
ing symptoms.  There  is  no  specific  treatment,  although  this  elTect  has  been 
claimed  for  more  than  one  remedy. 

The  supposed  frequent  causal  relation  between  syphilis  and  tabes 
renders  the  antisyphilitic  treatment  appropriate  in  all  cases  in  which  such 
relation  can  be  traced  or  where  it  is  suspected.  To  this  end  mercurials  are 
to  be  administered  imtil  the  specific  effect  is  produced.  This  is  best  ac- 
complished by  inunction,  a  dram  to  a  dram  and  a  half  being  rubbed  into 
different  parts  of  the  body  daily,  to  be  discontinued  when  the  gums  are 
affected.  After  this  the  hichlorid  may  be  given  in  doses  of  1/24  grain 
(0.0027  grn.)  three  times  a  day,  in  association  ^vith  the  iodid  of  potassium 
in  ascending  doses  if  well  borne,  or  the  biniodid  of  mercury  may  be  given  in 
doses  of  1/24  grain  (0.027  gm.)  three  times  a  day.  If  this  treatment  is 
found  effectual,  the  iodid  should  be  continued  in  the  minimum  doses, 
which  will  keep  up  the  effect.  The  antisyphilitic  treatment  is  more  success- 
ful in  those  cases  in  which  cerebrospinal  syphilis  simulates  tabes.  It  may 
be  harmful  in  true  tabes.  The  value  of  salvarsan  in  tabes  is  a  subject  of  more 
or  less  dispute,  in  some  cases  much  benefit  has  been  reported  from  its  use. 
At  the  meeting  of  the  Association  of  American  Physicians,  May,  19 13,  Dr. 
Swift  reported  the  use  of  Salvarsan  in  tabes  was  reported  in  the  following 
manner.  The  spinal  fluid  was  examined  for  the  Wassermann  reaction,  the 
character  and  number  of  the  leucocytes  and  the  globulin  reaction.  The 
patient  was  given  salvarsan  intravenously.  After  a  certain  time  he 
was  bled.  His  ovm  blood  serum  was  then  injected  into  his  spinal  canal. 
This  was  repeated  many  times.  Many  of  his  cases  showed  marked 
improvement.  Iodid  of  potassium  may  be  tried  apart  from  the  indi- 
cations of  syphilis.  The  rest  treattnent,  originally  suggested  by  Weir 
Mitchell,  has  been  found  useful  in  arresting  the  disease,  but  it  has  been 
followed  by  permanent  results.  Extension  of  the  spinal  column  and  pre- 
sumably of  the  cord  by  suspension  of  the  body  for  from  one  to  three 
minutes  daily  was  used  for  a  time,  among  others  by  INIitchell,  but  it  has 
been  discontinued. 


TABES  DORS  A  LIS  917 

In  Germany  electricity  is  still  a  popular  remed\',  and  failure  with  it  in 
this  country  may  be  due  to  imperfect  and  too  brief  trial.  Erb's  directions 
for  galvanism  are  to  place  a  moderate-sized  anode  in  the  vicinity  of  the 
sympathetic  in  the  neck,  and  a  large  kathode  on  the  side  of  the  vertebral 
column  for  four  or  five  minutes,  moving  it  at  intervals  from  above  dowm- 
ward.  Severe  pain  and  vesical  weakness  are  treated  by  galvanization  and 
the  faradic  brush.  The  latter,  as  recommended  by  Rumpf,  should  be 
brushed  over  the  skin  of  the  back  and  extremities  for  five  or  ten  minutes, 
using  a  strong  current.     This,  however,  does  good  only  for  the  symptoms. 

Hydrotherapy  likewise  maintains  its  popularity  in  Germany,  although 
claimed  by  some  authorities  to  be  sometimes  harmful,  especially  in  the 
shape  of  hot  baths  and  vapor  baths  and  wet  packs.  The  tepid  hath  is 
entirely  safe  and  often  symptomatically  useful.  Its  temperature  should 
be  from  80°  to  90°  F.  (26.6°  to  32.1°  C),  accompanied  by  gentle  rubbing. 
Wet  compresses  upon  the  abdomen  or  legs  at  night  sometimes  relieve  the 
pains.  In  Germany,  too,  there  are  numerous  water-cure  establishments 
in  the  hands  of  experienced  directors,  to  which  patients  may  be  advanta- 
geously sent,  but,  unfortunately,  there  is  nothing  of  the  kind  in  this  country 
which  can  be  recommended.  Oeynhausen-Rehme  in  Minden  has  the  best 
reputation  for  its  carbonic  acid  thermal  salt  baths,  but  the  baths  at  Nauheim 
in  Hess  are  similar.  Mud  and  iron  baths  are  found  at  Pyrmont,  near 
Brunswick;  Driburg,  in  Westphalia,  Prussia;  Elster,  pleasantly  situated 
in  Saxony;  Karlsbad,  Marienbad,  and  Frazenbad,  in  Bohemia. 

The  painful-  attacks  are  often  not  relieved  by  the  measures  thus  far 
suggested,  and  require  more  powerful  treatment.  The  first  to  be  used 
should  be  phenacetin,  acetanilid,  salophen,  aspirin,  and  antipyrin,  while 
morphin  should  be  deferred  as  long  as  possible.  It  may,  however,  be 
necessary,  when  it  should  be  used  hypodermicaUy.  Cocain  used  in  the 
same  manner  in  doses  of  from  1/6  to  1/4  grain  (o.oii  to  0.165  g™--)  is 
also  sometimes  efficient,  while  cannabis  indica  in  doses  of  1/4  to  1/2- grain 
(0.0165  to  0.033  gm-)  of  the  extract  may  also  be  tried.  Bandaging  with 
a  broad  flannel  bandage  from  toes  to  thighs  has  been  recommended  for 
the  sciatic  pain  and  pressure  for  the  relief  of  painful  spots.  Massive  doses 
of  strychnin  have  been  suggested  for  the  same  purpose. 

Fatigue  of  all  kinds  as  well  as  anxiety  of  mind  should  be  avoided,  while 
moderate  exercise  may  be  encouraged.  The  bladder  should  be  emptied 
at  regular  intervals  even  though  there  may  be  no  desire  for  micturition. 
Vesical  anesthesia  may  lead  to  retention.  Excessive  use  of  the  eyes  should 
be  avoided,  as  reading  by  a  poor  light  or  in  a  railroad  train.  Excesses  in 
smoking,  and  especially  in  the  use  of  alcohol,  are  harmful,  as  is  also  too 
frequent  sexual  indulgence.  Overeating  and  the  use  of  indigestible  articles 
of  food  should  be  avoided,  as  gastric  crises  are  invited  by  them.  Excessive 
use  of  iodid  may  produce  pseudocrises. 

Great  benefit  has  been  obtained  by  the  Frankel  movements.  They 
are  "based  upon  the  education  of  the  central  nervous  system  by  means 
of  repeated  exercises,  whereby  it  is  enabled  to  receive  sufficiently  distant 
stimuli  from  the  limbs  as  to  their  position,  although  the  available  quantity 
of  sensation  is  rather  small.  It  is  necessary,  of  course,  that  the  movements 
be  attempted  and  carried  out  repeatedly  and  with  great  attention."     They 


918  DISEASES  OF  THE  NERVOUS  SYSTEM 

are  too  complex  to  be  repeated  here,  and  the  student  is  referred  to  Frankcl's 
book.' 

HEREDITARY  ATAXIA. 
Synonyms. — Hereditary  Ataxic  Paraplegia;  Friedreich's  Disease. 

Definition. — A  disease  whose  cHnical  features  are  especially  ataxia 
and  paraplegia,  occurring  in  families  and  at  an  age  much  earlier  than 
ordinary  tabes,  from  which  it  differs  also  in  the  addition  of  peculiar  symp- 
toms associated  anatomically  with  lesions  in  the  posterior  and  lateral 
columns. 

Etiology. — Its  etiology  is  unknown.  It  is  more  common  in  males  than 
in  females,  affecting  86  males  and  57  females  out  of  143  cases  collected 
by  J.  P.  C.  Griffith.  Strumpell  makes  the  opposite  statement  as  to  sexes, 
but  other  observers  agree  with  Griffith.  Of  Griffith's  cases,  15  occurred 
before  the  age  of  two,  39  before  the  age  of  six,  45  between  six  and  ten, 
20  between  11  and  15,  18  between  16  and  20,  and  sLx  between  20  and  24. 
Cases  have  followed  the  acute  infectious  diseases. 

Morbid  Anatomy. — The  whole  cord  is  smaller  than  in  health.  There 
is  a  decided  degeneration  of  the  posterior  and  lateral  columns,  and  the 
degeneration  in  the  posterior  columns  may  extend  throughout  the  cord, 
involving  the  whole  of  Goll's  column  and  nearly  all  of  Burdach's,  leaving 
a  narrow  band  of  normal  tissue  near  the  posterior  comua.  Different 
opinions  are  held  in  regard  to  the  condition  of  the  posterior  roots.  The 
degeneration  of  the  lateral  columns  involves  the  area  of  the  crossed  py- 
ramidal tracts,  the  direct  cerebellar  and  Gowers'  tracts  as  well  as  the 
column  of  Clarke  with  degeneration  of  its  ganglion  cells.  The  pia  mater 
over  the  posterior  columns  is  sometimes  thickened. 

The  disease  seems  to  consist  of  a  double  morbid  process,  consisting 
in  early  degeneration  of  nerve  elements,  associated  with  a  tendency  to 
overgrowth  of  interstitial  or  neuroglia  tissue.  According  to  Dejerine  and 
Letulle,  it  is  a  gliosis  of  the  posterior  and  lateral  columns,  due  possibly 
to  defect  in  development. 

Symptoms. — The  essential  symptoms  are  ataxia  with  p  raplegia. 
Initial  pains  are  rare.  The  ataxia  is,  however,  peculiar.  As  in  tabes,  it 
begins  in  the  legs,  but  it  is  swa3ang  and  irregular,  more  like  that  of  drunken- 
ness, more  like  cerebellar  inco-ordination.  The  feet  are  not  often  raised 
too  high,  and  while  there  is  stamping,  as  in  true  tabes,  it  is  less  marked. 
Tabetic  swaying  may  or  may  not  be  present.  If  present  it  is  not  in- 
creased when  the  eyes  are  closed.     Ataxia  is  present  in  the  reclining  position. 

The  ataxia  of  the  arms  occurs  early  and  is  striking,  the  movements 
being  choreiform,  jerky,  irregular,  and  swaying..  The  hand  first  moves 
an  object  in  its  efforts  to  secure  it  and  then  pounces  upon  it.  There  seems 
to  be  a  superabundance  of  effort  in  voluntary'-  movements,  action  is  over- 
done, and  prehension  is  claw-like.  Again,  the  fingers  may  be  spread  out 
or  overextended.  The  first  manifestation  of  the  disease  in  children  is 
often  a  tendency  to  fall. 

'"The  Treatment  of   Tabetic  Ataxia  by  means  of   Systematic  Exercise,". Freyberger'a  Translation. 
Philadelphia,  1902. 


HEREDITARY  ATAXIA  919 

As  the  disease  advances,  irregular,  jerky  movements  affect  the  head 
and  shoulders,  sometimes  tremor-like.  In  most  cases  there  is  nystagmus 
when  the  eyes  are  moved  laterally  or  upward,  usually  a  late,  sometimes 
an  early,  symptom.  Atrophy  of  the  optic  nerve  is  rare,  and  the  pupils  are 
normal.  Speech  is  sometimes  impaired,  generally  as  a  late  symptom — 
three,  five,  or  ten  years  after  the  initial  symptoms.  Syllables  are  elided — 
the  speech  is  scanning — with  occasional  movements  of  the  tongue,  but  no 
twitching  of  the  lips. 

The  paresis  is  at  first  slight — indeed,  the  power  of  the  muscles  is  at 
first  imimpaired — while  there  is  rarely  ever  total  paralysis.  Some  patients, 
however,  never  walk.  The  nutrition  of  the  muscles  is  good.  The  knee- 
jerk  generally  disappears  early,  or  is  at  least  absent  when  the  cases  come 
under  observation.  In  a  few  this  symptom  appears  late,  while  in  some 
atypical  cases  this  reflex  has  been  reported  increased.  Sensory  symptoms 
are  not  usually  conspicuous.  There  may  be  none,  even  in  bad  cases.  At 
times  there  is  delayed  sensation  or  impaired  sensibility  to  pain  and  tempera- 
ture.    Increased  sensitiveness  may  be  present.     Visceral  crises  seldom  occur. 

While  trophic  lesions  of  the  usual  kind  are  rare,  there  occur  peculiar 
deformities,  especially  of  the  feet.  There  is  talipes  equinus  or  equinovarus, 
and  the  patient  walks  on  the  outer  edge  of  the  foot.  The  great  toe  is  over- 
extended or  dorsally  flexed,  and  occasionally  this  is  the  first  sign  of  the 
disease.  There  may  be  lateral  curvature  of  the  spine.  The  disease  may 
last  from  20  to  40  years. 

Diagnosis. — This  is  not  difficult,  although  sometimes  the  disease  is 
■confounded  with  chorea,  with  the  hereditary  form  of  which  it  has  certain 
points  in  common.  The  ataxia  in  early  life,  the  club-foot,  overextended 
great  toe,  spinal  curvature,  lost  knee-jerks,  nystagmus  and  scanning  speech 
form  a  complex  of  symptoms  not  found  in  any  other  disease. 

It  resembles  ataxic  paraplegia  or  combined  lateral  and  posterior  sclerosis 
in  more  than  its  symptomatology,  but  the  increased  knee-jerk,  foot  clonus, 
and  spasms  of  the  latter  disease  are  wanting.  In  cases  of  combined  sclerosis 
in  which  the  knee-jerk  is  absent,  the  family  history  and  youth  of  the  subject 
can  alone  settle  the  question.  The  loss  of  iris  reflex  in  children  points  to 
tabes,  the  resiolt  of  inherited  syphilis.  Disseminated  sclerosis  presents  inco- 
ordination, nystagmus,  and  defective  articidation,  but  the  .knee-jerks  are 
almost  always  exaggerated,  and  intention  tremor  is  characteristic. 

Prognosis. — This  is  invariably  bad,  so  far  as  recovery  is  concerned, 
although  the  disease  lasts  many  years. 

Treatment. — There  is  no  treatment  except  such  as  will  overcome  tend- 
ency to  deformity.     The  remedies  used  in  locomotor  ataxia  may  be  tried. 

Cerebellar  Hereditary  Ataxia  has  been  described  by  Marie,  Sanger- 
Brown,  Klippel,  and  Durante.  It  starts  after  20  years  of  age.  There 
are  ataxia,  disordered  speech,  nystagmus,  and  heredity,  but  the  knee-jerks 
are  normal  or  exaggerated,  there  is  Argyll-Robertson  pupil,  optic  nerve 
atrophy  with  limitation  of  the  field  of  vision,  while  there  is  no  scoliosis  or 
club-foot.  The  opposite  is  true  of  hereditary  ataxia.  Many  do  not  recog- 
nize the  cerebellar  hereditary  ataxia  as  a  distinct  symptom-complex. 

Progressive  Interstitial  Hypertrophic  Neuritis  of  Childhood  is 
also  a  family  disease.     The  symptoms  are  a  combination  of  those  of  tabes 


920  DISEASES  OF  THE  \ERVOUS  SYSTEM 

dorsalis  with  those  of  neurotic  muscular  atrophj'  (peroneal  type  of  pro- 
gressive atrophy).  There  are  hypertrophy  and  hardening  of  peripheral 
nerves.     It  was  first  described  by  Dejerine  and  Sottas. 

Toxic  Sclerosis,  especially  of  the  posterior  and  lateral  columns,  results 
from  such  diseases  as  pellagra,  ergotism,  and  pernicious  anemia. 


ATAXIC  SPASTIC  PARAPLEGIA  OR  COMBINED  SCLEROSIS. 

Synonyms. — Progressive  Spastic  Paraplegia;  Combined  Lateral  and  Posterior 

Sclerosis. 

Definition. — A  chronic  disease  of  the  spinal  cord,  characterized  by 
sj^mptoms  which  point  to  lesions  of  both  lateral  and  posterior  sclerosis, 
including,  therefore,  both  spastic  and  ataxic  features,  the  symptoms  of  one 
lesion  being  more  or  less  modified  by  the  other. 

Etiology. — This  is  obscure.  It  is  more  common  in  males,  is  a  disease 
of  adult  life  in  which  overexertion,  exposure,  spinal  traumatism,  and  sexual 
excess  each  has  been  an  antecedent  event.  Less  frequently  than  tabes  does 
it  follow  in  the  wake  of  the  syphilitic  taint.  It  may  be  associated  with 
general  paralysis  of  the  insane.  Heredity  has  been  obser\^ed  in  one-tenth 
of  the  cases,  and  the  neurotic  constitution  seems  to  favor  it.  It  is  most 
frequently  associated  with  syphilis  or  anemia. 

Morbid  Anatomy. — As  the  name  suggests,  lesions  are  found  in  both 
posterior  and  lateral  columns.  In  the  posterior  columns  they  resemble 
those  of  uncomplicated  tabes  dorsalis,  and  are  most  intense  in  the  cervical 
and  thoracic  portions  of  the  cord,  variously  distributed,  sometimes  equally, 
at  others  preponderating  in  one  or  the  other.  The  changes  in  the  psoterior 
root  zones  are  less  pronounced  than  in  true  tabes.  In  the  lateral  columns 
the  crossed  pyramidal  tracts  and  in  the  anterior  columns  the  direct  py- 
ramidal tracts  are  chiefly  involved,  though  the  mixed  zones  of  the  lateral 
colvunns,  the  lateral  limiting  layers,  and  the  direct  cerebellar  tracts  may 
also  be  invaded.  The  gray  matter  and  membranes  remain  intact.  Most 
cases  are  not  truly  systemic  but  are  examples  of  diffuse  lesions  wath  second- 
ary degeneration.  This  is  especially  true  of  the  cases  due  to  anemia  and 
syphiHs. 

Symptoms. — The  symptoms  are  slow  in  their  development,  though 
occasionally  the  course  is  more  rapid,  the  only  modification  in  this  being 
that  months  instead  of  years  are  sufficient  to  develop  the  distinctive  features. 
Those  of  either  lesion  may  predominate  at  first.  More  usually  those  of 
ataxia  are  the  first  to  appear,  including  fatigue  and  even  pain  after  com- 
paratively slight  exertion,  unsteadiness  of  gait,  increased  with  the  eyes 
closed,  though  an  associated  stiffness,  may  prevent  the  typical  gait  of  tabes. 
There  is  also  more  or  less  paresis. 

Sensibility  is  also  diminished  in  combined  sclerosis,  but  less  so  than  in 
pure  tabes.  There  may  be  dull  pain  or  numbness  in  the  lower  extremities 
and  in  the  back  or  sacral  region,  but  the  lightning  pains  of  tabes  are  rarely 
present;  nor  is  the  girdle  sensation,  while  visceral  crises  very  rarely  occur. 
The  Argyll-Robertson  pupil  is,  also,  commonly  absent,  but  nystagmus  is 
not  infrequent. 


ATAXIC  SPASTIC  PARAPLEGIA  921 

The  most  striking  difference  in  the  symptomatology  of  ataxic  para- 
plegia, as  contrasted  with  true  tabes,  is  the  presence  of  exaggerated  reflexes 
in  the  former,  including  knee-jerk  and  ankle  clonus.  Simple  tapping  of 
the  patella  or  the  belly  of  the  quadriceps  extensor  brings  out  the  former. 
The  upper  extremities  are  also  often  involved,  and  the  chief  symptoms  here 
are  weakness,  inco-ordination  with  exaggerated  wrist-  and  elbow-jerks. 

Electrical  reactions  are  unaltered,  at  least  in  the  early  stages  of  the 
disease.  With  advance  of  the  disease  the  features  of  a  purely  lateral 
sclerosis  become  very  pronounced;  those  of  tabes  less  so.  Muscular  paresis 
and  rigidity  become  marked,  and  the  patient  is  unable  to  leave  his  bed. 
There  is  no  localized  atrophy  of  the  muscles,  although  general  wasting  is 
not  uncommon  in  the  late  stages  of  the  disease.  Very  rarely  there  may  be 
atrophy  of  the  optic  nerve,  the  ocular  muscles  remaining  intact.  The 
sphincters  of  the  bladder  and  rectum  are  sometimes  involved;  at  others  not, 
that  of  the  bladder  more  frequently,  producing  difficult  micturition.  On 
the  other  hand,  by  rest  and  tonic  treatment  the  spastic  sj'mptoms 
may  be  diminished,  while  ataxia  remains  unchanged.  The  mind  remains 
normal. 

Diagnosis. — This  is  usually  easy,  enough  of  the  symptoms  of  each 
lesion  being  present  to  show  the  existence  of  a  combined  disorder.  The 
absence  of  co-ordination  on  the  one  hand  and  increase  of  knee-jerk  on  the 
other  are  the  two  antipodal  symptoms  around  which  others  of  each  lesion 
cluster.  The  presence  of  the  Babinski  reflex  is  regarded  as  distinctive 
of  organic  as  distinguished  from  functional  paraplegia.  So  it  is  in  asso- 
ciation with  other  signs  indicative  of  organic  disease.  It  is  not,  however, 
pathognomonic  and  may  be  found  in  pure  functional  conditions,  as,  for 
example,  uremia  affecting  the  brain.  Its  presence,  when  of  the  typical 
type — i.  e.,  when  the  upward  exten.sion  of  the  big  toe,  especially,  is  slow — 
strongly  suggests  organic  disease  of  the  central  motor  tracts. 

Then,  as  to  differential  diagnosis,  myelitis  may  present  similar  symp- 
toms. On  the  other  hand,  myelitis  is  usually  a  disease  of  sudden  develop- 
ment, characterized  by  a  rapid  increase  of  symptoms  as  contrasted  with 
the  slower  course  of  the  disease  under  consideration.  Friedreich's  ataxia 
resembles  ataxic  paraplegia  closely  in  its  pathology,  but  the  exaggeration  of 
the  tendon  reflexes  is  rare  and  the  spasticity  is  absent  in  the  former.  Cere- 
bellar tumor  may  be  mentioned  with  better  reason  as  a  disease  which  may  be 
confounded,  but  in  this  headache,  optic  neuritis,  and  vomiting  are  peculiar, 
and  while  there  is  ataxic  gait,  it  is  the  reel  of  a  drunken  man,  and  not 
the  inco-ordination  of  tabes.  So,  too,  there  may  be  spastic  symptoms  in 
cerebellar  disease,  but  they  are  less  decided  than  in  combined  sclerosis. 
Disseminated  sclerosis  is  a  disease  with  which  combined  sclerosis  may  be 
confounded,  and  although  it  is  the  less  pronounced  forms  of  each  which 
give  rise  to  doubt,  it  is  important  to  remember  that  the  disseminated 
sclerosis  has  been  found  postmortem  in  cases  which  presented  the  clinical 
symptoms  of  spastic  paraplegia  during  life.  Whence  it  is  not  impossible 
that  it  may  also  present  in  its  earlier  stages  symptoms  of  ataxic  paraplegia. 

Prognosis. — This  is  unfavorable  as  to  recovery,  but  the  disease  is  so 
slow  in  its  development  that  death  commonly  results  from  intercurrent  dis- 
ease or  from  complications  favored  by  the  disease  itself,  such  as  disorders 


922  DISEASES  OF  THE  NERVOUS  SYSTEM 

of  the  urinary  organs,  bed-sores,  and  septic  complications.     The  disease 
may  be  arrested  for  a  time. 

Treatment. — The  treatment  is  mainly  symptomatic:  warm  baths  and 
a  warm  climate  for  the  spastic  symptoms;  massage  and  exercise  for  the 
ataxic  symptoms.  Electricity  and  spinal  stimulants  like  strychnin  are  con- 
tra-indicated as  calculated  to  increase  the  spastic  symptoms,  while  bromids 
and  belladonna  may  be  of  service  in  controlling  these.  If  a  specific  history'- 
can  be  traced,  the  disease  should  be  appropriately  treated  by  iodids  or  mer- 
curials, and  when  anemia  is  present  the  treatment  should  be  directed  to 
the  improvement  of  this  condition. 

SYRINGOMYELIA. 

Definition. — A  term  applied  to  all  cavities  in  the  spinal  cord,  most  of 
which  are  surrounded  by  an  overgrowth  of  neuroglia. 

Etiology  and  Morbid  Anatomy. — The  cavities  are  formed  by  defective 
closure  of  the  central  spinal  canal  or  by  the  breaking  down  of  residual 
embryonal  tissue  or  of  gliomatous  tissue.  The  cavity  of  a  syringomyelia 
is  usually  in  the  posterior  part  of  the  cord,  extending  toward  the  posterior 
comua.  It  may  prevail  throughout  the  entire  extent  of  the  cord,  but  in 
most  cases  involves  only  the  cervical  or  thoracic  regions  or  more  limited 
areas.  The  transverse  section  is  oval  or  circular,  but  it  may  be  fissure-like 
or  quadrilateral,  even  irregular.  On  the  other  hand,  a  primary  hemorrhage 
of  traumatic  origin,  or  even  without  trauma,  may  be  the  starting-point  of  a 
syringomyelia,  and  it  has  been  supposed  that  such  a  hemorrhage  into  the 
spinal  cord,  occurring  at  birth  from  difficult  labor,  may  later  in  life  cause 
the  s3'mptoms  of  syringomyelia.  So,  also,  compression  of  the  cord  due  to 
fracture  or  dislocation  may  furnish  the  condition  which  wHl  result  in  cavity 
formation.  The  cavities  may  be  multiple.  The  term  hydromyelia,  applied 
to  the  forms  in  which  the  cavity  is  merely  the  dilated  central  canal,  is 
falling  into  disuse,  and  there  is  no  real  difference  between  this  and  the  other 
varieties.     It  is  probable  that  hydromyelia  may  change  into  s3'ringomyelia. 

Symptoms. — The  milder  degrees  are  without  sj'mptoms  and  are  often 
overlooked.  Symptoms  usually  make  their  appearance  about  the  period  of 
adolescence.  They  are  mostly  gradual  in  development,  and  are  partly  the 
result  of  the  secondary  processes  of  distention  which  derange  natural 
function.  The  symptoms  are  influenced  also  by  the  situation  of  the  cavity, 
which  is  found  most  frequently  in  the  cervico-thoracic  region,  whence  the 
arms  and  neck  are  correspondingly  affected.  They  depend  also  on  the 
greater  involvement  of  the  gray  matter  of  the  cord. 

The  essential  symptoms  are  modified  sensibility;  chiefly  to  pain,  tem- 
perature, and  to  a  less  degree  simple  touch;  also  muscular  atrophy,  the 
latter  progressive  in  development;  and  trophic  disturbances.  The  sensory 
symptoms  are  the  earlier  and  more  constant.  The  sense  of  tactile  im- 
pression may  be  lost  by  involvement  of  its  path,  which,  as  has  been  said, 
is  not  precisely  known  after  it  enters  the  posterior  roots,  though  it  is  probably 
in  the  posterior  and  lateral  columns.  The  comparative  raritj-  of  this 
involvement  may  be  said  to  be  due  to  the  difficulty  in  destroying  this 
path  completely.     Derangement  of  the  senses  of  pain  and  temperature  is 


SYRINGOMYELIA  923 

probably  due  to  implication  of  the  central  gray  matter,  since  it  is  through 
it  that  these  impressions  probably  radiate  to  the  white  conducting  tracts 
of  the  opposite  side.  The  extension  of  the  process  to  the  lateral  columns 
probably  explains  the  derangement  of  pain  and  thermal  sensations,  in 
portions  of  the  body  below  the  level  of  the  cavity  in  the  spinal  cord.  There 
may  not  only  be  a  loss  of  thermal  sense,  but  it  may  be  reversed  in  that 
heat  is  felt  as  cold,  and  vice  versa.  So,  also,  subjective  sensations  are 
felt,  including  heat  and  cold,  or,  in  their  absence,  pain,  which  may  be 
neuralgic  in  character  and  irregular. 

The  muscular  atrophy  is  the  result  of  injury  to  the  motor  cells  of  the 
anterior  comua  from  compression  or  destruction  of  these  cells.  This 
causes  degeneration  of  the  nerves  and  wasting  of  the  muscles,  and  along 
with  it  is  a  lowered  electrical  irritability.  There  is  also  muscular  weakness, 
involving  the  trunk  muscles,  and  possibly  to  this  is  due  the  lateral  cur- 
vature. If  the  legs  are  affected,  it  is  generally  from  simple  spastic  paralysis 
from  pressure  on  the  pyramidal  tracts,  but  sensory  changes  in  the  lower 
limbs  occur.  Great  wasting  of  the  legs  indicates  lumbar  involvement,  and 
the  presence  of  ataxic  symptoms  points  to  involvement  of  the  posterior 
columns.  The  remaining  symptoms  are  not  essential,  but  may  be  incident- 
ally present  from  the  action  of  the  causes  which  usually  produce  them. 

The  reflexes  may  or  may  not  be  increased,  and  may  in  rare  cases  be  lost, 
while  tremor  of  the  limbs  has  been  noticed  in  some  cases. 

Trophic  symptoms  are  not  rare  in  the  parts  affected  by  sensory  loss. 
The  skin  may  be  glossy  and  thin,  or  thick  and  homy,  while  there  may  be 
eczema,  herpes,  bullae,  and  even  ulceration  and  gangrene.  The  naUs  may 
become  fissured  and  drop  off.  There  may  bs  deformity  and  absence  of  the 
end  phalanges  and  lingual  hemiatrophy.  Vasomotor  disturbances  are  more 
common,  including  coldness,  lividity,  or  redness  with  swelling  and  heat. 
There  may  be  sweating,  brittleness  of  bone,  and  joint  changes  like  those  of 
tabes. 

The  area  of  the  cranial  nerves  may  be  invaded  when  there  is  involve- 
ment of  the  meduUa  oblongata.  The  phenomena  may  include  paralysis  of 
one  vocal  cord,  the  tongue  and  face,  difQculty  in  swallowing,  of  breathing, 
and  embarrassed  heart's  action.  The  eyes  may  be  disordered,  and  the 
pupils  unequal,  but  the  other  special  senses  escape. 

Diagnosis. — This  is  based  upon  the  sensory  symptoms,  and  of  these 
thermo-anesthesia  and  analgesia  rather  than  tactile  insensibility,  together 
with  muscular  atrophy  succeeding  after  some  interval.  Cervical  pachy- 
meningitis causes  like  symptoms  similarly  distributed.  J.  Hendrie  Lloyd, 
in  an  important  paper,  ^  has  also  called  attention  to  certain  traumatic 
affections  of  the  cervical  region  of  the  cord  simulating  syringomyelia. 
Cervical  pachymeningitis  runs  a  more  rapid  course;  the  anesthesia  includes 
all  varieties  of  sensation  and  corresponds  more  nearly  in  its  distribution 
to  that  of  the  muscular  atrophy,  pain  is  more  conspicuous,  and  the  reaction 
of  degeneration  is  commonly  present  in  the  wasting  muscles,  and  later, 
signs  of  compression  of  the  cord  are  observed. 

The  symptoms  of  syringomyelia  are  sometimes  simulated  by  the  anes- 
thesia and  wasting  of  anesthetic  leprosy,  but  in  the  latter  disease  the  trophic 

1  Read  before  the  Philadelphia  Neurological  Society,  March  26,  1894. 


924  DISEASES  OF  THE  XERVOUS  SYSTEM 

changes  arc  more  marked,  the  phalanges  often  drop  off,  while  the  sensory 
symptoms  include  all  varieties  of  sensation.  The  ncr\-es  may  be  enlarged 
and  the  leprosy  bacillus  may  be  foimd. 

Progressive  mtiscular  atrophy  differs  in  the  absence  of  altered  sensation. 
An  intramedullary  spinal  tumor  in  the  same  situation  as  a  syringomyelia 
furnishes  almost  identical  symptoms,  and  may  have  an  identical  origin  if 
it  starts  from  the  neuroglia,  but  the  symptoms  may  be  more  rapid  in  their 
development. 

The  diagnosis  of  syringomyelia  is  sometimes  exceedingly  difficult  to 
make,  as  the  characteristic  disturbances  of  sensation  may  be  absent. 

Prognosis. — This  is  ultimately  fatal,  although  the  course  is  slow, 
extending  over  a  long  period.  Toward  the  end  the  course  is  more  rapid, 
death  resulting  from  exhaustion  or  interference  with  the  functions  of  the 
medulla  oblongata. 

Treatment. — This  can  only  consist  in  measures  to  combat  symptons, 
and  tendencies  to  them,  such  as  cystitis,  bed-sores,  and  the  like. 

Morvan's  Disease. 

Synonyms. — Analgia  Panaritium;  Analgesic  Paresis  with  Panaritium; 
Painless  Whitlows. 

Definition. — This  term  is  applied  to  a  chronic  affection  described 
in  1883  by  a  Breton  physician  named  Mor\'an,  which  is  characterized 
by  neuralgic  pains,  tactile  and  thermal  anesthesia,  analgesia,  and  painless 
destructive  felons  (paronychia).  The  disease  is  probabl)-  in  most  cases 
the  same  as  syringomyelia;  in  some  instances  it  is  leprosy.  Twenty  cases 
were  recognized  in  a  population  of  50,000  in  Brittany.  One  or  two  cases 
have  been  reported  in  America. 

Zambuco,  of  Constantinople,  found  in  the  broken-down  matter  of  the 
sj'ringomyelic  cavity  of  what  seemed  a  typical  case,  Hansen's  lepra  bacillus. 
In  two  well-studied  cases  reported  by  Marinesco  and  Jeanselme  to  the 
Soci6t6  Medicale  des  Hopitaux  de  Paris,  February  12,  1897,  the  typical 
lesions  were  found,  but  no  bacilli. 

COMPRESSION  OF  THE  SPINAL  CORD. 

Synonyms. — Compression  Myelitis;  Pressure  Paralysis  oj  the  Spinal 

Cord. 

Definition. — Under  this  head  are  included  all  forms  of  paralysis  due 
to  gradual  compression  of  the  cord  from  whatever  cause. 

Etiology. — A  large  number  of  causes  may  operate  in  the  wav  indi- 
cated, among  which  are  tumors  or  inflammatory  new  formations,  including 
syphilitic  products  either  in  the  membranes  or  outside  of  them,  caries 
of  the  vertebrae,  especially  the  form  known  as  Pott's  disease  or  tubercu- 
losis of  the  vertebras,  cancer  of  the  vertebrae,  echinococci  and  cysticerci 
in  the  vertebral  canal.  Extraspinal  causes  may  also  produce  erosion  of 
the  vertebras  and  compression  of  the  cord;  among  these  are  aneurysm 
of  the  aorta,  retroperitoneal  sarcoma,  lymphadenoid  growths,  and  sup- 


COMPRESSION  OF  THE  SPIXAL  CORD  925 

purating  kidney;  also  retropharyngeal  abscess.  Pott's  disease  is  by  far 
the  most  frequent  cause. 

Morbid  Anatomy. — The  changes  in  the  cord  as  the  result  of  com- 
pression are  best  studied  in  the  compressions  due  to  dislocation  of  the 
vertebrae  in  the  breaking  down  of  the  bodies  of  one  or  more  from  tubercu- 
lous infiltration,  or  as  the  result  of  intrusion  into  the  spinal  canal  of  foci 
of  cheesy  pus  from  the  posterior  surface  of  the  bodies  of  the  vertebrae. 
Macroscopically,  the  cord  is  often  smaller,  softer,  and  sometimes  bent. 
In  old  cases  it  may  be  harder.  The  term  myelitis  has  been  applied  to  the 
changes  thus  produced  in  the  cord,  but  careful  examination  fails  in  most 
cases  to  find  any  of  the  usual  histological  products  of  inflammation,  and 
the  condition  is  one  of  softening.  In  the  early  stages  the  axis-cylinders 
are  swollen,  and  fatty  granular  cells  may  be  present.  The  nerve-cells 
undergo  more  or  less  alteration  depending  on  the  degree  of  pressure.  At 
a  later  stage  may  be  seen  a  secondary  overgrowth  of  neuroglia,  replacing 
the  destroyed  nervous  tissue,  first  loose,  later  firm  and  fibrillated.  After 
a  certain  duration  there  may  be  ascending  and  descending  secondary  de- 
generation of  certain  systems  of  fibers  in  the  spinal  cord. 

Symptoms. — When  tuberculous  disease  of  the  spine  is  the  cause,  the 
resulting  deformity — kyphosis — is  usually  seen  long  before  the  symptoms 
of  compression  of  the  cord  are  present.  On  the  other  hand,  when  the 
erosion  is  due  to  aneurysm  or  growths  within  the  thorax  or  abdomen, 
the  subjective  symptoms  appear  before  the  deformity,  or  more  frequently 
without  external  deformity.  The  first  of  these  sjnnptoms  is  usually 
pain  at  the  seat  of  the  compression,  which  often  does  not  amount  to  more 
than  a  dull  ache,  while  at  another  time  it  is  extremely  severe.  It  is  also 
aggravated  by  bending  or  straightening  the  body.  Again,  the  pain  is 
distributed  along  the  course  of  the  nerves,  when  the  compression  is  exerted 
on  the  nerve  roots.  Previous  to  such  pain  and  associated  with  it  are 
paresthesias  of  various  kinds,  such  as  numbness,  tingling,  and  formication. 
More  rarely  there  is  impaired  sensibility,  the  same  degree  of  pressure  which 
deranges  the  function  of  motor  fibers  having  often  no  effect  on  the  sen- 
sory. Marked  anesthesia  is  rare,  and  then  only  in  the  last  stages.  When 
the'  lesion  is  confined  to  the  thoracic  region,  there  may  be  girdle  sensation 
and  pain  in  the  course  of  the  intercostal  nerves. 

With  the  foregoing  soon  become  associated  motor  symptoms,  which 
may  consist  in  stiffness,  giving  rise  to  difficulty  in  moving  arms  or  legs, 
with  peculiarity  of  gait,  or  there  may  be  simple  weakness  or  paresis, 
increasing  to  complete  motor  paralysis.  These  symptoms  rarely  affect 
both  arms  or  legs  at  once,  but  rather  first  the  upper  and  then  the  lower 
limbs  if  the  lesion  is  in  the  cervical  region. 

The  seat  of  the  more  pronounced  sensory  and  motor  symptoms  varies 
with  the  segment  compressed.  Thus,  when  the  caries  is  in  the  upper 
cervical  region,  between  the  axis  and  the  atlas,  or  between  the  latter  and 
the  occipital  bone,  there  may  be  spasm  of  the  cervical  muscles,  the  head 
may  be  fixed,  and  movements  may  either  be  impossible  or  extremely  pain- 
ful. Retropharyngeal  abscess  may  be  the  cause  of  such  a  symptom,  as 
in  a  case  in  the  Montreal  General  •  Hospital  mentioned  by  Osier,  where 
movement  was  liable  to  be  followed  by  transient  instantaneous  paralysis 


926  DISEASES  OF  THE  NERVOUS  SYSTEM 

of  all  four  extremities  from  the  compression  of  the  cord.  The  patient  died 
in  one  of  the  attacks. 

If  in  the  lower  cervical  region,  there  may  be  dilatation  of  the  pupils 
from  interference  with  the  ciliospinal  center  or  ner\'e-fibers  arising  in  this 
center.  There  may  be  flushing  of  the  face  and  ear  on  one  side  or  unilateral 
sweating,  rigidity  of  the  muscles  of  the  neck,  whUe  the  sensory  and  motor 
symptoms  described,  if  present,  will  be  found  more  pronoimced  in  the  arms. 
The  deformity  of  tuberculous  caries  is  not  always  marked  in  this  locality, 
but  after  recovery  evidence  of  its  presence  may  be  found  in  a  conspicuous 
callus,  which  may  cause  permanent  rigidity  of  the  neck.  The  cortical 
inhibitory  influence  being .  suspended,  both  tendon  and  cutaneous  reflexes 
are  increased,  sometimes  so  markedly  as  to  produce  in  the  lower  extremities 
a  pronounced  type  of  the  spastic  paralysis,  with  increased  patellar  reflex 
and  anlde  clonus. 

When  the  thoracic  and  lumbar  segments  are  involved,  only  the  lower 
extremities  suffer  from  the  effect  of  compression;  commonly  the  paresis 
is  late,  though  rarely  it  may  appear  before  the  deformity  of  Pott's  disease. 
Girdle  sensation  and  pain  in  the  course  of  intercostal  ner^^es  were  named 
above  as  sensory  symptoms  of  compression  of  the  dorsal  cord.  Here, 
as  elsewhere,  motion  is  affected  before  sensation.  As  to  the  reflexes, 
since  the  reflex  arc  for  the  lower  tendon  reflexes  is  in  the  lumbar  region, 
compression  of  the  thoracic  cord  should  produce  an  increase  in  them, 
and  this  is  usually  the  case.  On  the  other  hand,  they  are  diminished 
when  the  lumbar  cord  is  compressed.  If  the  lower  thoracic  and  lumbo- 
sacral region  is  affected,  the  sphincters  are  apt  to  be  involved,  and  there 
is,  first,  difficulty  in  micturition,  then  retention,  and  finally  incontinence 
with  cystitis,  but  the  sphincters  may  also  be  involved  from  lesions  higher 
in  the  cord.  Yet  all  these  symptoms  may  disappear,  and  recovery  take 
place  after  many  months'  duration  of  the  disease. 

Trophic  symptoms  may  be  present  in  the  paralyzed  parts.  These 
may  include  herpetic  eruptions  in  the  course  of  the  nerves,  at  other  times 
derangement  of  nutrition,  manifested  by  bed-sores  forming  on  slight  ir- 
ritative provocation,  rapid  shedding  of  the  epidermis  and  brittleness  of  the 
nails.     With  the  involvement  of  their  trophic  center  the  muscles  may  waste. 

Diagnosis. — This  is  easy  when  there  are  evident  signs  of  caries  of  the 
spine,  manifested  by  prominence  of  spinous  processes  of  the  vertebrae 
and  by  tenderness  on  pressure.  Repeated  examination  of  the  spine 
should  be  made.  Nerve-root  symptoms,  or  symptoms  resulting  from 
pressure  of  nerve  roots,  as  they  pass  out  between  the  vertebrae,  are  always 
significant.  They  include  radiating  pains,  girdle  sensation,  and  hyperes- 
thesia or  anesthesia,  spasm  and  wasting.  Stiffness  on  motion  in  separate 
parts  of  the  spinal  column  is  also  significant.  Root  symptoms  are  said 
to  be  more  common  in  cancer  than  in  caries,  but  any  of  the  symptoms 
named  have  increased  diagnostic  value  if  there  has  been  cancer  elsewhere, 
especially  of  the  breast,  and  if  the  age  exceeds  40.  There  is  much  more 
pain  attending  the  paraplegia  of  cancer — whence  the  term  paraplegia- 
dolorosa,  when  the  pain  is  referred  to  areas  anesthetic  to  tactile  and  painful 
impressions.  Such  is  the  case  whenever  erosion  is  wrought  from  the  ab- 
domen outward,  as  by  retroperitoneal  growths  or  aneurysm. 


TUMORS  OF  THE  SPINAL  CORD  927 

Prognosis. — This  is  unfavorable  in  all  cases  except  tuberculous  spon- 
dylitis, which  often  terminates  in  cure,  for,  sooner  or  later,  especially 
with  suitable  treatment,  the  tuberculous  process  may  cease  and  the  symp- 
toms of  paralysis  disappear,  although,  of  course,  the  kyphosis  remains. 
However,  even  here,  if  the  paralysis  has  continued  for  some  time,  it  is 
likely  to  be  permanent.  In  some  cases  death  is  from  miliary  tubercu- 
losis, in  others  from  the  exhaustion  incident  to  bed-sores,  cystitis,  and 
pyelonephritis. 

Treatment. — Only  when  tuberculous  spondylitis  is  responsible  is 
there  hope  of  cure.  The  treatment  is  general,  by  the  usual  measures  found 
useful  in  tuberculosis,  such  as  cod-liver  oil  and  creasote  or  creasotol,  ■u'ith 
such  tonics  as  iron  and  iodin,  good  food,  fresh  air,  and  mechanical  ap- 
pliances suggested  by  the  orthopedic  surgeon.  These  should  be  so  ad- 
justed as  not  to  produce  pain.  Their  object  is  to  produce  extension  and 
thus  relieve  compression,  and  if  this  is  not  accomplished,  they  are  useless. 

Along  with  the  extension,  rest  in  bed  is  a  most  important  measure, 
and  in  many  cases  arrest  is  obtained  by  such  rest.  Local  measures,  like 
counter-irritation  and  the  hot  iron,  are  of  no  use — rather  harmful  than 
otherwise.  The  same  may  be  said  of  electrical  treatment  and  massage, 
except  so  far  as  they  are  useful  to  keep  up  the  nutrition  in  the  paralyzed 
muscles.  On  the  other  hand,  warm  bathing  is  useful  in  relieving  pain  and 
allaying  discomfort. 

Operative  treatment — laminectomy — has  lately  been  practised  with 
a  good  showing  of  result,  and  it  should  be  considered,  at  least,  after  other 
measures  have  failed.  Treatment  should  be  persevered  in,  as  recovery 
takes  place  sometimes  after  paralysis  has  long  persisted,  and  in  no  form 
of  tuberculosis  has  the  general  treatment  previously  recommended  been 
so  useful. 

In  the  incurable  forms  anodynes  must  be  employed  to  relieve  pain, 
including  even  the  hypodermic  use  of  morphin,  which  should  never  be 
used  without  bearing  in  mind  the  possibility  of  the  patient  acquiring  the 
morphin  habit. 

TUMORS  OF  THE  SPINAL  CORD  AND  MEMBRANES. 

Both  the  membranes  and  the  substance  of  the  cord  may  be  seats 
of  trunors,  while  the  cord  may  also  be  invaded  from  the  spinal  column 
by  enchondroma  or  sarcoma,  but  the  dura  usually  offers  a  successful  re- 
sistance to  tumors  on  its  outer  surface. 

Varieties. — From  the  spinal  column  enchondroma,  sarcoma,  endothe- 
lioma and  cancer  may  intrude  into  the  canal.  External  to  the  dura  mater 
in  the  extradural  space  occur  fatty  malignant  and  tuberculous  tumors,  while 
parasites  are  also  foruid  in  this  region.  The  extradural  tumors  may  spring 
from  the  dura  or  from  the  tissue  between  it  and  the  bone,  or  may  arise  out- 
side and  pass  through  the  intervertebral  foramina.  Subdural  tumors  may 
arise  from  the  inner  surface  of  the  dura,  the  arachnoid,  or  from  the  pia, 
and  may  include  sarcomata,  syphilitic,  tuberculous,  and  parasitic  growths. 
The  last  two  are  rare,  but  both  echinococci  and  cysticerci  have  been  met, 
developing  in  the  meshes   of  the  arachnoid.     Schlesinger  collected  44  cases 


928 


DISEASES  OF  THE  NERVOUS  SYSTEM 


of  ecchinococcus  disease.  When  the  parasite  is  intradural  it  is  round  or 
oval  and  compresses  the  cord.  The  dura  is  not  usually  implicated,  merely 
distended.  Of  the  44  cases  only  five  were  intradural,  so  that  the  extradural 
location  is  seven  times  more  frequent  than  the  intradural.  The  cysts 
are  usually  on  the  posterior  surface  of  the  cord  and  in  the  thoracic  portion 
of  the  vertebral  canal,  at  least  in  the  extradural  variety.  They  may  be  the 
size  of  a  pea,  of  a  walnut,  or  even  larger.  Their  contents  are  clear  and 
they  often  contain  daughter  cysts.  Their  growth  is  usually  slow.  It  is 
said  that  the  hydatids  are  sometimes  found  in  the  substance  of  the  bone. 

Fatty  tumors  are  also  rare,  but  have  been  found  and  are  probably 
congenital,  because  when  found  they  usually  are  associated  with  spina 
bifida.  In  the  cord  itself  occur  tuberculous, 
syphilitic,  sarcomatous  and  gliomatous  tumors. 
Glioma  and  sarcoma  are  the  most  common. 
Some  of  these  tumors  spring  from  the  pia 
mater,  but  tuberculous  growths  also  develop 
in  the  gray  matter.  Some  tumors  are  com- 
pound, as  myxosarcoma,  etc.  Sarcomatous  or 
carcinomatous  meningitis  occurs  infrequently. 

The  size  attained  by  tumors  of  the  spinal 
cord  and  membranes  is  necessarily  limited  by 


Fig.   155. — Sarcoma  of  the  Lower  Cervical  Cord- 
(Adamkieu'ics). 


Fig.  156. — Sarcoma  Compressing  the 
Cervical  Cord — (E.  Long  Fox). 


the  surrounding  space.  The  largest  do  not  exceed  two  inches  (5  cm.)  in 
diameter,  and  many  are  very  small,  not  larger  than  a  pea.  They  are  usually 
single,  rarely  multiple.  The  so-called  neuromata  are  usually  fibro-neuro- 
mata.     Tumors  developing  within  the  cord  may  lead  to  syringomyelia. 

Symptoms. — These  vary  with  the  seat  of  the  tumor  and  the  degree 
of  pressure  exerted.  When  the  latter  increases  slowly,  the  growth  may 
reach  quite  a  large  size  before  serious  symptoms  occur.  Pain  is  a  frequent 
and  conspicuous  symptom,  and  is  likely  to  be  maintained  by  pressure 
on  nerve  roots  which  are  in  the  way  of  the  growth.  The  seat  of  pain 
varies  with  the  course  of  the  nerves  impinged  upon,  and  may  be  of  every 
variety,  such  as  "burning,"  "tearing,"  "stabbing,"  "aching,"  "girdle 
sensations,"  and  the  like.  It  may  be  unilateral  or  bilateral,  and  is  worse, 
according  to  Horsley,  when  the  tumor  presses  forward.  Sometimes 
the  pain  is  in  the  spine  itself,  which  may  also  in  rare  instances  be  tender 
to  pressure.  When  the  growth  is  in  the  lower  lumbar  region,  the  pain 
may  be  referred  to  the  soles  of  the  feet,  and  may  ascend  from  this  seat. 
In  other  cases  there  is  hyperesthesia  of  the  skin,  which  may  be  associated 


TUMORS  OF  THE  SPINAL  CORD  929 

with  pain  felt  at  the  level  of  the  tumor,  or  pain  may  be  felt  in  anesthetic 
areas.     Very  rarely  pain  is  absent,  chiefly  in  extradural  lipoma. 

Muscular  spasm  is  also  frequent,  especially  when  the  tumor  springs 
from  the  membranes,  when  it  may  be  very  decided.  There  may  be  rigidity 
at  the  seat  of  the  growth,  most  marked  when  the  disease  is  at  the  more 
mobile  parts  of  the  spine,  as  the  cervical  region.  Then  there  is  apt  to  be 
pain  in  the  vicinity,  increased  by  motion.  Spasm  in  the  abdominal  muscles 
may  also  be  associated  with  girdle  pains.  Contractures  may  arise  in  the 
limbs,  both  those  supplied  by  nerves  directly  irritated  by  the  tumor  and 
by  those  given  off  lower  down.  It  is  important  to  note  the  seat  of  the 
rigidity  and  its  character,  which  may  aid  us  in  diagnosing  the  seat  of  the 
tumor,  whether  it  is  on  the  nerve  roots  or  conducting  tract  of  the  cord. 
Thus,  a  tumor  in  one-half  of  the  cord,  in  the  cervical  region,  may  cause 
persistent  contraction  of  the  arm  and  leg  on  the  side  of  the  growth,  and 
in  the  early  stage  of  thoracic  tumors  one  leg  only  may  be  rigid  at  a  time 
or  one  may  be  more  so  than  the  other.  In  the  thoracic  region  the  level  of 
the  pain  is  likely  to  be  a  little  below  the  level  of  the  growth,  and  the 
reflexes  centering  at  this  level  may  be  lost,  but  retained  in  the  legs. 

Paralysis  occurs  sooner  or  later  as  constantly  as  pain,  increasing 
gradually  with  the  pressure.  Paraplegia  is  more  common,  but  all  four 
limbs  may  be  paralyzed  by  a  timior  in  the  cervical  region,  one  limb  being 
usually  affected  before  the  other,  though  when  the  tumor  is  exactly  central, 
both  sides  are  affected  simultaneously.  Loss  of  sensation  follows  paralysis 
sooner  or  later.  It  corresponds  in  distribution  to  the  motor  palsy  when 
the  tumor  is  in  the  lumbar  region  of  the  cord,  but  if  higher  and  on  one  side, 
the  sensory  loss  may  be  greater  on  the  opposite  side;  and  the  symptoms 
may  be  those  already  described  under  the  head  of  Brown-Sequard's 
paralysis. 

Atrophy  follows  involvement  of  the  anterior  comua,  and  vasomotor 
disturbances  may  be  marked.  In  cases  of  prolonged  interruption  ascend- 
ing and  descending  degenerations  may  occur.  Tumors  not  infrequently 
cause  subacute  or  acute  softening,  whose  symptoms  may  mask  the  clinical 
picture. 

Diagnosis. — The  characteristic  symptoms  are  slow  development  of 
severe  and  constant  unilateral  root  symptoms,  later  bilateral,  at  the  level 
of  the  growth,  and  a  progressive  paralysis,  motor  and  sensory.  The  radi- 
ating pain  is  usually  at  the  level  of  the  tumor  or  below.  Pain  in  the  spine 
itself  is  an  important  sign.  Rigidity  of  the  muscles  of  the  spine,  muscular 
contractions  in  the  limbs,  early  and  marked  exaggeration  of  reflex  action 
when  the  cord  itself  is  involved,  are  also  important  signs,  especially  when 
associated  with  the  history  of  syphilis  or  tuberculous  disease.  Caries  of 
the  spine  may  produce  the  same  symptoms,  but  the  radiating  pains  are  less 
severe  and  the  effects  of  compression  of  the  cord  are  more  likely  to  be  bilat- 
eral, either  from  the  first  or  soon  after  their  commencement.  Tenderness 
of  the  spine  may  generally  be  elicited  by  careful  examination,  while  irregu- 
larity of  surface,  from  the  breaking  down  of  the  bone,  sooner  or  later  makes 
its  appearance.  When  the  tumor  is  in  the  bone  itself,  the  symptoms  at  first 
scarcely  differ  from  those  of  caries,  though  the  pain  on  motion  is  usually 
worse  in  the  former. 


930  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  symptoms  of  cervical  meningitis  also  closely  resemble  those  of 
tumor.  They  are,  however,  usually  bilateral  from  the  first  and  have  con- 
siderable vertical  extent.  Central  tumors  covering  a  like  area  may  produce 
identical  symptoms,  except  that  pain  is  usually  unimportant.  Pain  and  mus- 
cular atrophy  in  the  arms  without  wasting  occur  in  both  extramedullary 
tumor  and  meningitis,  but  wasting  is  likely  to  develop  later,  and  the 
diagnosis  between  the  two  conditions  may  be  extremely  difficult. 

Chronic  transverse  myelitis  also  closely  simulates  tumor  in  its  radiating 
pain,  sense  of  constriction,  progressive  paralysis,  and  a  differential  diag- 
nosis is  sometimes  impossible.  The  symptoms  here,  too,  are  from  the 
first  bilateral,  while  the  radiating  pain  is  commonly  not  severe  in  myelitis, 
which  invades  also  larger  areas  of  the  cord. 

Circumscribed  serous  spinal  meningitis  may  closely  simulate  clinically 
tumor  of  the  spinal  cord.  It  has  been  found  in  association  with  necrotic 
ostitis  of  the  vertebras  pachymeningitis,  caries  of  the  vertebrae,  adhesions 
between  the  dura  and  pia,  bony  projection  on  the  iimer  surface  of  a  verte- 
bra, and  meningo-myelitis.  A  few  cases  are  on  record  in  which  no  com- 
plication seemed  to  be  present.  At  operation  or  at  necropsy  a  collection  of 
clear  fluid,  resembling  cerebrospinal  fluid,  is  found  in  a  cyst,  the  wall  of 
which  is  made  by  the  delicate  pia.  Nothing  is  really  known  as  to  the 
cause  of  this  apparently  idiopathic  collection  of  fluid.  Inasmuch  as  it  is 
strictly  circumscribed,  it  produces  the  sj^mptoms  of  pressure  upon  the 
spinal  cord,  and  cannot  be  distinguished  clinically  from  spinal  tumor. 
Removal  of  the  fluid  by  operation  may  give  complete  relief  from  the  symp- 
toms, and  there  may  be  no  tendency  to  recurrence.  The  recognition  of  the 
condition  by  surgeons  is  therefore  of  much  practical  importance,  especially 
as  the  disorder  is  probably  more  common  than  the  paucity  of  reports  indi- 
cates.    Sometimes  the  meningitis  is  circumscribed  without  cyst  formation. 

As  to  the  exact  seat  of  the  tumor,  in  general  terms  it  may  be  said  that 
when  within  the  cord,  the  symptoms  are  those  of  a  gradually  increasing 
paraplegia  or  of  a  Brown-S6quard's  paralysis,  while  vasomotor  disturb- 
ances are  marked,  and  reflexes  are  bilaterallj'  influenced,  according  to  the 
law  explained.  Atrophy  means  involvement  of  the  ventral  comua.  Acute 
or  subacute  myelitis  may  be  associated  and  complicate  the  clinical  picture. 
Tumors  in  the  membranes  are  characterized  by  early  "root  symptoms," 
including  radiating  pains,  girdle  sensation,  and  hyperesthesia  or  anesthesia. 
Irritation  of  motor  nerves  may  cause  spasm  or  wasting,  ^\nth  paralysis 
late  in  the  disease. 

The  nature  of  the  tumor  may  be  inferred  only  from  the  historj-  of  the 
case,  syphilis  and  tuberculosis  giving  the  most  valuable  assistance.  Its 
seat  is  suggested  by  the  level  of  the  transverse  symptoms.  It  is  never 
below  these,  while  it  may  be  a  distance  of  three  or  four  vertebrae  above 
the  nerves  corresponding  to  the  highest  level  of  anesthesia  or  pain.  The 
diagnosis  of  tumor  from  other  transverse  lesions  of  the  cord  may  be  at 
times  impossible. 

Prognosis. — In  aU  forms  the  symptoms  gradually  increase  until  paraly- 
sis results,  unless  operative  interference  produces  a  more  favorable  termi- 
nation— a  practice  which  modem  methods  are  rendering  more  frequent 
and  justifiable. 


LESIONS  OF  CAUDA  EQUINA  931 

Treatment. — When  there  is  reason  to  believe  syphilis  is  present,  the 
antisyphilitic  treatment  may  be  used  with  reasonable  expectation  of  suc- 
cess, as  some  cases  of  syphilitic  meningitis  simulate  tumors.  Beyond  this, 
symptoms  must  be  met  as  they  arise.  Attempts  made  of  late  years  to 
formulate  the  laws  governing  surgical  operations  in  these  cases  have  been 
more  or  less  successful,  but  wider  experience  is  necessary  before  they  can 
be  thoroughly  relied  upon.  We  may,  however,  close  this  subject  with  the 
advice  of  Victor  Horsley,  whose  studies  on  surgery  of  the  nerv^ous  system 
entitles  his  opinion  to  the  highest  respect:  "If  it  is  clear  that  the  growth 
is  not  syphilitic,  and  that  no  good  can  be  done  by  other  treatment,  delay 
in  an  operation  can  only  cause  harm— can  only  result  in  a  less  favorable 
state  for  the  proceeding,  less  chance  of  recovery,  longer  and  greater  suffering, 
and  should,  on  every  ground,  be  avoided. " 

LESIONS  OF  THE  CAUDA  EQUINA  AND  CONUS 
MEDULLARIS. 

The  Cauda  equina  is  the  bundle  of  nerves  coming  off  from  the  lower 
cord  and  occupying  the  spinal  canal  from  the  second  lumbar  vertebra 
downward.  At  this  vertebra  the  cord  itself  ■  terminates  in  the  conus  medul- 
laris,  prolonged  into  the  thread-like  filum-  terminale.  Fractures  and  dis- 
locations in  the  lumbosacral  region  may  impinge  on  these  parts,  while  the 
filaments  of  the  nerves  of  the  cauda  equina  may  be  invaded  by  tumors  or 
compressed  by  cicatrices. 

Symptoms. — Compression  of  the  conus  and  of  the  last  sacral  nerves 
given  off  from  it,  such  as  may  be  caused  by  a  dislocation  of  the  first  lumbar 
vertebra,  produces  paralysis  of  the  bladder  and  rectum  and  loss  of  sexual 
power,  whence  it  has  been  inferred  that  the  anovesical  center  and  the 
center  for  the  sexual  functions  are  seated  in  this  part  of  the  cord.  This 
paralysis  may  be  the  only  symptom  or  it  may  be  associated  with  disturbance 
of  sensation  about  the  anus  and  in  the  perineum  and  external  genital  organs 
except  the  testicle,  the  latter  being  supplied  with  sensation  from  a  higher 
segment  of  the  cord. 

When  the  lumbar  nerve-roots^  are  involved,  from  the  second  to  the  fourth 
inclusive,  there  is  paralysis  embracing  all  the  muscles  of  the  thigh  and  leg 
except  the  outer  rotators  of  the  thigh,  the  flexors  of  the  knee  and  of  the 
ankles,  the  peroneal  muscles,  the  long  flexors  of  the  toes,  and  the  small 
foot  muscles.  There  is  also  loss  of  sensation  in  the  front,  inner,  and  outer 
parts  of  the  thighs  and  the  inner  side  of  the  leg  and  foot. 

Involvement  of  the  fifth  lumbar  and  first  and  second  sacral  nerves 
produces  paralysis  of  the  muscles  just  excepted,  and  loss  of  sensation  in  the 
outer  and  posterior  part  of  the  leg,  foot,  and  sole  of  the  foot.  Lesion  of  the 
third,  fourth,  and  fifth  sacral  and  coccygeal  nerves  causes  paralysis  of  the 
perineal  muscles,  the  bladder,  rectum,  and  of  the  external  genitals,  the 
coccygeus,  with  loss  of  sensation  in  the  back  of  the  thigh,  anus,  perineum, 
genital  organs,  and  skin  about  the  anus  and  coccyx. 


1  Of  the  lumbar  nerves,  the  first  root  appears  between  the  first  and  second  lumbar  vertebr£e,  the  fifth 
between  the  last  lumbar  and  the  base  of  the  sacrum.  The  four  upper  sacral  nerves  pass  from  the  spinal 
canal  through  the  sacral  foramina,  the  fifth  between  the  sacrum  and  coccyx. 


932  DISEASES  OF  THE  XERVOUS  SYSTEM 

SPINA  BIFIDA. 

Synonyms. — Split  Spine;  Hydrorrachis;  Myelocele;  Meningocele. 

Definition. — A  name  applied  to  a  congenital  defect  in  the  closure  of  the 
spinal  canal,  through  which  protnidcs  a  sac-like  portion  of  the  dura  contain- 
ing cerebrospinal  fluid,  at  times  a  part  of  the  cord,  either  normal  or  altered, 
and  forming  also,  as  a  rule,  an  external  prominence  of  tumor  covered  by  skin. 

Description. — The  tumor  is  found  commonly  in  the  lumbar  and  sacral 
portions  of  the  spine,  rarely  in  vaote  than  one  place,  very  rarely  throughout 
the  whole  column.  Its  size  ranges  from  that  of  a  small  nut  to  that  of  an 
orange,  and  occasionally  it  is  so  large  as  to  interfere  with  the  birth  of  a 
child  afflicted  with  it.  On  section  of  the  skin  the  protruding  sac  of  the 
dura  is  seen  and  beneath  this  the  arachnoid.  Rarely  is  the  dura  cleft  so 
that  the  sac  is  formed  by  the  arachnoid  only.  There  may  be  a  dilatation  of 
the  central  canal — hydromyelia — when  the  substance  of  the  cord  is  found 
more  or  less  atrophied,  while  the  central  canal  communicates  directly 
with  the  cavity  of  the  spina  bifida.  At  other  times  the  cord  is  normal, 
while  its  lower  end  may  be  adherent  to  the  sac.  A  tumor  of  similar  char- 
acter is  occasionally  seen  protruding  through  the  skull. 

Symptoms. — At  first  there  are  usually  no  clinical  symptoms.  By 
pressure  the  contents  of  the  tumor  can  often  be  forced  into  the  spinal  canal, 
causing  expansion  of  the  fontanels  and  increase  of  cerebral  pressure  -nath  its 
consequences — viz.,  somnolence,  with  changes  in  the  pulse  and  breathing, 
which  may  be  fatal  if  the  pressure  is  continued.  The  absence  of  such 
symptoms  goes  to  show  that  communication  of  the  tumor  with  the  spinal 
cord  is  cut  oE. 

With  the  lapse  of  time  the  tumor  usually  grows  slowly,  and  the  effects  of 
pressure  on  the  spinal  cord  or  cauda  equina  appear.  These  are  paralysis, 
atrophy,  anesthesia,  bed-sores,  vesical  derangements,  talipes  varus,  and 
trophic  phenomena,  of  which  perforating  ulcer  of  the  foot  is  one.  The  sac 
may  burst,  or  the  walls  become  inflamed,  converting  the  contents  into  pus. 

Prognosis  and  Treatment. — Unless  removed  by  surgical  interference, 
the  child  dies  sooner  or  later  of  exhaustion.  The  tumor  has  been  rarely 
obliterated  by  gradually  increasing  pressure  or  by  injecting  the  cavity, 
after  evacuation  of  the  fluid,  wdth  iodin,  producing  obliteration  through  an 
inflammatory  process.  Other  surgical  measures  may  be  found  in  text- 
books on  surgery. 

PROGRESSIVE  BULBAR  PALSY. 

Synonyms. — Polioencephalitis  inferior  chronica;  Glossolahiopharyngeal Paraly- 
sis; Paralysis  of  the  Tongue,  the  Soft  Palate,  and  the  Lips; 
Duchenne's  Disease;  Atrophic  Bulbar  Paralysis. 

Definition. — Bulbar  palsy  is  a  progressive  paralysis  invading  the  lips, 
the  tongue,  the  palate,  the  pharynx  and  larynx,  and  in  more  advanced 
cases  the  lower  face  muscles  due  to  lesion  of  the  motor  nuclei  in  the  medulla 
oblongata  (or  bulb),  whence  arise  the  ner\'es  distributed  to  those  parts. 

Etiology. — Primary  progressive  bulbar  palsy  is  difficult  to  account  for. 
It  is  more  frequent  in  men,  and  sometimes  heredity  or  family  tendency  is 


PROGRESSIVE  BULBAR  PALSY 


933 


noted.  It  has  been  ascribed  to  the  overuse  of  the  muscles  of  the  mouth, 
as  in  the  blowing  of  wind-instruments ;  to  a  tumor  in  the  medulla  oblongata 
or  vicinity;  while  syphilis,  to  which  so  many  of  the  unaccountable  lesions  of 
the  nervous  system  are  ascribed,  is  less  commonly  held  responsible  for 
this  affection  than  for  some  others.  Cold,  emotional  excitement,  and 
extreme  fatigue  have  all  been  named  as  causes.  Most  frequently,  however, 
no  cause  is  traceable. 

Morbid  Anatomy. — Most  writers  concede  that  the  lesion  starts  in  the 
motor  nuclei  of  the  medulla  oblongata.  It  may  be  that  the  entire  motor 
apparatus  from  the  muscular  fiber  to  the  ganglionic  cell  is  invaded  simulta- 
neously. Certain  it  is  that  bulbar  paralysis  is  often  associated  both  with 
progressive  spinal  muscular  atrophy  and  amyotrophic  lateral  sclerosis, 
the  symptoms  now  of  one  and  now  of  the  other  preceding.     There  can  be 


Fig.   157. — Situation  of  the  Granial  Nerves — [after  Edinger). 
Cranial  nerve  nuclei,  oblongata,  and  pons  represented  as  transparent.     Motor  nuclei,  black; 
sensitive  nuclei,  red. 

no  doubt  that  these  three  conditions  are  closely  allied.  The  nature  of  the 
lesion  is  the  same  in  each,  the  motor  cells  in  each  are  involved,  the  muscles 
are  wasted  in  each,  though  the  particular  ones  involved  vary  as  the  situation 
of  the  motor  cells  is  different. 

The  anatomical  lesion  is  an  atrophy  of  the  motor  cells  of  the  medulla 
oblongata.  The  nucleus  of  the  hypoglossus,  the  nucleus  of  the  pneumo- 
gastric,  to  a  less  degree  that  of  the  facial  and  that  of  the  glossopharyngeal 
are  all  involved,  while  the  sensory  nuclei  are  intact.  Very  rarely  the  nuclei 
of  the  ocular  nerves,  third,  fourth,  and  sixth,  are  involved.  From  these 
nuclei  the  degeneration  extends  to  the  nerves  which  have  their  origin  in 
them,  and  thence  to  the  muscles  to  which  they  are  distributed. 

The  nature  of  the  degeneration  is  a  more  or  less  complete  destruction 
of  the  motor  cells.  In  addition,  there  is  an  overgrowth  of  neuroglia  tissue 
and  a  thickening  of  the  walls  of  the  blood-vessels.  The  nerve  fibers  of 
the  pyramidal  tract  may  undergo  degeneration. 

Symptoms. — The  symptoms  of  progressive  bulbar  paralysis  are  exceed- 
ingly gradual  in  their  development.  The  first  symptom  noticeable  is 
usually  a  difficulty  in  the  pronunciation  of  words  containing  letters  which 
require  the  use  of  the  tongue  in  their  formation,  such  as  E,  R,  L,  S,  G  (hard), 


934  DISEASES  OF  THE  NERVOUS  SYSTEM 

K,  D,  T,  and  N.  Still  later  there  is  difficulty  in  pronunciation  of  words 
requiring  the  aid  of  the  lips,  as  P,  B,  F,  V,  0,  A  (long),  and  the  sound  of  O 
in  tool,  while  whispering  becomes  impossible. 

Symptoms. — Concurrently  with  these  symptoms  the  tongue  and  lips  are 
observed  to  waste,  the  tongue  becomes  thinner  and  narrower,  the  lips  thin 
and  compressed  in  appearance,  the  loss  of  power  being  commensurate  with 
the  degree  of  wasting.  Fibrillary  tremors  are  usually  seen  in  the  tongue,  and 
the  mucous  membrane  may  be  thrown  into  transverse  folds.  Finally,  the 
tongue  cannot  be  protruded,  or  can  be  brought  only  to  the  edge  of  the  teeth, 
while  the  mouth  cannot  be  closed  because  of  complete  paralysis  of  the  orbicu- 
laris oris  muscle.  In  more  advanced  stages  other  muscles  of  the  face  become 
involved,  the  labionasal  fold  is  less  distinct,  and  the  face  becomes 
expressionless. 

Before  this  degree  has  been  attained,  however,  the  muscles  of  the 
palate  have  commenced  to  fail  in  their  action,  and  thus  a  further  difficulty 
in  the  articulation  of  words  is  added,  whUe  the  voice  is  nasal.  Fluid  begins 
to  pass  through  the  nose  when  swallowing  is  attempted.  The  difficulty  in 
swallowing  is  increased  by  growing  paralysis  0}  the  pharyngeal  muscles,  and 
is  further  aggravated  by  the  inability  of  the  tongue  to  carry  the  bolus  of 
food  backward.  Feeding  the  patient  is  a  troublesome  process,  the  food 
being  scattered  all  about  and  sometimes  thrown  to  a  considerable-  distance, 
by  the  act  of  coughing  facilitated  by  absence  of  power  in  the  lips  to  retain 
substances  in  the  mouth.  By  this  time,  too,  the  laryngeal  muscles  are  in- 
volved, and  the  patient's  efforts  to  speak  resvdt  in  mere  grunts. 

Thus  he  cannot  talk,  he  cannot  swallow,  he  cannot  close  his  mouth 
he  cannot  expectorate,  the  saliva  flows  from  his  mouth  because  he  can 
neither  swallow  nor  close  his  lips,  and  the  term  "driveling  idiot "  well  covers 
the  impression  caused  by  his  appearance.  Yet  his  mental  powers  are 
unimpaired,  and  may  remain  so  until  the  last.  The  motor  electrical 
phenomena  in  the  muscles  involved  may  be  altered,  and  the  reaction  of 
degeneration  may  be  present. 

To  these  sArmptoms  are  to  be  added  complications  due  to  the  paralysis. 
From  the  difficulty  in  swallowing,  particles  of  food  may  enter  the  larynx, 
be  insufflated  to  the  deeper  parts  of  the  lungs,  and  there  cause  a  pneumonia 
which  may  be  fatal,  or  the  fragment  which  enters  the  larynx  may  be  so 
large  as  to  cause  death  by  suffocation. 

In  rare  cases  the  lower  distribution  of  both  facial  nen-es  is  involved, 
producing  diplegia  facialis;  but  the  upper  distribution  usually  escapes. 
Or  there  may  be  parah^sis  of  the  ocular  nerves  to  which  it  may  be  confined 
(anterior  bulbar  paralysis  or  progressive  ophthalmoplegia  of  von  Graefe). 
Even  the  muscles  supplied  by  the  spinal  accessory  and  the  motor  branch  of 
the  trifacial  may  be  invaded.  In  all  these  instances  the  nuclei  of  the 
corresponding  nerves  are  affected. 

Diagnosis. — The  diagnosis  is  generally  easy,  the  sjTnptoms  are  so 
characteristic  and  so  evident.  For  a  typical  case  they  must  be  purely 
motor;  they  must  be  disassociated  from  other  muscular  involvements 
which  would  go  to  make  them  a  part  of  progressive  spinal  muscular  paralysis 
or  amyotrophic  lateral  sclerosis.  If  there  are  disturbances  of  sensation, 
paralysis  of  the  upper  division  of  the  facial,  of  nerves  of  special  sense,  the 


ACUTE  BULBAR  PALSY  935 

disease  is  not  true  bulbar  paralysis.  There  must  be  some  general  involve- 
■ment  of  the  medulla  oblongata,  thrombosis,  or  embolism,  a  tumor  develop- 
ing near  it  or  diffuse  sclerosis  through  it. 

There  is  a  glossolahiopharyngeal  paralysis  of  cerebral  origin  known  as 
"pseudobulbar  paralysis,"  in  which  there  is  partial  or  complete  paralysis 
of  the  tongue  and  lips,  due  to  bilateral  and  possibly  even  unilateral  cerebral 
lesions.  Close  examination  will,  however,  detect,  sooner  or  later,  devia- 
tions from  the  typical  course,  which  include  absence  of  fibrillary  tremor, 
and  of  atrophy,  and  of  reaction  of  degeneration.  The  symptoms  tend,  too, 
to  occur  first  with  the  involvement  of  the  limbs  of  one  side  and  later  of  those 
of  the  ■other  side.  Mentality  is  much  affected,  and  the  reflexes  may  be 
exaggerated.  Bulbar  tumors  run  a  like  chronic  course,  but  almost  always 
present  unilateral  symptoms. 

Prognosis. — The  disease  is  invariably  sooner  or  later  fatal,  although 
it  is  said  that  its  progress  may  be  delayed  by  treatment;  this,  however,  is 
questionable. 

Treatment. — If  there  be  any  suspicion  that  syphilis  is  the  cause,  mercury, 
salvarsan  or  iodid  of  potassium  should  be  used.  Galvanism  is  recommended, 
electrodes  being  applied  to  the  two  mastoid  processes  daily  for  two  or  three 
minutes,  the  current  often  reversed.  The  sympathetic  nerve  and  the 
affected  muscles  of  the  lips  and  the  tongue  may  be  similarly  treated,  faradi- 
zation being  also  substituted  for  galvanism  in  the  case  of  the  muscles.  Deg- 
lutition may  even  be  excited  by  galvanism  when  it  begins  to  be  impaired. 
This  is  accomplished  by  placing  the  anode  on  the  nape  of  the  neck  and  the 
cathode  on  one  side  of  the  larynx.  At  every  cathodal  closure,  or  every 
time  that  the  cathode  is  carried  across  the  side  of  the  larynx,  there  is  a 
reflex  act  of  deglutition.  When  deglutition  becomes  very  difficult,  the 
stomach-tube  should  be  used  and  nutrient  substances  thus  introduced. 
Great  care  should  be  exercised  in  feeding  the  patient  without  the  tube, 
lest  the  food  pass  into  the  trachea  and  cause  suffocation.  Hence,  too, 
the  use  of  the  tube  should  not  be  too  long  deferred. 

Iodid  of  potassium  should  be  given  in  such  doses  as  the  stomach  will 
tolerate,  while  salivation  may  be  controlled  by  atropin — i/ioo  to  1/60 
grain  (0.00066  to  o.ooii  gm.). 

Acute  Bulbar  Palsy. 

Etiology. — Besides  the  chronic  or  progressive  form  of  bulbar  palsy, 
there  is  an  acute  variety  which  is  caused  by  hemorrhage  into  the  pons  and 
medulla,  or  possibly  by  thrombosis  or  embolism  of  the  vessels  supplying 
these  centers — viz.,  tne  anterior  spinal,  vertebral,  and  basilar.  Inflamma- 
tion of  the  medulla  oblongata  is  also  a  cause,  as  in  polioencephalomyelitis. 
Thrombosis  may  occur  in  any  of  the  vessels,  and  is  commonly  due  to  athero- 
matous or  syphilitic  endarteritis. 

Hemorrhage,  thrombosis,  and  embolism  are  subject  to  the  same  causes 
here  as  elsewhere  in  the  brain,  but  the  cause  of  the  inflammatory  form  of 
acute  bulbar  palsy  is  unknown.  It  is  probably  infection  or  intoxication 
and  allied  to  poliomyelitis. 

Symptoms. — In  any  event  the  symptoms  are  sudden.  They  are  those 
already  detailed  in  connection  with  progressive  bulbar  paralysis,  but  others 


936  DISEASES  OF  THE  XERVOUS  SYSTEM 

are  added.  There  is  usually  no  loss  of  consciousness,  though  there  may  be. 
There  may  also  be  deranged  cardiac  action  and  respiration,  including 
irregular  and  frequent  pulse,  vasomotor  derangements,  and  Cheyne-Stokes 
breathing.  The  temperature,  normal  at  first,  may  rise  to  105°  to  107°  F. 
(40.5  to  40.71°  C.)  and  higher  as  a  fatal  termination  is  approached.  Sen- 
sation is  rarely  affected.  Most  characteristic  of  all  is  the  so-calledcrossed 
paralysis,  described  on  page  932,  which  attends  most  hemorrhages  into  the 
pons,  in  which  there  is  paralysis  of  the  face  on  one  side  and  of  the  extrem- 
ities on  the  other;  but  the  motor  tract  may  not  be  involved,  and  in  that  case 
paralysis  is  not  observed. 

Diagnosis. — Suddenness  of  occurrence  of  the  s}'mptoms  named  indi- 
cates one  of  the  accidents  previously  mentioned,  while  a  crossed  hemi- 
plegia, provided  it  is  of  the  limbs  on  one  side  and  of  the  face  on  the  other, 
is  conclusive.  When  inflammation  of  the  medulla  oblongata  is  present, 
the  phenomena  of  bulbar  paralysis  do  not  occur  quite  so  suddenly.  They 
may  be  several  days  or  even  a  few  weeks  in  developing,  and  may  be  pre- 
ceded by  prodromal  sjTnptoms,  such  as  vertigo  and  painful  sensations  in 
the  back  of  the  neck.  It  must  not  be  fcrgotten  that  certain  cases  of  acute 
poll omeye  litis  begin  mth  bulbar  symptoms. 

Treatment. — The  treatment  is  the  same  as  for  similar  lesions  elsewhere 
in  the  brain. 


MYASTHENIA  GRAVIS. 

Synonyms. — Pseudoparalytic  Myasthenia;  Bulbar  Palsy  ivithout  Discernible 
Anatomical  Changes;  Asthenic  Bulbar  Paralysis;  General  Profound 
Myasthenia;  Erb's  Disease;  Hoppe-Goldflam  Symptom  Complex. 

Definition. — A  disease  beginning  usually  with  weakness  of  the  muscles 
of  the  tongue,  lips,  lar>-nx,  and  eyes,  followed  by  rapid  exhaustion  and 
temporarv"  paralysis  of  the  muscles  of  the  extremities;  by  temporar\^  re- 
coverv'  of  power  after  rest;  occasionally  terminating  in  persistent  paralysis. 

Etiology  and  Pathology. — The  disease  occurs  usually  in  those  from 
twenty  to  forty  years  of  age,  and  in  both  sexes  alike.  It  is  believed  to  be 
due  to  an  autogenetic  toxin.  Congenital  defect  or  abnormality  either 
in  the  construction  or  mode  of  functionating  of  the  neuro-motor  apparatus, 
rather  than  in  the  muscles,  has  been  suggested  by  E.  Bramwell,  and  es- 
pecially the  lower  motor-neuron.  It  has  followed  the  infectious  diseases, 
and  in  about  one-fourth  of  the  cases  neuropathetic  heredity  has  been 
noted.  At  necropsy  no  lesion  was  found  for  a  long  time,  which  would 
account  for  the  sjTnptoms,  but  more  recently  several  cases  have  been  re- 
ported in  which  a  cellular  infiltration  of  muscles  was  observed. 

Symptoms. — These  include  ptosis,  paresis  of  the  facial  muscles,  difficult 
mastication,  and  difficulty  in  swallowing  and  talking.  They  are  due  to 
fatigue  of  the  muscles  involved,  and  the  patient  can  talk  a  few  sentences 
quite  glibly,  but  his  speech  soon  grows  indistinct  and  vdtimately  incompre- 
hensible. So  wdth  chewing  and  swallowing  so  far  as  the  first  mouthfuls 
are  concerned,  but  these  acts  soon  become  impossible.  The  muscles  of  the 
extremities  and  trunk,  as  well  as  those  innervated  by  the  cranial  nerves,  are 


AMYOTROPHIC  LATERAL  SCLEROSLS  937 

involved,  the  same  rapid  fatigue  supervening  on  effort.  Thus  one  of 
Strumpell's  patients  could  ascend  a  flight  of  stairs  very  well  once,  but  in 
making  a  second  effort  had  to  invoke  the  aid  of  a  bannister,  while  the  third 
and  fourth  efforts  were  ineffectual.  Such  a  condition  is  known  as  the 
myasthenic  state.  At  times  the  abnormal  fatigue  and  consequent  symptoms 
are  limited  to  the  lower  extremities.  A  similar  effect  succeeds  on  continued 
faradization  of  the  muscles,  first  detected  by  Jolly,  and  is  called  the  myas- 
thenic reaction.  Almost  equally  characteristic  is  the  disappearance  of  fatigue 
after  the  muscles  have  been  put  at  rest  for  a  time. 

Diagnosis. — In  well-marked  cases  this  is  easy,  but  when  the  symptoms 
are  less  pronounced,  there  may  be  difficulty.  Cases  are  often  met,  espe- 
cially in  hysterical  women,  who  complain  of  inability  to  hold  up  the  head, 
which  clearly  do  not  belong  to  this  class.  It  is  to  be  remembered  that 
true  myasthenia  gravis  is  very  different  from  hysteria.  An  ability  to  use 
the  muscles  at  first,  followed  rapidly  by  loss  of  power  must  always 
be  looked  for,  and  these  conditions  may  be  applicable  to  the  muscles  of 
the  lower  extremities,  as  well  as  to  those  of  the  bulbar  nerves.  The  absence 
of  muscular  atrophy  is  important  in  myasthenia  gravis,  though  it  has  been 
reported  in  rare  cases ;  the  ocular  and  upper  face  muscles  are  more  likely  to 
be  paralyzed  in  than  bulbar  palsy.  The  myasthenic  reaction  should  be 
sought.     The  muscles  respond  normally  to  galvanism. 

Prognosis. — This  is  not  always  unfavorable,  but  one  must  not  be  mis- 
led by  the  apparent  improvement  succeeding  rest,  which  is  often  temporary. 

Treatment. — It  is  evident  from  what  has  been  said  that  rest  is  most 
important.  Prolonged  rest  and  the  avoidance  of  mental  excitement, 
and  the  use  of  massage  and  mild  galvanization  of  muscles  are  recommended, 
and  even  central  galvanization  of  the  spinal  cord  and  medulla  oblongata. 
Galvanization  of  the  respiratory  muscles  may  produce  unfavorable  results. 
Since  faradization  excites  the  myasthenic  state,  it  should  not  be  used. 

The  nourishment,  or  mode  of  nourishment,  is  most  important,  in  view 
of  the  fact  that  the  muscles  of  mastication  and  deglutition  are  at  fault. 
The  food,  therefore,  should  either  be  liquid  or  very  finely  minced,  and 
unless  deglutition  is  natural  and  easy,  the  stomach  tube  should  be  used, 
but  great  care  should  be  exercised  in  its  use  for  fear  of  producing  exhaustion. 
Dark  glasses  may  relieve  the  fatigue  of  the  ocular  muscles. 

The  drugs  recommended  are  the  usual  ones:  strychnin,  arsenic,  phos- 
phorus, and  other  tonics,  but  no  direct  results  have  been  traced  to  them. 
Calcium  lactate  seems  to  be  of  benefit. and  suprarenal  gland  may  be  tried. 

AMYOTROPHIC  LATERAL  SCLEROSIS. 

Synonym. — Charcot's  Disease. 

Notwithstanding  the  similarity  of  the  clinical  phenomena,  and,  to  a 
certain  extent,  of  the  morbid  anatomy  of  amyotrophic  lateral  sclerosis 
to  those  of  the  so-called  progressive  spinal  muscular  atrophy,  to  be  next 
considered,  there  appears  to  me  sufficient  difference  to  justify  a  separate 
consideration. 

Definition. — Amyotrophic  lateral  sclerosis  is  a  systemic  degeneration 
of  the  pyramidal  tracts  of  the  spinal  cord,  with  atrophy  of  motor  cells 


938  DISEASES  OF  THE  NERVOUS  SYSTEM 

in  the  anterior  comua  and  medulla  oblongata,  and  consequent  wasting  of 
muscles,  depending  upon  these  cells  for  their  trophic  influence. 

Etiology. — The  causes  of  this  condition  are  still  essentiallj'  unknown. 
Severe  muscular  exertion  has  been  assigned  as  a  cause,  as  it  has  also  of 
the  allied  affection,  progressive  spinal  muscular  atrophy.  As  in  it,  too, 
the  male  sex  suffers  most.  It  is  a  disease  of  middle  age.  It  is  probably 
due  to  the  degeneration  of  an  imperfectly  formed  central  motor  system. 
Some  cases  may  be  the  result  of  syphilis. 

Morbid  Anatomy.^ — A  sclerosis  of  the  crossed  pyramidal  tracts  in  the 
two  lateral  columns  and  the  direct  pyramidal  tracts  in  the  anterior  columns 
is  essential  to  the  morbid  anatomy  in  a  tj'pical  case.  As  important  is 
atrophy  of  the  corresponding  large  ganglion  cells  in  the  anterior  comua 
and  medulla  oblongata.  The  degeneration  has  been  traced  in  the  pyram- 
idal tracts  from  the  sacral  cord  upward  to  the  pyramids  in  the  medulla 
oblongata,  sometimes  even  through  the  pons  and  crura  into  the  internal 
capsule  and  central  convolutions,  in  which,  too,  the  large  ganglion  cells 
have  been  found  atrophied.  The  nerve  nuclei  which  are  affected  in  the 
medulla  oblongata  are  especially  those  of  the  vagus  and  hypoglossal  nerves. 
The  motor  cranial  nerves  are  sometimes  degenerated. 

The  changes  in  the  motor  ganglion  cells  of  the  cord  and  the  nerve 
nuclei  in  the  medulla  oblongata  are  analogous  and  produce  corresponding 
results  in  the  muscles  supplied  by  the  motor  nerves  originating  from  them. 
These  results  are  an  atrophy  present  in  various  degrees,  some  fibers  dis- 
appearing almost  entirely,  others  partially.  The  process  is  by  fatty 
metamorphosis  and  absorption  of  resulting  fat,  leaving  a  residue  of  con- 
nective tissue. 

Symptoms. — The  clinical  phenomena  are  in  strict  accord  with  what 
would  be  expected  from  the  lesions,  consisting  in  muscular  wasting  and 
corresponding  paresis.  Before  the  muscular  w^asting  appears,  a  sense  of 
fatigue  succeeding  slight  effort  may  be  manifested,  followed  by  a  positive 
weakness,  primarily  almost  always  in  the  upper  extremity,  first  one  and 
finally  both.  This  is  followed  by  wasting  of  the  muscles  of  the  same  ex- 
tremity, usuall}^  first  seen  in  the  thenar  and  hypothenar  eminences,  the 
interossei  and  the  muscles  of  the  extensor  side  of  the  forearm,  while  the 
flexors  of  the  hand  and  fingers  remain  longer  uninvaded.  The  atrophy 
is  particularly  well  seen  in  the  deltoid,  and  to  a  less  degree  in  the  triceps, 
still  less  in  the  biceps  and  shoulder  muscles.  Usually  s^Tnptoms  do  not 
appear  in  the  lower  extremities,  with  the  exception  of  exaggeration  of  the 
tendon  reflexes,  until  some  time  after  they  have  appeared  in  the  upper,  but 
occasionally  the  disease  begins  in  the  lower  limbs. 

When  the  lower  limbs  are  affected,  the  patient  tires  easily  in  walking, 
the  gait  becomes  unsteady  and  stiff,  and  rising  from  the  chair  becomes 
difficult.  Tremor  may  appear  in  the  legs.  The  paresis  in  both  extremities 
is  proportionate  to  the  destruction  of  muscle,  though  first,  at  least,  it  is 
independent  of  the  atrophy.  Associated  \\ath  muscular  atrophy,  sooner 
or  later,  is  a  diminished  electrical  excitability.  Some  excitability,  however, 
remains  as  long  as  the  muscles  are  intact,  diminishing  as  their  destruction 
spreads.  A  reaction  of  degeneration  may  also  develop  in  the  muscular 
fibers  still  intact.     The  excitability  remains  for  the  most  part  intact  in  the 


PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY  939 

nerve  trunk  because  in  any  event  a  large  number  of  fibers  are  preserved  in 
their  normal  state. 

A  distinctive  feature  of  amyotrophic  lateral  sclerosis  is  found  in  the 
reflexes,  which,  in  strong  contrast  to  progressive  muscular  atrophy,  are 
markedly  increased.  Even  in  the  early  stages  of  the  disease  vigorous 
contractions  are  obtained  by  gently  tapping  the  tendons  of  almost  any  of 
the  muscles  in  the  extremities.  Always  most  conspicuous  is  the  patellar 
reflex,  while  more  rarely  ankle  clonus  may  be  obtained.  The  same  is 
true  of  the  masseter  reflex.  In  the  arms  the  biceps  and  triceps  and  the 
flexors  of  the  hands  may  be  excited  to  strong  contraction. 

Contractures  may  take  place  in  the  later  stages  of  the  disease  in  the 
arms  and  hands,  but  not  always.  In  the  lower  extremities,  where  the 
atrophic  symptoms  develop  some  months  later  and  are  less  marked,  spastic 
symptoms  are  a  more  prominent  feature.  The  legs  become  rigid  and  some 
strength  is  required  to  flex  them,  though  the  muscles  themselves  are  paretic. 
A  typical  spastic  paraplegia  may  be  produced,  which  is  due  mainly  to  the 
increase  of  the  tendon  reflexes,  and  a  spastic  paretic  gait  is  common — that 
is,  at  first. 

Later  on  in  the  disease  btdbar  symptoms  may  present  themselves, 
manifested  first  bj^  defects  of  speech,  difficulty  in  retaining  the  saliva 
and  in  swallowing;  and  later  still  the  lips  and  tongue  may  be  seen  to  be 
atrophied,  and  ultimately  there  is  difficulty  in  taking  food,  whence  nutrition 
is  impaired,  and  the  patieilt  gradually  sinks.  In  some  cases  the  disease 
may  begin  without  bulbar  symptoms. 

Throughout,  sensibility  remains  normal  in  the  upper  and  lower  ex- 
tremities, and  the  superficial  reflexes  are  not  much  altered.  The  sphincters 
are,  as  a  rule,  unaffected,  although  micturition  may  be  disturbed.  There 
may  be  constipation,  but  no  actual  paralysis  of  the  bowel.  Sexual  power 
may  be  lost. 

The  successive  involvement  of  the  upper  extremities,  the  lower  extremi- 
ties, and  the  bulbar  centers  marks  quite  well-defined  stages  of  the  disease. 

Death  comes  ultimately  from  exhaustion,  or  more  frequently  through 
an  inspiration  pneumonia,  caused  by  entrance  of  foreign  matter  into  the 
air-passages  as  a  result  of  defective  deglutition,  or  through  bulbar  palsy. 

Diagnosis. — The  disease  is  distinguished  from  progressive  spinal 
muscular  atrophy  by  the  invariable  increase  in  the  tendon  reflexes,  even 
in  the  early  stages,  as  contrasted  with  their  absence  in  the  latter  disease. 

Prognosis  and  Treatment. — The  prognosis  is  very  unfavorable  and 
the  disease  cannot  be  arrested.  By  rest  in  bed,  massage,  electricity,  and 
hot  bathing  we  may  be  able  to  defer  the  end  somewhat.  (See,  also.  Treat- 
ment of  Progressive  Spinal  Muscular  Atrophy.) 

PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY. 

Synonyms. — Wasting  Palsy;  Progressive  Muscular  Atrophy,  Type  Duch- 
enne-Aran;  Duchenne-Aran' s  Disease;  Cruveilhier' s  Atrophy;  Chronic 
Anterior  Poliomyelitis;  Chronic  Degeneration  of  the  Motor  Nuclei. 

Definition. — Progressive  spinal  muscular  atrophy  is  a  progressive 
wasting  of  more  or  less  limited  groups   of  voluntary  muscles,   associated 


940  DISEASES  OF  THE  NERVOUS  SYSTEM 

with  degenerative  atrophy  of  the  corresponding  portion  of  the  motor  nerve 
tract,  including  the  ganglion  cells  of  the  anterior  comua,  but  imaccont- 
panied  by  disease  of  the  pyramidal  tracts.  The  existence  of  this  condition 
has  been  disputed,  but  degeneration  of  the  cells  of  the  anterior  horns 
without  degeneration  of  the  pyramidal  tracts  has  been  seen  by  most  re- 
liable investigators.-  It  is  well  to  include  the  word  spinal  in  the  description 
of  this  disease,  as  thereby  the  disease  is  distinguished  from  j^rogrcssive 
muscular  atrophy  from  other  causes. 

Etiology. — In  the  majority  of  instances  we  fail  to  find  a  sufhcient 
cause.  Heredity  has  been  regarded  as  playing  an  important  role  in  its 
causation,  but  Striimpell  considers  the  cases  thus  originating  as  instances 
of  the  juvenile  myopathic  variety  of  atrophy — that  in  which  no  nervous 
lesion  is  traceable.  On  the  other  hand,  excessive  muscular  exertion  seems 
to  be  more  than  an  accidental  coincidence.  Exposure  to  cold,  especially 
to  very  cold  water,  and  the  infectious  diseases — typhoid  fever,  influenza, 
diphtheria,  and  syphilis — have  all  been  held  accountable,  but  it  is  likely 
that  some  of  the  atrophies  thus  resulting  include  other  forms  than  the 
true  progressive  spinal  muscular  atrophy. 

It  is  a  disease  commonly  of  adult  males,  most  supposed  cases  among 
those  who  are  younger  being  probably,  as  held  by  Erb,  instances  of  the 
juvenile  form  of  muscular  dystrophy,  although  a  rare  family  form  of  pro- 
gressive spinal  muscular  atrophy  has  been  observed  in  children. 

Morbid  Anatomy. — The  anterior  horns  of  the  gray  matter  are  wasted 
and  reduced  in  size;  their  ganglion  cells  wholly  or  partially  destroyed; 
the  neuroglia  is  proliferated  and  is  intercalated  in  places  with  spider  cells. 
The  anterior  nerve-roots  passing  from  the  horns  are  atrophied,  as  are  also 
the  motor  nerve  filaments  in  the  peripheral  nerves.  But  the  crossed 
pyramidal  tracts  in  the  lateral  columns  containing  the  crossed  motor 
fibers  descending  from  the  brain  to  the  cells  in  the  anterior  cornua  are 
intact  in  typical  cases.  A  slight  degeneration  may  be.  seen  in  some  cases  in 
the  anterolateral  columns  about  the  anterior  horns.  The  muscles  seen  to  be 
wasted  before  death  are  found  converted  into  fat  and  connective  tissue,  a 
remnant  of  true  muscular  tissue  remaining.  At  times  also  they  are  the  seat 
of  waxy  change,  at  others  still,  narrowed  but  retaining  their  transverse 
striation. 

Symptoms. — One  of  the  most  striking  features  of  the  disease  is  its 
slow  development.  Like  its  congener,  amyotrophic  lateral  sclerosis,  it  begins 
most  frequently  in  the  upper  extremities,  seven  out  of  nine  times  in  Aran's 
cases.  Of  the  upper  extremities,  the  right  was  first  invaded  in  37  out 
of  62  of  Sandahl's  cases,  the  left  14  times,  while  the  involvement  was 
simultaneous  in  11.  The  disease  may  begin  in  the  lower  extremities, 
as  shown  by  Friedreich's  statistics,  according  to  which  these  were  first 
invaded  27  times  out  of  146,  the  upper  extremities  iii,  the  lumbar  muscles 
in  eight. 

The  atrophy  usually  begins  with  the  short  muscles  of  the  thumb, 
the  abductor  pollicis  brevis  first,  then  the  opponens  and  the  abductor. 
The  consequent  flattening  of  the  ball  of  the  thumb  and  its  persistent  ap- 
proximation to  the  second  metacarpal  bone  produces  the  so-called  "ape- 
hand."     Simultaneously,  or  almost  simultaneously,  the  interossei   begin 


PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY 


941 


to  waste,  producing  conspicuous  depressions  between  the  metacarpal 
bones,  associated  with  loss  of  power  to  extend  completely  the  terminal 
phalanges  of  the  fingers.  Atrophy  of  the  lumbricales  follows,  producing 
a  flattening  of  the  hollow  of  the  hand.  The  ultimate  result  is  the  char- 
acteristic main  en  griff e  of  Duchenne,  in  which  the  extensor  tendons  on 
the  dorsum  of  the  hand,  and  the  flexors  in  the  palm,  may  become  as 
distinct  as  if  dissected  out. 

From  the  hand  the  wasting  creeps  up  the  forearm  and  thence  to  the 
arm,  or  it  may  skip  the  forearm  and  pass  into  the  arm,  sparing  usually 
the  triceps  extensor.  In  the  forearm  the  muscles  on  the  extensor  (ex- 
ternal) side  are  usually  first  aft'ected,  then  the  abductor  poUicis  and  ex- 
tensor longus  poUicis,  and  later  the  supinators  and  flexors.     It  may  come 


Fig.  158.— Position  of  Hands  and  Fingers  in  Ulnar  Paralysis  of  Long  Standing;  Bird-claw 

Hand,    "Main    en    Griffe" — {after    Duchenne). 
A,  A.     Wound  of  the  ulnar  nerve.     B,B,B,B,B.     Ends  of  the  metacarpal  bones.     D.     Ten- 
dons of  the  fle.xor  sublimis  digitorum.     C.     Muscles  of  the  ball  of  the  thumb. 

to  a  Standstill  at  either  of  these  stages,  or  may  involve  the  muscles  of 
the  shoulder,  especially  the  deltoid,  in  which,  indeed,  it  may  begin,  pref- 
erably in  the  right,  passing  thence  to  the  scapular  and  trapezius  muscles, 
the  pectorals,  the  rhomboidei  and  latissimus  dorsi,  while  a  grotequeness 
of  effect  is  often  produced  by  reason  of  certain  adjacent  muscles  retaining 
their  natural  size  or  being  even  seemingly  hypertrophied.  This  is  partic- 
ularly the  case  with  the  inferior  part  of  the  trapezius  and  platysma  myoides 
which  are  almost  never  involved.  The  disease  may  be  arrested  at  almost 
any  of  these  stages. 

The  lower  extremities  may  escape  altogether  and  the  atrophy  here 
usually  develops  late.  The  small  muscles  of  the  foot  would  naturally  be 
the  first  affected.  Very  rarely  there  may  be  exceptions  to  this  rule.  The 
muscles  of  the  face  are  invaded  late  or  not  at  all,  but  ultimately  even  the 
intercostal  and  abdominal  muscles  may  be  involved.  The  restdt,  then,  is  a 
veritable  living  skeleton,  instances  of  which  are  sometimes  exhibited.  De- 
formities, including  lordosis  or  anterior  curvature  of  the  spine  may  resitlt. 


942  DISEASES  OF  TUE  NERVOUS  SYSTEM 

With  all  this,  sensibility  is  unaffected  in  the  vast  majority  of  cases, 
but  the  patient  may  complain  of  a  numbness  and  coldness  of  the  affected 
limbs.  Very  rarely  pains  precede  the  wasting  in  the  muscles,  when  they 
are  sometimes  regarded  as  rheumatic.  The  galvanic  and  Jaradic  irri- 
tability of  the  muscles  progressively  diminishes  and  disappears  with  the 
complete  destruction  of  the  muscle,  the  galvanic  persisting  longer.  The 
reaction  of  degeneration  may,  however,  be  elicited  late  in  the  disease  in 
certain  muscles,  more  especially  in  the  modified  form  known  as  "partial 
reaction"  of  degeneration.  If  the  disease  runs  a  rapid  course,  it  may  occur 
earlier  and  be  more  typical.  Fibrillary  muscular  contractions  may  be 
present,  and  idiopathic  muscular  contractions,  or  myoid  tumors  brought 
out  by  a  blow,  may  be  thus  produced.  The  bladder  and  rectum  remain 
intact,  but  sexual  function  may  be  lost. 

Sweating  and  other  vasomotor  disturbances  may  occur  in  the  affected 
muscles,  such  as  pemphigoid  bullous  eruptions,  thickening  and  fissuring 
of  the  skin,  and  curving  and  grooving  of  the  nails.  In  certain  places  there 
is  an  overaccumtdation  of  fat,  producing  an  appearance  of  hypertrophy 
when  there  is  actual  atrophy. 

Along  with  wasting  there  is  a  corresponding  paresis,  the  result  of 
the  atrophy  and  not  its  cause.  The  arms  are  flaccid  and  toneless  and 
hang  loosely  at  the  sides.  The  patient  can  no  longer  dress  himself,  and 
various  devices  are  resorted  to  in  order  to  accomplish  certain  acts.  Es- 
pecially characteristic  is  one  of  these — when,  the  shoulders  being  first  af- 
fected, the  arm  and  forearm  retain  their  usefulness.  Under  these  circum- 
stances the  power  of  lifting  the  arm  from  the  side,  and  especially  of  raising 
it  above  the  head,  is  lost,  while  that  of  the  forearm  remains.  Hence,  if  the 
patient  wishes  to  lay  hold  of  an3d;hing,  he  swings  the  arm  forward  with 
a  jerk  until  the  object  is  brought  within  reach  of  his  fingers,  when  it  may 
often  be  caught  by  the  pathologically  hooked  terminations  of  these.  So 
long  as  the  neck  muscles  remain  active,  objects  may  be  grasped  by  the 
mouth. 

In  true  progressive  spinal  muscular  atrophy  the  rejlexes  are  entirely 
absent,  at  least  in  the  wasted  extremities,  a  natural  result  of  the  atrophy 
of  the  ganglion  cells  in  the  anterior  comua  and  of  the  centrifugal  motor 
fibers  of  the  reflex  arc.     The  special  senses  and  the  sphincters  remain  normal. 

Toward  the  close  of  the  disease  sometimes,  and  then  only  after  it  has 
existed  for  a  long  time,  the  phenomena  of  bulbar  paralysis  may  present 
themselves  after  invasion  of  the  ganglia  of  the  medulla  oblongata.  These 
have  been  detailed  in  the  section  on  that  subject.  They  are  by  no  means 
always  present,  even  in  advanced  cases. 

Diagnosis. — Muscular  atrophy  is  not  confined  to  the  disease  under 
consideration.  It  occurs  in  diffuse  myelitis,  in  tumors  of  the  cord  and 
when  cavities  are  formed  in  its  interior,  in  multiple  neuritis,  and  especially 
in  amyotrophic  lateral  sclerosis.  From  all  these  named,  except  the  last, 
it  is  easily  distinguished  by  strict  attention  to  the  conditions  and  order 
of  development  of  the  symptoms — viz.,  insidious  and  progressive  atrophy 
of  groups  of  muscles  to  the  exclusion  of  others,  beginning  usually  in  the 
hand  or  more  rarely  in  the  shoulder  and  upper  arm;  accompanied  by 
a  corresponding  loss  of  power  in  the  affected  muscles  and  partial  or  com- 


PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY  943 

plete  reaction  of  degeneration  in  the  same,  by  diminished  reflexes  and 
fibrillar  twitchings. 

Differential  Diagnosis. — From  amyotrophic  lateral  sclerosis  it  is  to 
be  distinguished  by  its  greatly  slower  course  and  absence  of  the  reflexes 
and  of  spastic  symptoms.  It  is  also  to  be  distinguished  from  muscular 
dystrophy  in  its  various  forms — the  myopathic  juvenile  muscular  atrophy 
of  Erb,  pseudohypertrophic  muscular  paralysis,  and  Duchenne's  infantile 
type.  In  the  juvenile  progressive  muscular  atrophy  of  Erb  there  is  also  slow, 
symmetrical,  and  intermittent  wasting,  with  weakness  in  certain  groups 
of  muscles,  especially  those  of  the  shoulder  girdle  and  upper  arm,  and 
later  possibly  the  pelvis,  upper  thigh,  and  back,  associated  at  times  with 
true  or  false  muscular  hypertrophy,  but  usually  imassociated  with  fibrillar 
contraction  or  reaction  of  degeneration.  The  average  age,  also,  in  the 
juvenile  form  is  much  less,  Erb's  cases  ranging  from  seven  to  46  1/2  or 
an  average  of  26  1/2  years,  while  in  the  spinal  form  or  true  progressive 
spinal  muscular  atrophy  the  average  age  is  much  greater.  Of  Roberts' 
cases,  all  of  which  seem  to  be  true  cases  of  progressive  spinal  muscular 
atrophy,  the  youngest  was  20,  while  the  ages  of  the  remaining  four  were 
38,  39,  47,  and  67. 

While  in  the  pseudo-hypertrophic  form  there  are  also  great  weakness 
and  wasting  of  muscles,  though  the  latter  may  be  obsciired  by  the  fatty 
deposit,  there  are  no  alterations  in  the  spinal  cord.  It  is  a  disease  of  child- 
hood, and  strikingly  hereditary,  beginning  in  the  lower  extremities,  while 
progressive  muscular  atrophy  is  a  disease  of  adults,  is  not  hereditary, 
and  begins  usually  in  the  upper  extremities. 

Duchenne's  infantile  type  is  characterized  by  onset  at  an  early  age, 
infancy  or  adolescence,  and  by  beginning  in  the  facial  mtiscles.  It  is  often 
hereditary.  The  distribution  of  the  atrophy  is  very  similar  to  that  of 
Erb's  form,  when  the  disease  has  involved  the  muscles  of  the  shoulders, 
but  it  begins  in  the  face  and  may  be  confined  to  the  face.  The  muscles  of 
the  hands  and  fingers  are  spared  in  Duchenne's  form;  fibrillar  tremors  are 
not  present,  and  there  is  no  reaction  of  degeneration. 

Prognosis. — Many  j^ears  are  required  to  develop  these  s^nnptoms 
in  their  entirety,  and  there  may  be  spontaneous  arrest,  during  which  the 
patient  may  die  of  other  causes.  Sooner  or  later,  if  the  patient  lives, 
they  recur,  and  their  march  is  irresistible. 

Treatment. — It  has  already  been  said  that  cure  is  impossible,  although 
well-authenticated  cases  of  arrest  are  reported.  Merctirials  and  iodide  of 
potassium  or  salvarsan  should  be  used  in  cases  of  suspected  syphilitic  origin. 
Cooke  reports  a  case  of  arrest  under  a  course  of  mercury,  after  the  disease 
had  progressed  for  five  years,  during  which  many  remedies  were  tried.  In 
the  main  the  treatment  must  consist  of  measures  intended  to  maintain 
the  health  and  strength  of  the  patient  and  to  counteract  the  muscular  wast- 
ing. To  the  former  end  an  abundance  of  nutritious  food,  fresh  air,  and 
outdoor  life  should  be  supplied,  while  tonics,  including,  especiallj-,  cod- 
liver  oil,  iron,  arsenic,  and  strychnin,  are  indicated.  The  muscular  wast- 
ing may  be  combated  by  electricity  and  judicious  massage.  Both  kinds 
of  electricity  may  be  used,  the  faradic  with  rapid  interruption  to  stimulate 
the   circulation,   or  with   slow  interruption  to   excite  individual  muscles 


944  DISEASES  OF  THE  XERVOUS  SYSTEM 

to  contraction.  The  current  should  be  of  moderate  strength,  not  too 
frequently  interrupted,  and  continued  for  a  few  minutes  only.  Duchenne 
recommended,  particularly,  treatment  of  important  muscles,  like  the 
diaphragm  through  the  phrenic  nerve,  or  the  intercostal  muscles  and 
the  deltoids  before  they  are  actually  invaded  by  the  disease.  In  evidence 
of  its  usefulness  he  relates  the  case  of  a  man  who  had  lost  many  of  his 
trunk  muscles,  and  who  was  beginning  to  sufTer  from  dyspnea,  on  whom 
faradization  of  the  phrenic  nerves,  repeated  three  or  four  times  a  week,  was 
of  great  service,  enabling  him  to  walk  considerable  distances  and  to  go 
upstairs  without  fatigue.  Another  patient,  whose  arms  were  much  wasted, 
became  again  able  to  support  his  family.  The  direct  current — galvanism 
— is  usefvd  in  advanced  stages  of  the  disease,  when  the  strongest  faradic 
currents  fail  to  produce  response.  When  galvanic  currents  fail  to  excite 
contractions,  the  treatment  ought  to  be  persevered  in  for  a  long  time, 
using  very  strong  currents  at  the  onset,  gradually  reducing  them  as  con- 
tractility returns.  Remak,  who  especially  advocated  the  use  of  the  con- 
tinuous current,  advised  placing  the  positive  pole  in  the  front  of  one  mas- 
toid process  and  the  negative  pole  on  the  opposite  side  of  the  neck,  near 
the  spinous  process  of  the  vertebrje,  not  higher  than  the  fifth  cervical, 
by  which  he  produced  the  contractions  already  described  as  diplegic  in 
the  fingers  and  other  paralyzed  parts.  Galvanization  of  the  sympathetic 
has  been  apparently  useful. in  the  hands  of  some,  Erb  reporting  a  case  of 
complete  cure. 

Massage  is  especially  important,  and  should  be  used  in  connection 
with  electricity,  but  at  a  different  time  of  day.  Eulenberg  refers  to  a 
case  said  to  have  been  brought  to  a  standstill  by  it. 

Hypodermic  injections  of  strychnin,  from  i/ioo  to  1/40  grain  (0.0005 
to  0.002  gm.),  are  said,  on  the  authority  of  Gowers,  to  have  arrested  the 
disease. 

In  families  in  which  a  hereditarj^  tendency  exists  prophylactic  treat- 
ment should  be  used.  It  shoiild  include  hygienic  measures  of  the  kind 
already  referred  to  and  the  avoidance  of  undue  fatigue  and  exposure, 
and  in  the  selection  of  an  occupation  these  matters  should  be  kept  in 
view.  On  the  supposition  that  the  disease  is  a  purely  local  one,  gymnastics 
involving  the  exercise  of  the  groups  of  muscles  prone  to  attack  are  indicated, 
but  assume  less  importance  from  the  standpoint  that  it  is  a  spinal  cord 
disease.  At  the  same  time  the  patient  should  have  the  benefit  of  any 
doubt  in  the  pathogeny,  and  as  gymnastics  are  eminently  calculated  to 
improve  the  general  health  and  thus  indirectly  to  avert  disease,  their  use  is 
indicated  on  these  grounds. 

DISEASES  OF  THE  BRAIN. 

LOCALIZATION  OF  CEREBRAL  DISEASE. 

Synonyms. — Cerebral    Localization;    Relation    of   Locality    to    Symptoms; 
Topical  Diagnosis  of  Cerebral  Lesions. 

Physiology. — The  brain  is  the  organ  of  consciousness  and  of  percep- 
tion of  impressions  and  sensations — of  memory,  of  thought,  of  origination 


CORTICAL  LOCALIZATION 


945 


ot  voluntary  motion,  and  of  speech.  It  is  also  the  seat  of  the  instinctive 
acts.  It  has  been  learned  from  clinical  observation  in  connection  wnth 
studies  at  the  autopsy  table  and  from  experiment  that  certain  parts  of 
the  cortex  are  concerned  with  corresponding  offices,  especially  motion, 
speech,  vision,  and  hearing,  so  that  from  the  presence  of  given  symptoms 
the  involvement  of  corresponding  localities  may  be  inferred.  Allusion 
has  already  been  made  to  the  subject  of  topical  diagnosis.  Such  diag- 
nosis, it  is  important  to  remember,  gives  no  information  as  to  the  nature 
of  the  lesion,  the  result  being  the  same  whether  it  be  abscess,  hemor- 
rhage, or  softening.  We  are  simply  informed  that  such  and  such  area 
is  involved. 

I.  The  Motor  Areas  of  the  Cortex. 

An  examination  of  the  following  illustrations  (Figs.  ii6  and  117)  will 
convey  an  idea  of  the  gyri  and  sulci  of  the  surface  of  the  brain. 

Functional  Assignments. — The  motor  region  was  formerly  regarded  as 
made  up  of  the  two  central  convolutions,  anterior  central  and  posterior 
central,  also  known  as  ascending  frontal  and  ascending  parietal;  the  pos- 
terior part  of  the  three  frontal  convolutions ;  the  upper  part  of  the  parietal 


MIliD  BunOfVESS 


Fig.  159. — Lateral  Aspect  of  the  Brain — {ajler  Ecker,  modified). 

lobe  adjoining  the  ascending  parietal  convolution,  and  the .  paracentral 
lobule  (Fig.  159)  on  the  median  surface  of  the  hemisphere.  The  investiga- 
tions of  Griinbaum  and  Sherrington^  on  the  gorilla  seem  to  show  that  the 
motor  cortex  is  entirely  in  front  of  the  Rolandic  fissure,  and  this  view  has 
been  widely  accepted  (Fig.  160).  All  diseases  which  destroy  any  consider- 
able portion  of  this  cortical  area  invariably  produce  paralysis  of  the  opposite 
half  of  the  body,  while  no  matter  how  extensive  the  destructive  process 
'  Sherrington.     The  Integration  Action  of  the  Nervous  System,  London,  1906. 


946 


DISEASES  OF  THE  NERVOUS  SYSTEM 


elsewhere  in  the  cortex,  motion  remains  intact  if  this  is  not  touched.  An 
acute  cortical  lesion  sufficient  to  involve  all  the  motor  centers  of  one  side 
and  cause  total  hemiplegia  would  be  likely  to  be  fatal,  while  a  smaller  lesion, 
extending  into  the  white  matter,  involving  fibers  coming  from  uninjured 
portions  of  the  cortex,  might  produce  a  more  extensive  palsy  than  a  more 
superficial  cortical  lesion. 

We  can  even  point  out  separate  regions  which  act  as  separate  centers  for 
various  groups  of  muscles.     The  center  for  the  movements  of  the  facial 


.     Toes 
Ankle  \ 
Knee 


Anus& 


AtxJomen 
Che6t 


Shoulder 
Elbow 
Wrlsf^ 


finders 
ammb 


Ear-   . 


Ofj3<^0pdnin^ 

ofjdlV.       VoCdl 

cords. 


Su/cus  centrdl/s. 
Mastication 


Fig.  i6o. — Brain  of  a  chimpanzee  {Troglodyles  niger) — {Jrom  Criiiibaum  and  Sherrington). 

Left  hemisphere  viewed  from  side  and  above  so  as  to  obtain  as  far  as  possible  the  configura- 
tion of  the  sulcus  ccniralis  area.  The  figure  involves,  nevertheless,  considerable  foreshorten- 
ing about  the  top  and  bottom  of  sulcus  centralis.  The  extent  of  the  "motor"  area  on  the  free 
surface  of  the  hemisphere  is  indicated  by  the  black  stippling,  which  e.xtends  back  to  the 
sulcus  cetitralis.  Much  of  the  "motor"  area  is  hidden  in  sulci;  for  instance,  the  area  extends 
into  the  sulcus  centralis  and  the  sulci  prcccntralcs,  also  into  occasional  sulci  which  cross  the 
precentral  gyrus.  The  names  printed  large  on  the  stippled  area  indicate  the  main  regions 
of  the  "motor"  area;  the  names  printed  small  outside  the  brain  indicate  broadly  by  their 
pointing  lines  the  relative  topography  of  some  of  the  chief  subdivisions  of  the  main  regions  of 
the  "motor"  cortex.  But  there  exists  much  overlapping  of  the  areas  and  of  their  subdivi- 
sions which  the  diagram  does  not  attempt  to  indicate. 

The  shaded  regions,  marked  "eyes,"  indicate  in  the  frontal  and  occipital  regions,  respec- 
tively, the  portions  of  cortex  which,  under  faradization,  yield  conjugate  movements  of  the 
eye  balls.  But  it  is  questionable  whether  these  reactions  suflicicntly  resemble  those  of  the 
"motor"  area  to  be  included  with  them.  They  are  therefore  marked  in  vertical  shading 
instead  of  stippling,  as  is  the  "motor"  area.  S.  F.,  superior  frontal  sulcus.  S.  Pr.,  sui)erior 
precentral  sulcus.     I.  Pr.,  inferior  precentral  sulcus. 

muscles  lies  at  the  lower  end  of  the  precentral  convolution  (Figs.  159  and 
160).  Near  by  and  lower  down  is  the  center  for  movements  of  the  tongue 
and  vocal  cords,  while  the  center  for  the  movements  of  the  arm  lies  somewhat 
higher  than  that  for  the  face — that  is,  about  the  middle  of  the  anterior 
central  convolution.  From  above  downward  the  various  segments  are  rep- 
resented as  follows:  Shoulder,  elbow,  wrist,  fingers — the  index  finger  and, 
lowest  of  all,  the  thumb.     The  center  for  the  leg  lies  in  the  uppermost  part 


CEREBRAL  LOCALIZATION 


947 


of  the  central  convolutions,  but  mostly  in  the  paracentral  lobule.  Most 
anterior  is  the  hip,  next  the  knee  and  ankle,  next  the  great  toe,  the  center 
for  the  movement  of  which  surrounds  the  upper  end  of  the  fissure  of  Ro- 
lando; still  further  back  are  the  centers  for  the  small  toes.  The  center 
for  the  trunk  is  situated  in  the  precentral  convolution  between  those  for 
the  upper  and  lower  limbs.  The  different  regions  are  not  sharply  defined, 
but  merge  into  one  another. 

As  to  the  so-called  muscular  sense,  it  has  been  believed  that  it  resides 
also  in  the  motor  area,  while  there  have  been  those  who  have  claimed  for 
it  also  a  separate  and  different  localization.  M.  Allen  Starr  and  A.  J. 
McCosh'  have  reported  a  case  of  injury  with  symptoms  which  go  to  prove 
the  latter  view  and  to  show  that  the  seat  of  the  muscular  sense  is  "a  spot 
in  the  brain  about  at  the  junction  of  the  superior  and  inferior  parietal 


Cyrus  i 


Fig.  i6i. — Aspect  of  the  Median  Surface  of  the  Cerebrum  as  it  appears  when  the  Two  Hem- 
ispheres are  Separated — {after  Ecker). 
The  gyri  and  fissures  are  indicated  by  the  lettering. 

convolutions,  clearly  posterior  to  the  posterior  central  convolution,"  and 
many  investigations  have  shown  that  the  so-called  muscular  sense  is 
probably  largely  represented  in  the  parietal  lobe. 

These  cortical  motor  areas  are  united  with  spinal  centers  by  nerve-fibers 
which  proceed  from  cell  to  cell  in  each,  without  connection  with  interven- 
ing cells.  Their  route  is  through  the  white  matter  of  the  hemispheres, 
where  they  form  the  corona  radiata,  the  fibers  of  which  converge  to  the 
internal  capsule  which  lies  between  the  optic  thalamus  and  the  caudate 
nucleus  on  the  inside,  and  the  lenticular  nucleus  on  the  outside.  (See 
Fig.  i6i.)  The  anterior  portion  of  the  posterior  limb  of  the  capsule — the 
knee — ^is  occupied  by  the  fibers  from  the  face,  tongue,  eye,  and  speech 
centers;  behind  these  lie  the  fibers  from  the  upper  extremities,  while  those 
from  the  lower  extremities  occupy  the  middle  of  the  posterior  part.  Thence 
the  fibers  of  the  motor  path  pass  into  the  cms  cerebri  through  its  middle 
third,  then  through  the  pons,  covered  by  the  superficial  transverse  fibers  of 

'  "Amer.  Jour,  of  the  Med.  Sciences,"  November,  1894,  p.  520. 


948 


DISEASES  OF  THE  NERVOUS  SYSTEM 


this  body,  into  the  medulla  oblongata,  of  which  they  form  the  anterior 
pyramids.  At  the  lower  portion  of  the  medulla  oblongata  a  large  portion 
of  these  pyramidal  fibers  cross  over  into  the  opposite  half  of  the  spinal  cord, 
constituting  the  crossed  pyramidal  tract  of  the  lateral  column,  while  a  small 
bundle  of  fibers  descends  into  the  anterior  column  of  the  same  side,  form- 
ing the  direct  pyramidal  tract,  or  Tiirck's  column;  some  fibers  probably 
pass  to  the  lateral  column  of  the  same  side.  Both  pyramidal  tracts  dimin- 
ish in  bulk  as  they  descend,  because  they  give  off  fibers  which  pass  into 
the  gray  matter,  dividing  and  subdividing,  to  come  into  contact  with  the 
protoplasmic  processes  which  are  continuous  with  the  large  nen.'e  cells  of 
the  anterior  comua. 


Armrer/ion  ■.      1-eg  region 


■iftfr  disttitMralttn  of 
Ihefimrfin^rrc 


(Face) 


Fig.  162. — Lateral  Aspect  of  the  Brain — {a^ier  v.  Monakow). 
Lateral  aspect  of  the  human  cerebral  hemisphere.  Motor  fields  (principal  foci)  after 
Allen  Starr,  \V.  W.  Keen,  Charles  K.  j\Iills,  Victor  Horsley,  and  ilonakow's  obser\-ations. 
y,  Spot  on  the  posterior  centra!  convolutions  whose  isolated  irritation  causes  thumb  move- 
ments, and  whose  destruction  in  a  case  of  cranial  injury  caused  continued  defect  of  motion  of 
the  thumb  and  finger;  also  derangement  of  the  stereognostic  sense.  The  lines  q-p,  10-10, 
etc.,  20-20  indicate  certain  planes  of  section  in  other  figures  in  Jlonakow's  monograph  in 
Nothnagel's  system. 


These  motor  fibers  form  the  upper  or  cerebrospinal  segment  of  the  motor 
system.  Between  the  motor  nerve  cells  in  the  anterior  comua  and  the 
muscles  to  which  the  motor  nerve-fibers  are  distributed  is  the  lower  or 
spino-muscular  segment.  In  response  to  the  law  already  mentioned  as  to 
the  nutritive  independence  of  each  neuron,  each  of  these  segments  has  a 
certain  nutritional  independence,  depending  for  its  integrity  upon  the 
integrity  of  its  neuron,  the  upper  or  cerebral  depending  upon  the  cortical 
cells  and  the  lower  upon  the  large  cells  in  the  anterior  comua. 

Lesions  of  the  Upper  Motor  or  Cerebrospinal  Segment. — If,  therefore, 
the  cortical  cells  of  the  motor  area  degenerate,  the  fibers  attached  to  them 
will  waste  as  far  as  the  beginning  of  the  lower  segment,  and  if  the  cells  in 


CEREBRAL  LOCALIZATION 


949 


the  latter  degenerate  or  are  cut  off,  not  only  do  the  nerve-fibers  below  them 
waste,  but  the  muscles  to  which  they  are  distributed  as  well.  Accordingly; 
all  the  cases  of  paralysis  due  to  destructive  disease  in  the  motor  cortical 
region  have  been  found  associated  with  descending  degeneration  of  the 
motor  tract  previously  outlined,  into  the  direct  pyramidal  tract  in  the 
anterior  column  of  the  cord  on  the  same  side,  and  the  crossed  pyramidal 
tract  in  the  lateral  column  of  the  other  side.  At  the  same  time  the  paralysis 
is  accompanied  by  a  spastic  condition,  manifested  by  an  exaggeration 
of  the  tendon  reflexes  and  an  increase  in  the  tension  of  the  muscles,  ascribed 
to  a  loss  of  the  inhibitory  control  exerted  by  the  cells  of  the  cortex  in  the 


Fig.  163.— The  Motor  Tract— (a//er  Starr). 
S,  S,  Fissure  of  Sylvius.  NL,  NL,  Lenticular  nucleus.  OT,  OT,  Optic  thalamus,  no, 
NC,  Caudate  nucleus.  C,  Crus.  P,  Pons.  M,  Medulla.  0,  Olivary  body.  The  tracts  for 
the  arm,  leg,  and  face  gather  in  the  capsule  and  pass  together  to  the  lower  pons,  where  the 
face  fibers  cross  to  the  opposite  seventh  nerve  nucleus,  while  the  others  pass  to  the  lower 
medulla,  where  they  partially  decussate,  to  enter  the  lateral  columns  of  the  cord.  The  non- 
decussating  fibers  pass  into  the  anterior  median  columns. 

normal  state.  This  explanation,  however,  is  not  entirely  satisfactory. 
In  other  respects  the  paralysis  due  to  cortical  lesion  does  not  differ  from  that 
due  to  focal  disease  lower  down  in  the  upper  tract,  except  that  the  latter 
is  apt  to  involve  more  muscles  because  of  the  compactness  of  the  tract  at 
this  point.  Atrophy  is  usually  not  intense  in  muscles  paralyzed  by  lesion 
of  the  upper  segment,  but  occasionally  is  observed  in  muscles  thus  paralyzed, 
but  the  reaction  of  degeneration  does  not  occur.  Lesions  of  the  motor 
cortex  are  sometimes  limited,  causing  correspondingly  limited  paralysis 
and  even  monoplegias,  never,  however,  affecting  less  than  a  whole  limb  or  a 
segment  of  a  limb.  A  lesion  may  involve  two  centers  lying  close  to  each 
other,  producing  paralysis  of  the  face  and  arm  or  of  the  arm  and  leg,  but 


950  DISEASES  OF  THE  NERVOUS  SYSTEM 

rarely  of  the  face  and  leg  without  involvement  of  the  arm.  It  happens  not 
infrequently  that  the  whole  motor  cortex  is  involved,  producing  paralysis 
of  one  side — -cortical  hemiplegia.  The  lesion  then  is  usually  thrombosis  of 
the  middle  cerebral  artery. 

Such  is  the  effect  of  destructive  lesion  of  the  cortex.  Quite  different 
is  that  of  irritative  lesions.  These  produce  convulsive  seizures  known 
as  Jacksonian  or  cortical  epilepsy,  characterized  by  convulsions  begin- 
ning in  a  single  muscle  or  group  of  muscles  and  proceeding  in  a  definite 
order  to  the  involvement  of  other  muscles  corresponding  to  portions  of  the 
cortex  affected.  Thus,  the  convulsions  may  begin  in  the  face,  and  extend 
thence  to  the  arm  and  thence  to  the  leg.  The  convulsions  may  also  be 
accompanied  by  sensory  symptoms  and  followed  by  weakness  of  the  muscles 
involved,  as  a  result  of  exhaustion  of  the  motor  centers  implicated. 

In  point  of  fact,  most  lesions  of  the  cortex  are  both  destructive  and 
irritative,  consisting  in  the  destruction  of  nerve  cells  in  one  center  and 
increasing  the  activity  of  cells  of  neighboring  centers. 

Lesions  of  the  upper  segment  include  hemorrhages,  timaors,  abscesses, 
injuries,  inflammations,  and  degenerations  involving  the  brain  and  spinal 
cord. 

Lesions  of  the  Lower  or  Spinomuscular  Segment. — Here,  as  in  the  upper 
segment,  the  destructive  lesions  produce  motor  paralysis.  The  added 
peculiarity  is,  however,  a  degeneration  of  the  muscles  as  well  as  the  nerve- 
fibers  distributed  to  them  from  the  motor  cells  of  the  anterior  comua, 
as  evidenced  by  the  wasting  of  the  muscles,  and  further  characterized 
by  the  presence  of  the  reaction  of  degeneration.  In  these  lesions  there  is 
also  a  loss  of  reflex  excitability  in  the  areas  supplied  from  the  segments 
destroyed,  the  reflexes  are  lost,  and  there  is  reduced  muscular  tension. 
Lesions  of  the  lower  segment  may  also  cause  paralysis  of  limited  groups  of 
muscles  when  confined  to  limited  areas  of  the  cord. 

Irritative  lesions  of  the  lower  segment  do  not  occur  unless  we  regard 
as  the  result  of  such  the  slow  atrophy  of  the  ganglion  cells  of  the  anterior 
cornua  in  progressive  spinal  muscular  atrophy,  and  consider  the  fibrillary 
contractions  foimd  in  this  affection  as  a  result  of  the  stimulation  of  these 
cells  in  their  slow  degeneration. 

II.  Sensory  Areas  of  the  Cortex  and  Sensory  Paths. 

Our  knowledge  of  the  sensory  areas  is  much  less  definite  than  that 
of  the  motor.  Beginning  at  the  periphery,  we  learn  that  sensory  fibers 
emanating  from  tactile  surfaces,  like  the  skin,  promptly  and  for  the  most 
part  become  associated  with  motor  nerve  filaments  in  the  lower  motor 
segment,  the  union  of  both  constituting  a  mixed  nerve.  The  two  sets  of 
fibers,  however,  separate  again  within  the  spinal  canal,  the  motor  filaments 
are  continuous  with  the  anterior  roots,  and  the  sensory  enter  the  cord 
by  the  posterior,  on  which  is  a  ganglion.  The  areas  whence  the  posterior 
roots  gather  their  nerves  mil  be  found  in  Starr's  table  on  page  g6i.  The 
precise  routes  of  sensory  impressions  to  the  brain  are  not  determined, 
but  experiment  and  clinical  pathology  show  that  probably  a  considerable 
number  of  sensory  fibers  cross  at  once  and  become  associated  with  other 


SENSORY  AREAS  IN  CORTEX  951 

fibers  which  ascend  to  the  brain  in  the  opposite  half  of  the  cord.  The 
following  seems  to  be  the  results  of  the  latest  histological  studies: 

The  sensory  nerve-fibers,  entering  the  spinal  cord  from  the  spinal 
ganglion  on  the  posterior  root,  pass  to  the  posterior  columns  and  divide 
dichotomously,  one  branch  passing  upward,  the  other  downward.  From 
these  longitudinal  branches  arise  short  transverse  branches  which  pene- 
trate the  gray  matter  and  end  in  the  tufts  or  arborizations  which  charac- 
terize the  distributary  ends  of  nerve  filaments.  These  tufts  or  arboriza- 
tions in  which  the  sensory  fiber  ends  in  the  gray  matter  are  apparently 
in  close  contact,  but  possibly  not  in  direct  anatomical  relation  with  the 
ganglion  cells  in  the  anterior  and  posterior  horns  and  in  Clarke's  column. 
From  these  ganglion  cells  other  nerve-fibers  are  projected,  the  course  of 
which  is  not  clear  except  as  to  those  which  pass  into  the  anterior  roots, 
and  those  from  Clarke's  column  which  pass  over  to  form  the  ascending  cere- 
bellar tract.  Some  pass  up  the  anterolateral  columns,  some  decussate 
through  the  gray  commissure  with  fibers  from  the  opposite  side.  Many 
fibers  from  the  posterior  roots  ascend  in  the  posterior  columns  of  the 
same  side  and  decussate  in  the  medulla  oblongata  to  form  the  fillet  or 
lemniscus.  Further  confirmation  of  this  course  is  found  in  the  fact  that 
if  a  posterior  nerve  root  is  cut,  the  ascending  Wallerian  degeneration  is 
seen  only  in  the  posterior  columns  of  the  same  side,  and  ceases  in  the 
nuclei  of  the  funiculus  gracilis  or  funiculus  cuneatus,  which  are  ganglionic 
bodies  in  the  medulla  oblongata  beginning  another  stage  of  the  sensory 
path.  It  is  questionable  whether  there  are  separate  strands  of  conduction 
for  tactile,  thermal,  or  painful  impressions,  but  probably  there  are  such 
fibers.  The  experiments  of  Gotch,  Horsley,  and  Mott  also  go  to  show  that 
tactile  impressions  pass  up  the  same  side  in  the  posterior  columns,  while 
impressions  made  by  pain,  cold,  and  heat  radiate  into  the  gray  matter  of 
the  cord,  and  through  these  probably  again  into  the  white  conducting 
tracts  of  the  lateral  column.  Testicle  fibers  are  probably  in  the  antero- 
lateral column  as  well  as  in  the  posterior  columns.  Diseases  involving 
extensively  the  gray  matter,  as  syringomyelia,  cause  alteration  in  the 
temperature  sense,  but  also  diseases  of  peripheral  parts,  as  pachymeningitis 
and  neuritis.  Many  hold  very  different  views  from  those  just  expressed 
and  believe  that  different  fibers  exist  for  the  conduction  of  the  different 
forms  of  sensation. 

Many  investigators  believe  that  all  the  sensory  fibers  of  the  opposite 
side  of  the  body  are  collected  in  the  posterior  third  of  the  posterior  limb 
of  the  internal  capsule,  just  behind  the  motor  fibers  of  the  tipper  segment. 
Dejerine  utterly  rejects  this  teaching,  and  holds  that  the  sensory  fibers 
are  mingled  with  the  motor  in  the  posterior  limbs  of  the  internal  capsule. 

Sensory  Areas  in  the  Cortex. — Much  doubt  exists  as  to  the  seat 
of  the  sensory  areas  in  the  cortex.  Horsley  suggested  that  the  muscular 
and  tactile  senses  are  localized  in  the  motor  cortex,  and  that  two  of  the 
three  principal  layers  of  cells  in  this  region  subserve  these  functions.  The 
experimental  studies  of  Munk  lead  to  the  same  conclusions — that  the 
so-called  "sphere  of  sensation"  lies  in  the  same  region  as  the  motor  centers 
of  the  cortex.  Dana  also  has  shown  that  many  lesions  of  the  motor  area, 
especially  in  the  hinder  part,  are  associated  with  anesthesia,  whUe  Ferrier 


952 


DISEASES  OF  THE  NERVOUS  SYSTEM 
Fcis    p^.  '^'",1.,  s-  FPv. 


Med  oblong 


Muscle 


Fro.  164. — Sensory  and  Motor  Paths  in  the  Spinal  Cord — {aflcr  Barker). 
Description  of  Fig.  121. 

Black. — Med.  oblong.,  transverse  section  through  the  medulla  oblongata  at  the  level  of  the 
decussatio  lemniscorum;  Med.  sp.  pars  ccrv.,  transverse  section  through  the  medulla  spinalis 
pars  cervicalis;  Med.  sp.  pars  liimb.,  transverse  section  through  the  medulla  spinalis  pars 
lumbalis;  Med.  sp.  pars  lliorac.,  transverse  section  through  the  medulla  spinalis  pars 
thoracalis;  sens,  surface,  sensory  surface;  muscle,  muscle. 

Red. — The  areas  of  white  matter  in  the  spinal  cord  and  medulla  oblongata  occupied  by  sensory 
a.\ons  are  indicated  by  red  lines  or  dots.  The  cell  bodies  and  axons  of  sensory  neurons  are 
also  colored  red.  D.  I.,  decussatio  lemniscorum;  D.  r.  f.,  dorsal  root  fiber  (central  a.xonof 
peripheral  centripetal  neuron);  F.c,  axon  of  fasciculus  cuneatus;  F.  els.,  axon  of  fasciculus 
cercbeUospinaUs  (direct  cerebellar  tract);  F.  vl.  C,  axon  of  fasciculus  ventrolateralis  [Gow- 
ersi];  St.  i.  I.,  axons  of  stratum  interohvare  lemnisci;  i,  ceU  bodies  of  peripheral  centripetal 
neurons  (situated  in  the  spinal  ganglia);  1',  ascending  limb  of  bifurcated  central  a.Kon  of 
peripheral  sensory  neuron  extending  from  the  pars  lumbalis  of  the  spinal  cord  to  the  medulla 
oblongata,  being  situated  first  in  the  fasciculus  cuneatus,  in  higher  levels  of  the  cord  in  the 
fasciculus  gracilis,  and  finally  terminating  in  the  nucleus  funiculi  gracilis.  l",  ascending 
limb  of  bifurcated  central  axon  of  peripheral  sensory  neuron  pertaining  to  the  thoracic 
portion  of  the  spinal  cord.  It  enters  the  fasciculus  cuneatus,  and  passing  upward,  ap- 
proaches the  medial  border  of  this  fasciculus  without,  however,  entering  the  fasciculus 


CORTICAL  LOCALIZATION  953 

considers  the  hippocampal  convolution,  and  Schafer  the  gyrus  fornicatns, 
as  the  sensory  center  in  the  cortex.  CHnical  evidence  on  this  point  is  not 
uniform.  In  some  cases  of  motor  paralj'sis  there  is  undoubted  simultaneous 
disturbance  of  sensation,  in  others  not.  By  some  the  parietal  lobe  is  con- 
sidered the  important  sensory  area,  and  the  weight  of  opinion  is  in  favor 
of  this  view.  The  muscular  sense  is  also  sometimes  impaired  in  paralyzed 
limbs,  in  consequence  of  which  the  patient  cannot  tell  with  his  eyes  closed 
the  position  of  the  affected  limb. 

Among  the  cortical  areas  representing  sensation  must  be  included  those 
for  sight,  hearing,  smell,  and  taste,  which  will  be  considered  in  connection 
with  affections  of  the  peripheral  nerve.  Suffice  it  to  say,  briefly,  that 
the  auditory  center  is  located  in  the  first  temporal  g>'rus,  the  visual  in 
the  occipital  lobe,  the  cortical  visual  center  being  on  the  mesial  surface 
in  the  cmw^m^,  especially  about  the  calcarine  ("calcar,"  a  spur)  fissure, 
where  are  represented  the  opposite  half  visual  fields.  Some  authorities 
include  more  of  the  occipital  lobe  than  this  in  the  visual  area. 


ragcilis.  It  is  seen  to  terminate  ultimately  in  the  nucleus  funiculi  cuneati.  i"',  ascending 
limb  of  bifurcated  central  axon  of  peripheral  sensory  neuron  pertaining  to  the  pars  cervicalis 
of  the  spinal  cord.  It  passes  upward  in  the  fasciculus  cuneatus  to  terminate  at  a  level 
higher  than  that  indicated  in  the  diagram,  i"",  reflex  collaterals  extending  from  the  central 
axons  (or  their  subdivisions)  of  the  peripheral  sensory  neurons  to  the  \entral  horns  of  the 
spinal  cord,  there  coming  into  conduction  relation  with  the  cell  bodies  and  dendrites  of  the 
lower  motor  neurons,  i,  collaterals  from  the  axons  of  the  fasciculus  cuneatus  to  the  nucleus 
dorsaUs  [Clarkii];  2,  cell  bodies  in  substantia  grisea  giving  rise  to  axons  of  the  fasciculus 
ventrolateraHs  [Gowersi];  2',  axons  of  fasciculus  ventrolateralis  [Gowersi];  3,  cell  body  in 
nucleus  dorsalis  [Clarkii]  gixing  rise  to  axon  of  fasciculus  cerebellospinalis;  3',  axon  of  fas- 
ciculus cerebellospinalis  (direct  cerebellar  tract);  4,  ceDs  of  nucleus  funiculi  gracilis  giv- 
ing rise  to  axons  of  fibrffi  arcuatffi  interuEe  which  undergo  decussation  (decusatio 
lemniscorum)  in  the  raphe;  4',  continuation  of  axons  of  fibrs  arcuatce  interns  after  decussa- 
tion. They  run  cerebralward  in  the  stratum  interohvare  leminisci.  5.  cells  of  nucleus 
funiculi  cuneati  which  give  rise  to  axons  of  fibrEe  arcuate  internae  which  undergo  decussa- 
tion (decussatio  lemniscorum)  in  the  raphe.  5',  continuation  of  axons  of  fibrae  arcuatse 
internae  after  decussation.  Having  had  their  origin  in  the  nucleus  funiculi  cuneati  of  the 
opposite  side,  they  now  run  forward  in  the  stratum  interohvare  lemnisci. 

Blue. — The  areas  of  white  matter  in  the  spinal  cord  and  medulla  oblongata  indicated  by  parallel 
blue  hues  correspond  to  the  position  of  the  fasciculi  cerebrospinales  (pjTamidales).  The 
cell  bodies  and  axons  of  the  lower  motor  neurons  are  also  printed  in  blue.  F.  cs.  I.,  fascicu- 
lus cerebrospinalis  lateraHs  or  lateral  pyramidal  tract;  F.  cs.  v.,  fasciculus  cerebrospinalic 
ventralis  or  ventral  pjTamidal  tract;  F.  Py.,  fasciculi  pjTramidales  in  the  medulla  oblongata; 
Py.,  pyramis  medulla  oblongata,  v.  r.,  radix  ventraUs,  nervi  spinalis;  i,  cell  bodies  of  lower 
motor  neurons  situated  in  the  ventral  horns  of  the  gray  matter  of  the  spinal  cord  gi\ing  off 
axons  which  go  to  form  the  ventral  roots  of  the  spinal  nerves;  3',  axons  of  fascicuh  pjTam- 
idales  which  undergo  decussation  in  the  decussatio  pyramidum  and  pass  down  in  the 
fasciculus  cerebrospinalis  lateralis  of  the  opposite  side  of  the  spinal  cord  to  terminate  in  the 
ventral  horns  of  the  cerNdcal  region.  The}'  throw  the  lower  motor  neurons  which  innervate 
the  musculature  of  the  upper  extremity  of  one  side  under  the  influence  of  the  paUium  of 
the  opposite  side.  4',  axons  of  fasciculi  pyramidales  which  undergo  decussation  in  the  de- 
cussatio pjTamidum  and  pass  down  in  the  fasciculus  cerebrospinalis  lateralis  of  the  op- 
posite side  of  the  spinal  cord  to  terminate  in  the  ventral  horns  of  the  lumbosacral  region. 
They  throw  the  lower  motor  neurons  which  inner\'ate  the  muscidature  of  the  lower  extremity 
of  one  side  of  the  body  under  the  influence  of  the  paUium  of  the  opposite  side.  4",  axon 
of  fasciculi  pyramidales  which  does  not  undergo  decussation  in  the  decussatio  pjTamidum, 
but  passes  down  in  the  fasciculus  cerebrospinalis  laterahs  of  the  same  side  (homolateral  fiber). 
4'",  axon  of  fasciculi  pjTamidales  which  does  not  undergo  decussation  in  the  decussatio 
pyramidum,  but  passes  down  in  the  fasciculus  cerebrospinahs  ventrahs  to  terminate  in  the 
ventral  horn  of  the  same  side.  It  would  throw  the  lower  motor  neurons  governing  a 
portion  of  the  musculature  of  one  side  under  the  influence  of  the  pallium  of  the  same  side. 
It  is  probable  that  in  addition  to  these  fibers  of  the  fasciculus  cerebrospinalis  ventralis, 
which  terminate  in  the  ventral  horn  of  the  same  side,  there  are  other  fibers  (not  shown  in 
the  diagram)  which,  passing  through  the  ventral  commissure,  terminate  in  the  Ventral  horn 
of  the  opposite  side.     (See  text.) 

Yellow. — Cell  bodies,  axons,  collaterals,  and  terminals  belonging  to  the  fasciculi  proprii  of  the 
ventral  and  lateral  funiculi — {Barker). 


954 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Lesions  of  the  Sensory  Tract. — These  may  also  be  destructive  or 
irritative.  Destructive  lesions  would,  of  course,  destroy  sensation  in  the 
part  whence  the  nervous  supply  comes  to  the  point  of  lesion.  Most  fre- 
quently it  is  an  injury  to  a  peripheral  nerve,  though  loss  of  sensation  is 
rarely  complete  in  the  part  to  which  such  neWe  is  distributed,  because 
that  area  may  receive  sensory  nerves  from  another  segment  of  the  spinal 
cord.  Complete  transverse  section  of  the  spinal  cord  itself  causes  complete 
anesthesia  in  the  parts  supplied  from  the  segment  below  the  injury.  The 
effects  of  a  lesion  invading  one-half  of  the  cord  are  detailed  on  page  882. 

Irritative  lesions  of  the  sensory  path  cause  paresthesias,  including 
formication,  tingling,  numbness,  and  finally  pain  corresponding  to  the 
degree  of  irritation.  The  last  is  commonly  due  to  irritation  in  the  course 
of  a  peripheral  nerve,  though  it  may  also  be  caused  by  irritation  to  the 
sensory  path  within  the  central  nervous  system. 

CORTICAL  AREAS  COVERING  SPEECH. 

THE    VARIOUS     FORMS     OF    APHASIA    AND    THEIR    ANATOMICAL    LESIONS. 

It  has  already  been  stated  that  almost  our  first  accurate  knowledge 
of  cerebral  localization  was  the  discovery  by  Broca,  in  186 1,  that  derange- 


a 


Perceptive  in  first  tem- 
poral convolution 


I  "Y*    Receptive. 


n 


Tit 


Fig.  163. — Primitive  Speech  Apparatus  of  the  Child  in  Mechanical  Repetition  of  Words,  ac- 
cording to  Wernicke  and  Lichtheim. 
a,  Sensory  speech  center,     h,  Motor  speech  center,     x,  Acoustic  center  of  pure  sense  of  hearing. 
m-x.  Route  to  acoustic  center,     h-n,  Motor  speech  tract. 


ments  of  speech  result  from  lesions  of  the  third  or  inferior  left  frontal 
convolution.  The  loss  of  power  to  comprehend  words  correctly  and  to 
use  them  properly  is  covered  by  the  general  term  aphasia.  Further  derange- 
ment consists  in  inability  to  artictilate  words,  and  is  due  to  lesions  of 
nuclei  situated  for  the  most  part  in  the  pons  and  medulla  oblongata, 
regulating  the  action  of  the  vocal  cords,  the  tongue,  and  the  lips,  and  is 
known  as  anarthria  or  dysarthria. 

The  study  of  the  phenomena  of  aphasia  will  be  facilitated  by  a  brief 


CORTICAL  AREAS  OF  SPEECH 


955 


review  of  the  conditions  of  acquired  language.  Language  is  acquired 
by  the  child  gradually  through  imitation.  Thus,  when  the  mother  teaches 
it  to  say  "cat"  or  "bell"  or  "papa,"  she  names  the  word,  and  its  sound 
impresses  the  distribution  of  the  auditory  nerve,  m  (see  diagram,  p.  954) 
whence  it  passes  to  the  acoustic  center,  x,  and  thence  to  the  sensory  speech 
center,  a,  in  the  first  or  upper  temporal  convolution,  where  it  is  stored 
as  a  sound  memory.  From  this  it  passes  from  behind  forward  along 
the  association  fibers  to  b,  the  motor  speech  center  in  the  left  inferior 
frontal  convolution  (Broca's  center,  propositionizing  center  of  Broadbent),' 
whence  the  muscles  of  articulation  are  put  into  operation  and  the  word 


Tactile  con- 
ception,       /i 


}gX*  Receptive. 


n 


VI 


Fig.  166. — Wernicke's  Schema,  Showing  the  Association  of  the  Various  Partial  Conceptions 
to  Form  the  Whole  Conception  or  Word  Image  of  an  Object. 
For  the  sake  of  simplicity  only  three  partial  conceptions  and  three  sensory  areas  are  shown, 
instead  of  the  many  which  go  to  make  up  our  notions  of  complex  objects.  The  letters  a,  b,  m. 
and  n  have  the  same  application  as  in  the  previous  figure,  but  x  may  indicate  the  seat  of  any  of 
the  special  senses — hearing,  vision,  smell,  touch. 


is  spoken.     Thus,  the  speech  mechanism  consists  of  receptive,  perceptive, 
and  emissive  centers. 

The  development  of  voluntary  speech  in  the  child  continues  through 
the  accumtdation  of  associated  ideas  in  the  perceptive  and  emissive  centers, 
a  and  b.  The  voord  image  or  picture  which  is  the  foundation  of  every 
word  is  made  up  of  the  sum  of  a  number  of  partial  conceptions  of  memorj^ 
pictures  acqtiired  by  experience  and  stored  for  further  use  in  the  different 
sensory  areas  of  the  cerebral  cortex.  Thus,  the  memory  of  the  sound 
of  a  word  as  spoken,  the  memory  of  the  appearance  of  a  word  as  written 

*  That  is,  the  center  where  thoughts  are  set  in  a  framework  of  words,  but  through  which  utterance 
IS  not  consummated;  whence  other  cortical  centers  are  necessary  to  motor  speech,  and  these  are  found 
caudal  of  Broca's  convolution  at  the  foot  of  the  antfrior  central  convolution.  This  region  Broadbent  calls 
the  uttering  center. 


956  DISEASES  OF  THE  NERVOUS  SYSTEM 

or  printed,  as  well  as  the  imiscidar  movements  needed  to  speak  the  word 
or  write  it,  are  distinct  from  one  another  and  yet  associated.  Loss  of 
one  of  these  memory  pictures  or  derangement  in  their  association  im- 
pairs the  integrity  of  the  word  image  and  produces  such  defects  in  the 
use  of  the  word  as  are  covered  by  the  different  varieties  of  aphasia.  These 
derangements  have  been  arranged  in  two  divisions,  according  as  the  de- 
fect is  in  (i)  the  receptive  and  perceptive  and  (2)  emissive  function  of 
the  brain,  the  former  constituting  the  sensory  aphasias,  the  latter  the 
motor. 

The  Physical  Basis  of  Thought — Apraxia. 

A  word  is  a  means  of  expression  of  a  thought.  Thus,  when  we  say 
the  word  "bell,"  with  a  full  conception  of  its  meaning,  such  conception 
or  mental  picture  is  made  up  of  as  many  distinct  partial  conceptions  or 
memory  pictures  as  there  are  special  senses,  these  conceptions  being  seated 
in  the  most  diverse  parts  of  the  brain.  Especially  concerned  in  the  case 
of  the  bell  is  the  acoustic  conception,  c,  derived  from  its  sound;  the  optic, 
c',  from  its  appearance;  the  tactile,  c" ,  from  what  is  learned  by  touch,  united 
to  form  one  conception,  as  shown  in  Fig.  167,  where  the  partial  concep- 
tions, c,  c' ,  c",  among  others,  taken  together,  give  us  the  idea  of  a  bell. 
In  the  blind,  of  course,  the  sensory  perceptions  are  smell,  taste,  touch, 
and  hearing  only.  The  schema  of  conscious  voluntary  speech  may  be 
still  further  simplified  by  combining  the  partial  conceptions,  c,  c',  and 
c",  into  one  single  point,  C  (Fig.  168),  as  the  sum  of  intellectual  concepts, 
m  representing  any  of  the  special  senses — hearing,  vision,  smell,  etc. 

Broadbent  has  gone  a  step  further,  and  suggested  the  existence  of 
a  center  on  the  sensory  side  of  the  nervous  system,  to  which  converge 
sensory  fibers  from  all  the  receptive  centers  and  in  which  is  combined  all 
the  evidence  respecting  the  nature  of  the  object,  which  he  called  the  naming 
center.  He  suggested  a  locality  for  this  center  in  an  unnamed  lobule  on 
the  under  surface  of  the  temporal  lobe  near  its  junction  with  the  occipital 
lobe.  Charles  K.  Mills'  has  reported  a  case  of  glioma  with  autopsy  which 
goes  to  confirm  Broadbent's  speculation  and  to  locate  the  exact  posi- 
tion of  this  center  in  the  third  temporal  convolution.  Its  correlative 
center  is  the  propositionizing  center  in  which  names  or  nouns  are  set  in  a 
framework  for  outward  expression  or  utterance. 

The  loss  of  these  memory  pictures  is  known  as  apraxia,  which  may 
be  defined  as  a  state  in  which  there  is  impairment  or  loss  of  the  power 
to  recognize  the  nature  and  purpose  of  objects,  and  which  is  something 
apart  from  aphasia.  In  one  form  of  it  any  object,  such  as  a  watch,  a  knife, 
or  a  spoon,  may  be  taken  up  and  handled  by  the  patient,  but  all  knowledge 
of  its  use  or  purpose  is  gone.  Such  a  condition,  when  dependent  on  loss 
of  the  visual  memories,  was  well  named  by  Munk  mind-blindness.  A 
person  formerly  familiar  with  the  tick  of  a  watch  or  the  sound  of  a  bell 
no  longer  interprets  such  sounds  aright;  or  is  unable  to  follow  melodies 
or  appreciate  music  as  he  once  did.     Thus  we  have  mind-deajness,  or 


1  Dercum,  "  Diseases  of  the  Nervous  System  "  by  American  authors,  p.  427.  1895- 


CORTICAL  LOCALIZATION 


957 


auditory  amnesia,  or  in  the  case  of  music,  amusia.  Again,  the  odor  of  the 
rose  and  violet  no  longer  suggests  these  flowers,  giving  mind  anosmia; 
or  the  taste  of  an  orange,  mind  ageusia;  or  the  soft  feel  of  fur  or  velvet 
gives  no  notion  of  these  substances,  mind  atactilia.  For  the  sum  of  these 
defects  the  term  apraxia  is  now  used,  but  mind-blindness  and  mind-deaf- 
ness are  the  most  important  subvarieties.  Apraxia  may  occur  alone, 
but  it  is  usually  associated  with  sensory  or  motor  aphasia.  In  simple 
apraxia  the  patient  may  be  able  to  read,  but  the  words  arouse  no  intelli- 


FiG.   167. — Simplification  of  the  Schema  of  Voluntary  Speech  by  Uniting  the  Ideas  into  the 

Point,  C,  and  Omitting  the  Acoustic  Center,  x. 

The  letters  have  the  same  meaning  as  in  Figures  122  and  123. 


gent  impression  in  his  mind.  Some  observations  go  to  show  that  the 
lesion  in  mind-blindness  is  in  the  supramarginal  and  angular  gyri,  or  in 
the  tracts  interior  to  these  in  the  white  matter  beneath  them;  and  pos- 
sibly mine-blindness  only  occurs  when  this  area  is  injured,  in  the  left 
hemisphere  in  right-handed  persons,  and  in  the  right  hemisphere  in  those 
left-handed.  Mind-blindness  is,  however,  at  times  functional  and  tran- 
sitory, and  as  such  is  associated  with  many  forms  of  mental  disturbance. 
There  are  as  many  varieties  of  apraxia  as  there  are  organs  of  sense, 
but  the  most  common  appears  to  be  psychical  or  mind-blindness,  generally 
associated  with  the  form  of  aphasia  known  as  word-blindness.  The 
seat  of  the  lesion  in  mind-atactUia  has  been  placed  in  the  gyrus  fomicatus, 
hippocampal  gyrus,  precuneus  and  parietal  lobe,  but  it  is  doubtful  whether 
all  these  parts  are  concerned  in  this  function.  The  parietal  lobe  probably 
is  the  most  important.  Mind  anosmia  in  the  uncinate  and  hippocampal 
gyri,  and  mind  ageusia  probably  as  in  anosmia. 


958  DISEASES  OF  THE  NERVOUS  SYSTEM 

Aphasia,  or  Loss  of  the  Faculty  of  Speech. 

Aphasia  is  sensory  or  motor  according  as  it  is  caused  by  a  loss  of 
memory  of  words,  or  by  an  inability  to  enunciate — according  as  it  is 
the  receptive  or  the  emissive  center  which  is  at  fault. 

Sensory  Aphasia.  Including  Word-blindness,  Word-deafness,  Amnesic 
Aphasia. — By  word-blindness  is  meant  loss  of  the  memory  of  the  ap- 
pearance of  a  word.  In  this  condition  the  patient  does  not  recognize 
words  which  he  sees  on  the  written  or  printed  page,  and  although  he  may 
be  able  to  pronounce  them  after  hearing  them  or  write  them  at  dictation 
or  copy  them,  he  does  not  understand  what  he  reads  or  writes.  On  the 
other  hand,  figures  are  sometimes  recalled  when  words  are  forgottten, 
and  the  patient  may  even  be  able  to  solve  mathematical  problems  and 
to  recognize  playing-cards.  Word-blindness  may  occur  alone  or  with 
motor   aphasia.     The   lesion  in   most   cases  of  word-blindness   has   been 


Fig.  i68. — Situations  of  Lesions  Causing  Aphasia — {after  Starr). 
f '.  First  frontal  convolution.  F^.  Second  frontal.  F^  Third  frontal.  TK  First  temporal 
T^.  Second  temporal.  T\  Third  temporal.  PK  First  parietal.  P^  Second  parietal. 
I.  Lesion  of  v/ord-deafness  and  deafness  for  musical  sounds,  or  mind-deafness,  according 
to  M.  AUen  Starr.  2.  Lesion  of  mind-blindness  and  woTd-hlindiiess,  according  to  Ferricr. 
3.  Lesion  of  motor  aphasia.     4.  Supposed  lesion  of  agraphia. 

in  the  angular  and  supramarginal  gyri  on  the  left  side,  as  located  by  Ferricr, 
but  this  area  is  not  believed  by  all  to  be  the  center  for  word-seeing.  Alexia, 
or  inability  to  read,  is  a  corollary  growing  out  of  this,  as  is  also  agraphia, 
or  inability  to  write,  so  far  as  it  depends  on  sight.  It  is  often  associated, 
as  already  stated,  with  mind-blindness,  but  may  occur  independently 
of  it. 

Word-deafness  is  a  condition  in  which  the  patient  has  forgotten  the 
significance  of  spoken  words,  although  he  hears  them  as  sounds.  The 
words  of  his  own  language  are  as  a  foreign  tongue  which  he  does  not  un- 
derstand, while  there  is  deafness  also  to  musical  sounds — aniusia,  the 
"  Tontaubheit"  of  the  Germans.  Word-deafness  is  commonly  associated 
with  other  forms  of  sensory  aphasia  in  various  degrees,  but  cases  of  pure 
word-deafness  occur  in  which  the  patient  has  been  able  to  read  and  to 
speak,  but  is  unable  to  recognize  the  meaning  of  a  word  when  spoken. 
It  is  a  rare  variety  of  deafness  whose  lesion  is  placed  by  most  students 
of  the  subject  in  the  first  temporal  convolution  or  its  posterior  part,  but 
Starr,  basing  his  conclusion  on  50  cases  which  he  has  collected  with  au- 


CORTICAL  LOCALIZATION 


959 


topsies,  places  it,  with  Seppilli,  in  the  posterior  half  of  both  the  first  and 
second  temporal  convolutions  of  the  left  side  in  right-handed  persons, 
and  of  the  right  side  in  left-handed  persons,  as  shown  in  the  drawing. 
Recent  investigations  indicate  that  the  posterior  convolutions  in  the  left 
island  of  Reil  in  right-handed  persons  is  important  in  word  hearing. 

A  simple  variety  of  sensory  aphasia  is  amnesic  aphasia,  in  which  the 
patient  simply  forgets  words — just  as  we  are  all,  at  times,  at  loss  for  a 
word.  Such  a  person  sees  a  dog  or  another  animal,  knows  perfectly  well 
what  it  is,  but  cannot  recall  its  name.  The  moment,  however,  the  word 
"dog"  is  suggested,  he  knows  all  about  it.  In  disease  usually  a  num- 
ber of  words  are  thus  lost.  Such  aphasia  is  called  amnesic,  because  it 
is  really  a  loss  of  memory  for  words.     It  may  be  partial,  as  when  a  patient 


Fig.  i6g. — The  Left  Hemisphere,  with  the  Fissure  of  Sylvius  Drawn  Apart  in  Order  to 
Show  the  Convolutions  in  the  Island  of  Reil  or  sth  Lobe.  The  Island  of  Reil  is  covered  by 
the  pars  opercidaris  or  posterior  part  of  Broca's  convolution,  which  is  here  drawn  aside — {after 
Henle). 

Sc.  Sulcus  centralis.  Gca,  Gap.  Gyrus  centralis,  anterior  and  posterior.  Fop.  Fissura 
parieto-occipitalis. 


forgets  nothing  but  his  own  name  and  remembers  all  other  words,  or 
when  he  is  able  to  express  himself  in  another  tongue.  If  permanent, 
it  is  probably  due  to  a  break  in  the  association  tract,  to  be  later  considered, 
and  should  be  so  limited.  Word-deafness  may  be  distinguished  from 
amnesic  aphasia  by  asking  the  patient  to  do  some  act,  such  as  to  touch 
an  object,  when  he  will  respond  correctly  if  he  has  simple  amnesic  aphasia, 
but  will  not  if  he  is  the  subject  of  word-deafness. 

Allied  to  amnesic  aphasia  is  sensory  or  amnesic  agraphia,  in  which 
a  word  cannot  be  written  because  it  .cannot  be  called  to  mind.  A  person 
thus  affected  may  be  unable  to  write  voluntarily,  but  may  be  able  to 
write  at  dictation  if  he  is  one  who  writes  much.  As  already  mentioned, 
agraphia  also  occurs  as  a  part  of  word-blindness  so  far  as  it  depends  on 
sight. 


960  DISEASES  OF  THE  XERVOUS  SYSTEM 

Motor  or  Ataxic  Aphasia  or  Aphemia — Alalia. — In  this  condi- 
tion the  memory  of  the  muscular  action  necessary  to  transfer  the  word 
image  into  speech  is  lost.  There  is  disturbance  of  the  emissive  center, 
b,  in  which  this  transfer  takes  place.  The  patient  Icnows  perfectly  well 
what  he  wishes  to  say,  but  cannot  say  it,  though  he  may  make  the  great- 
est effort  to  do  so.  Nor  can  he  repeat  a  word  after  hearing  it.  The  degree 
varies  greatly.  In  complete  cases  he  may  be  able  to  read,  though  not 
aloud,  and  understand  what  is  said,  but  cannot  say  a  word  himself.  More 
commonly,  he  can  say  one  or  two  words,  such  as  "no,"  "yes,"  while  in 
mild  cases  he  may  simply  misplace  or  omit  letters,  saj'  "widow"  instead 
of  "window,"  or  "wrelsters"  instead  of  wrestles."  Singularly,  too, 
when  in  a  passion  he  may  be  able  to  say  the  right  word  or  to  swear.  This 
is  because  such  words  are  uttered,  to  a  certain  degree,  involuntarily. 
A  man  who  has  acquired  the  French  and  German  languages  may  lose 
the  power  of  expressing  his  thoughts  in  them  while  retaining  his  mother 
tongue,  and  if  completely  aphasic,  he  may  recover  one  language  before 
the  other.  This  is  the  form  of  aphasia  long  ago  recognized  by  Broca 
and  localized  by  him  in  the  third  left  frontal  convolution,  and  since  this 
is  in  contact  with  the  center  for  the  face  and  arm,  there  is  not  infrequently 
partial  or  complete  right-sided  hemiplegia.  Alexia,  or  inability  to  read 
aloud,  is  a  necessary  corollary  to  motor  aphasia  so  far  as  it  depends  on 
the  power  to  speak. 

Paraphasia,  or  mixed  aphasia,  and  monophasia  are  allied  to  motor 
or  ataxic  aphasia.  Paraphasia  is  a  confounding  of  words,  the  wrong  word 
being  used  instead  of  the  right  one,  because  of  a  confusion  between  the 
idea  and  the  proper  word.  All  degrees  of  this  also  occur,  only  a  single 
word  being  sometimes  erroneously  used,  while  in  others  whole  sentences 
are  wrong.  The  patient  may  also  use  a  wrong  word  which  has  a  certain 
resemblance  to  the  correct  one,  beginning,  for  example,  vnth.  the  same  sylla- 
ble, as  "between"  for  "bewitch";  or  the  idea  usurps  the  situation,  as  in  the 
case  of  one  of  Strumpell's  patients,  who  called  a  white  handkerchief 
"snow."  In  these  cases  the  association  or  conduction  tract  between  the 
perceptive  center  and  the  emissive  center  is  broken,  whence  it  was  called 
by  Wernicke  aphasia  of  conduction.  The  lesion  in  paraphasia  is  usually 
in  the  island  of  Reil  and  in  the  convolutions  which  unite  the  frontal 
and  temporal  lobes.  But  any  disturbance  in  the  association  processes 
of  language,  no  matter  where  the  break  lies,  may  cause  it.  In  monophasia 
the  patient  can  command  but  one  syllable  or  one  word  or  a  short  phrase, 
which  he  repeats  over  and  over  again. 

Motor  agraphia  must  also  be  distinguished  from  sensory.  Sensory 
agraphia  is  sometimes  amnesic — that  is,  the  patient  cannot  write  the 
word  because  he  cannot  call  it  to  mind;  at  others  it  is  a  part  of  word- 
blindness.  Motor  agraphia  is  quite  independent  of  ability  to  read  aloud — 
that  is,  of  effort  memories  necessary  to  speech,  the  difficulty  being  con- 
nected with  the  movements  of  the  hand;  but  when  motor  aphasia  exists, 
motor  agraphia  is  usually  also  present.  In  sensory  agraphia  the  patient  may 
still  be  able  to  write  by  dictation,  in  the  latter  not.  Agraphia  also  varies 
greatly  in  degree.  The  patient  may  write  one  or  two  letters,  or  he  may 
be  totally  unable  to  write  voluntarily  or  from  dictation.     The  seat  of  the 


CORTICAL  LOCALIZATION 


961 


lesion  of  motor  agraphia  is  still  unsettled.  According  to  some  authorities 
the  graphic  center  is  located  in  the  second  frontal  convolution  of  the  left 
side,  near  the  ascending  frontal  convolution.  Starr  locates  it  in  the  middle 
of  the  convolution.  Paragraphia  is  a  condition  in  which  one  word  is  written 
when  another  is  intended.     It  is  a  corollar}''  to  paraphasia. 

Amimia  is  the  loss  or  impairment  of  the  power  of  expression  by  signs 
when  caused  by  cerebral  disease.  Paramimia,  the  misuse  of  signs  in  the 
attempt  to  express  thought,  is  comparable  to  paraphasia  for  speech  and 
paralexia  for  reading,  and  is  dependent  on  a  like  cause — the  destruction 
or  impairment  of  comm-issttral  or  association  tracts  between  sensory  and 
motor  centers.  It  is  not  correct  to  suppose  that  the  aphasic  can  sub- 
stitute signs  for  words  and  thus  express  himself,  for  the  two  defects  go 
hand  in  hand,  even  though  he  retain  the  power  of  moving  his  hands.  A 
patient  may,  however,  regain  pantomimic  power  before  he  regains  speech. 
Loss  of  pantomimic  power  is  found  often  associated  with  destruction  of 
the  third  left  frontal  convohition,  or  destruction  of  the  receptive  speech 
centers  or  their  connecting  tracts.  It  may  accompany  verbal  amnesia 
due  to  disease  of  these  areas  or  disturbance  of  the  association  tracts.  Just 
as  the  aphasic  may  say  "yes"  when  he  means  *'no,"  so  he  may  use  a  sign 
which  will  be  affirmative  when  he  intends  to  be  negative. 

The  following  table  may  aid  somewhat  a  review  of  the  pre\'ious  text, 
while  Fig.  i6S,  from  Starr's  book  of  "Familiar  Forms  of  Nen'ous  Disease," 
shows  the  situation  of  the  lesions  causing  aphasia: 


ad  purpose  of  an  object. 


Apraxia,  inability  to  recognize  the  nature  i 
Mi  nd-h\indness. 


Mind  atactilia. 

Mind  anosmia. 

Mind  ageusia 

Aphasia,  inability  to  comprehend  words  correctly  and  to  use  them 

Sensory  aphasia,  inability  to  rec-  lT''or(i-blindness,  in  which  mei 
ognize  word  pictures  and  word  ory  of  the  appearance  of 
sounds,  loss  of  memory  of  word  word  is  lost, 

pictures  and  word  sounds. 

TT'ortf- deafness,  in  which  mer 
ory  of  the  sound  of  a  word 
lost. 


Seat  of  Lesion. 
Supramarginal  and  angular  gj'ri, 
or  the  white  matter  beneath,  in 
the  left  hemisphere  in  the  right- 
handed  and  right  hemisphere 
in  the  left-handed. 

Upper  temporal  gyrus  of  left 
hemisphere  in  the  right-handed. 

Gyrus  fornicatus,  hippocampai 
gyrus,  precuneus,  and  post- 
parietal  (Mills) . 

Uncinate  gyrus  (Ferrier)  and 
hippocampai  gyrus. 


properly. 
n-     Angula 


Motor   aphasia,   inability   to    utter     Including  alexia. 
words,  though  knowing  well  what         read  aloud, 
to  say. 


nability   to   recall   a 
nability  to 


nd  supramarginal  g^Tus. 


Posterior  part  of  first  and  second 
temporal  gyri  (Seppilli  and 
Starr) . 

Disturbance  of  association  tract. 

Posterior  part  of  third  left  from  a 
(Broca's  convolution). 


A  confounding  of  words  in  speak- 
ing, in  which  the  wrong  word  is 
used  instead  of  the  right  one. 


Loss    of    power    of    expression    by 
signs. 


Paramimia 
Misuse  of  signs  to  express  thought. 
Agraphia,  inability  to  write. 


Disturbance  of  association  tracts. 


962 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Sensory  Agraphia. 
Inability  to  write  because  (a)  of 
want  of  idea  as  to  what  a  word 
is  or  (6)  looks  like. 

Motor  Agraphia. 
Inability  to  write  because  of 
want  of  motor  power  of  writ- 
ing, although  the  other  move- 
ments of  the  hand  may  be  ex- 
cellent. 


Seat. 
Association  tract. 
Angular  and  supramarginal  gyrus. 


Not  settled,  but  possibly  middle  of 
the  ascending  frontal  convolution 
or  ascending  parietal — i.  e.,  in 
the  arm  center.  Possibly  pos- 
terior part  of  second  left  frontal 
convolution. 


Availing  ourselves  of  Wernicke's  condensed  schema  (Fig.  166)  most 
aphasic  derangements  met  in  practice  are  easily  explained  by  it  by  sup- 
posing lesion  and  interruption  of  conduction  in  certain  places.  Accord- 
ing as  the  centripetal  conduction,  m,  a,  C,  or  the  centrifugal  conduction, 
C,  b,  n,  is  interrupted  we  have  sensory  or  motor  aphasia,  while  the  inter- 
ruption of  the  line,  a,  b,  produces  the  conduction  aphasia  of  Wernicke. 
Lesions  between  a  and  b  on  the  one  hand  and  C  on  the  other  are  called 
transcortical  aphasias;  between  a  and  b,  cortical,  and  between  a  and  b  on 
the  one  hand  and  the  periphery  on  the  other,  subcortical.  These  distinctions 
are  schematic. 


Derangememts  of  Speech  of  Irritative  Origin. 

In  addition  to  those  due  to  direct  lesion  of  the  speech  centers  there 
are  also  derangements  of  speech  due  to  irritation.  Such  are  the  different 
kinds  of  stuttering,  the  labiochoreic  and  gutturotetanic  stuttering  and 
choreic  speech.  The  first  two  probably  reside  in  the  cortical  speech  cen- 
ters, but  the  choreic  spasms  not  necessarih^  since  the  function  of  muscles 
concerned  in  their  production  may  be  disturbed  from  lesions  in  other  centers 
as  well. 

Diagnosis. — The  study  of  derangements  of  speech  is  b}^  no  means  an 
easy  matter,  but  it  may  be  facilitated  by  pursuing  a  systematic  method 
like  the  following,  which  is  that  of  M.  AUen  Starr,  slightly  modified: 


A.  To  determine  whether  apraxia  is  present. 

B.  To  test  integrity  of  the  auditory  speech 
area  and  association  tracts  between 
other  sensory  areas  and  the  temporal 
convolutions. 


To  test  the  condition  of  the  visual  word 
memories  in  the  angular  gyrus  and  of  the 
connections  between  this  area  and  the 
surrounding  sensory  and  motor  areas. 


D.    To  test  the  integrity  of  Broca's  center 
and  its  association  tracts. 


(1)  Test  the  power  of  recognizing  the 
nature,  uses,  and  relations  of  ob- 
jects. 

The  power  to  recall  the  spoken 
name  of  objects  seen,  heard, 
handled. 

(2)  The  power  to  understand  speech 
and  musical  sounds. 

(3)  The  power  to  call  to  mind  objects 
named. 

The  power  to  understand  printed 
or  written  words. 
The    power    to    read    aloud    and 
understand  what  is  read. 

(3)    The  power  to  recall  objects  whose 

names  are  seen. 

The  power  to  write  spontaneously 

and  to  write  the  names  of  objects 

seen,  heard,  etc. 

The  power  to  copy  and  write  at 

dictation. 

The   power   to    read    understand- 

ingly  what  has  been  written, 
(i)    The  power  to  speak  voluntarily; 

and  if  it  is  lost,  the  character  of  its 

defects. 
(2)    The  power  of  repeating  words  one 

after  another. 


f(i) 


[(I) 
(2) 


CEREBRA  L  LOCA  LIZA  TION 


963 


When  aphasia  is  associated,  as  is  so  often  the  case,  with  paralysis  of 
the  right  arm,  the  writing  test  may  be  made  with  the  left  hand,  when  the 
patient  may  produce  the  so-called  aphasic  mirror  writing,  which  can  only 
be  read  by  the  use  of  a  mirror;  or  if  he  cannot  write  with  the  left  hand, 
as  also  happens,  he  may  be  asked  to  form  words  by  letters  cut  out  of  printed 
pages  or  with  the  letter  blocks  of  children. 

Recently  Marie  has  announced  some  iconoclastic  views  as  regards 
aphasia.  He  believes  hearing  is  not  localized  in  the  first  temporal  convo- 
lution, and  denies  that  impairment  of  hearing  has  ever  been  obser\-ed  as  a 
result  of  a  lesion  of  the  right  first  temporal  convolution.  In  aphasia  there 
is  more  or  less  difficulty  in  understanding  spoken  words  due  to  defect  of 


n 


7n 


Fig.  1 70. — Simplification  of  the  Schema  of  Conscious  Speech  by  Reduction  of  the  Ideas  to  the 
Point,  C,  and  Omission  of  the  Acoustic  Center,  x. 
The  letters  have  the  same  application  as  in  pre^aous  figures. 


intellect,  and  not  to  a  lesion  of  the  left  third  frontal  convolution,  since 
Broca's  area  has  been  destroyed  without  causing  aphasia,  and  motor 
aphasia  has  occurred  without  a  lesion  in  Broca's  area.  He  declares  that 
the  left  third  frontal  convolution  plays  no  part  in  the  function  of  language, 
and  when  a  lesion  occurs  in  this  convolution  the  occurrence  of  aphasia  is  a 
mere  coincidence.  In  motor  aphasia  which  Marie  calls  the  aphasia  of 
Broca,  the  patient  cannot  read  or  write  and  understands  imperfecth'  what 
is  said  to  him.  It  is  similar  to  sensory  aphasia  which  he  calls  the  aphasia 
of  Wernicke,  from  which  it  differs  solely  in  that  the  patient  cannot  speak. 
In  what  Marie  calls  anarthria  the  patient  cannot  speak,  but  understands 
what  is  said  to  him  and  can  read  and  write.  It  is  the  condition  described 
as  subcortical  motor  aphasia.  Everyone,  says  Marie,  places  the  lesion  of 
anarthria  in  or  near  the  lentictdar  nucleus,  it  may  be  in  the  right  hemi- 
sphere.    When  the  lesion  is  limited  to  one  hemisphere  the  anarthria  tends 


964  DISEASES  OF  THE  NERVOUS  SYSTEM 

to  disappear,  but  is  persistent  when  the  lesion  is  within  or  near  each  len- 
ticular nucleus  and  is  usually  a  part  of  a  pseudobulbar  symptom-complex. 

He  also  says  aphasia  is  a  unit  and  that  the  aphasia  of  Broca  is  only 
aphasia  complicated  by  anarthria.  According  to  Marie,  the  only  region 
capable  of  causing  aphasia  when  damaged  is  the  zone  of  Wernicke,  i.  e.,  the 
supramarginal  and  angular  gyri  and  foot  of  the  first  two  temporal  convo- 
lutions. The  aphasia  of  Broca  is  caused  by  a  lesion  of  Wernicke's  zone,  or 
of  the  fibers  coming  from  it,  associated  with  a  lesion  in  or  near  the  lenticular 
nucleus.  The  speech  zone  should  not  be  divided  into  separate  centers. 
The  intensity  of  aphasia  corresponds  with  the  extent  of  the  lesion.  Dejerine 
denies  most  of  Marie's  assertions. 

Prognosis  and  Treatment. — Aphasia  is  a  symptom  of  a  disease  and 
not  a  disease  itself.  Yet  it  is  a  symptom  which  in  its  various  phases  informs 
us  so  precisely  of  the  seat  of  the  lesion  that  it  sometimes  suggests  a  point  of 
operative  interference  comparatively  easy  of  access.  Where  the  symptoms 
of  diffuse  cerebral  disease  are  wanting,  and  where  the  continuation  of  the 
symptoms  and  the  addition  of  others  suggest  the  presence  of  a  possible 
circumscribed  cause,  such  as  abscess  or  tumor,  operation  is  justified,  and  by 
it  not  only  cortical,  but  also  subcortical  lesions  and  abscesses  have  been 
relieved.  In  cases  of  sensory  aphasia  the  trephine  shoxild  be  applied  over 
the  upper  part  of  the  temporoparietal  region,  in  word-deafness  over  the 
posterior  part  of  the  first  temporal,  in  word-blindness  over  the  angular 
gyrus,  in  word-deafness  and  word-blindness  combined  over  the  inferior 
parietal  and  first  temporal  gyrus,  especially  if  verbal  amnesia  be  present. 
In  purely  motor  aphasia,  in  which  the  understanding  of  language  is  pre- 
ser\'ed  but  the  power  of  talking  lost,  the  trephine  should  be  applied  over 
the  posterior  part  of  the  third  frontal  convolution,  or  Broca's  center.  The 
lesion  of  simple  agi-aphia  is  not  sufficiently  determined  to  warrant  surgical 
interference.  With  newer  surgical  methods  the  bone  flap  is  used  to  expose 
these  various  areas. 

When  urgent  symptoms  do  not  exist,  attempt  should  be  made  to  reedu- 
cate the  patient,  and  much  may  be  accomplished  in  this  way  by  persever- 
ance, especially  in  the  young.  With  adults,  the  prognosis  is  more  unfavor- 
able, especially  in  cases  of  complete  motor  aphasia  associated  with  right 
hemiplegia.     In  them  the  patient  may  be  taught  to  write  with  his  left  hand. 

Cortical   Areas   Whose    Function   is   Unknown   or   Uncertain. 

After  subtracting  the  motor,  visual,  and  speech  areas  of  the  two  hemi- 
spheres there  remain  extensive  cortical  areas,  the  function  of  which  is  more 
or  less  uncertain,  and  which  are  unexcitable.     They  include: 

I.  The  Frontal  Region,  Including  all  the  Frontal  Convolutions  except 
the  Posterior  Half  of  the  Third  Frontal  on  the  Left  Side,  and  if  Starr  be  correct, 
the  Middle  of  the  Second  Frontal  Convolution  on  the  Left  Side  where  he  Locates 
the  Graphic  Center. — Of  this  area  the  most  that  can  be  said  is  that,  if  in- 
jured,' mental  symptoms  are  quite  likely  to  be  prominent — symptoms 
ascribable  to  a  loss  of  self-control.  It  is  to  the  greater  development  of 
the  region  of  the  frontal  lobes  in  man  as  compared  with  the  lower  animals 
that  his  higher  mental  qualities  are  ascribed.     Various  forms  and  degrees 


CEREBRAL  LOCALIZATION  965 

of  dementia  have  been  observed  after  such  lesions,  and  when  such  mental 
symptoms  are  present,  it  may  with  reason  be  inferred  that  there  is  lesion 
of  the  frontal  lobes,  especially  of  the  left  frontal  lobe  according  to  some 
investigators,  more  particularly  when  the  lesion  elsewhere  can  be  excluded. 
It  should  never  be  forgotten,  however,  that  the  intellectual  development 
depends  on  the  integrity  of  the  entire  brain. 

2.  The  Region  of  the  Cortex  Lying  between  the  Rolandic  Fissure  and  the 
Occipital  Convolutions,  Including  all  the  Parietal  Convolutions  except  the  Left 
Inferior  Parietal  Lobule. — Recent  investigations  seem  to  show  that  this  is 
the  chief  sensory  region  of  the  brain.  The  recognition  of  objects  b}'  con- 
tact when  the  eyes  are  closed,  the  sense  of  position,  and  general  sensibility 
have  all  been  found  affected  in  extensive  lesions  of  the  parietal  lobe. 

3.  The  Region  Covering  the  Entire  Temporosphenoidal  Lobe  on  tite  Right 
Side  except  the  First  Temporal,  which  prDbablj'-  has  to  do  with  hearing 
of  ordinary  sounds,  and  the  temporosphenoidal  on  the  left  side,  exclud- 
ing the  parts  not  concerned  in  hearing  of  words,  as  well  as  ordinars^  sounds. 
To  the  first  temporal  gyrus  the  function  of  hearing  is  assigned,  but  the  re- 
mainder, so  far  as  the  cortex  is  concerned,  appears  unexcitable.  Abscesses 
are  common  here  after  otitis  media,  and  are  sometimes  reached  -ndth  the 
trephine,  the  diagnosis  being  based  on  the  presence  of  otitis  wath  s\Tnptoms 
of  brain  disease. 

4.  The  Apex  of  the  Temporosphenoidal  Lobe,  including  the  uncinate 
convolution.  To  this  the  olfactory  and  taste  senses  have  been  ascribed 
with  some  show  of  reason. 

5.  Of  the  Entire  Median  Surface  of  the  Hemispheres,  except  the  para- 
central lobule,  which  is  motor,  and  the  cuneus,  which  is  \'isual,  and  includ- 
ing the  gyrus  fomicatus  and  the  hippocampal  cortex,  the  function  is  un- 
known, although  the  h'ppocampal  is  probably  a  part  of  the  olfactory  and 
taste  area. 

Tracts  within  the  Brain — Centrum  Ovale,  Internal  Capsule, 
Central  Ganglia,   Corpora   Quadrigemina. 

Centrum  Ovale. — In  the  centrum  ovale,  constituting  the  mass  of 
white  fibrous  substance  beneath  the  cortex  and  above  the  level  of  the  basal 
ganglia,  the  fibers  of  the  motor  paths  are  more  or  less  closely  associated 
with  other  systems  of  fibers.  They  include  three  sets — projection,  com- 
missural, and  association  systems;  the  first  connecting  the  cortex  with 
nervous  structures  lying  below  it,  the  second  joining  the  two  hemispheres, 
while  the  third,  or  association  fibers,  join  different  parts  of  the  same  hemi- 
sphere. By  these  fibers  adjacent  convolutions,  alternate  convolutions,  and 
more  distant  regions  are  connected,  and  through  these  as  a  physical  basis  the 
activities  of  the  various  cortical  areas  are  harmonized  and  the  different 
memories  united. 

The  diagnosis  of  lesions  involving  this  mass  is  exceedingly  difficult. 
We  can  only  surmise  in  cases  of  disturbance  of  association,  such  as  occur 
with  aphasia  and  kindred  disorders,  that  the  association  fibers  have  been 
destroyed.  A  break  in  the  continuity  of  the  fibers  of  the  corona  radiata 
must  produce  the  same  symptoms  as  if  the  corresponding  center  were 


me  DISEASES  OF  THE  NERVOUS  SYSTEAI 

destroyed.  Thus  disease  of  the  white  substance  of  the  occipital  lobe  may 
cause  hemianopia;  of  the  left  temporal  lobe,  word-deafness.  If  the  coronal 
fibers  which  proceed  from  the  third  left  frontal  convolution  are  injured, 
motor  or  ataxic  aphasia  occurs;  yet  quite  extensive  disease  of  the  white 
substance  of  the  frontal  lobe  has  been  found  postmortem  without  any 
symptoms  having  been  present  during  life. 

Internal  Capsule. — Since  in  the  comparatively  narrow  space  in  the 
posterior  limb  of  the  internal  capsule  is  centered  the  pyramidal  tract  on  its 
way  from  the  cerebral  convolutions  to  the  cms  cerebri,  a  very  limited  focal 
disease  in  this  locality  will  lead  to  hemiplegia  on  the  opposite  side,  while 
clinical  experience  shows  that  almost  all  cases  of  persistent  hemiplegia  are 
occasioned  by  disease  in  this  spot. 


Fig.  171. — Transverse  Section  through  the  Crura  Cerebri  in  Secondary  Degeneration  of  the 

Right  Pyramidal  Tract — (after  Charcot). 

sn.  Substantia  nigra,     p.  The  degenerated,  and  therefore  translucent,  pyramidal  tract.     ///. 

Oculomotor  nerves.     AS.   Aqueduct  of  Sylvius. 

According  to  the  views  of  many  neurologists,  a  purely  motor  hemi- 
plegia, unattended  by  impairment  of  sensation,  implies  a  lesion  that  does 
not  involve  the  most  posterior  portion  of  the  internal  capsule,  while  such 
involvement  is  probable  when  there  is  sensory  disturbance  as  well  as  motor 
paralysis.  Dejerine,  on  the  other  hand,  believes  that  disturbance  of  sensa- 
tion in  hemiplegia  indicates  involvement  of  the  optic  thalamus,  and  that 
there  is  no  distinct  sensory  tract  in  the  posterior  part  of  the  posterior 
limb  of  the  internal  capsule. 

Central  Ganglia — i.  e.,' Caudate  Nucleus,  Lenticular  Nucleus,  and  Optic 
Thalamus. — It  is  considered  that  the  optic  thalamus  may  have  to  do 
with  the  movements  of  mimetic  or  emotional  expression,  such  as  laugh- 
ing and  crying,  which  are  lost  in  lesion  of  the  thalamus,  but  which  re- 
main when  the  thalamus  is  intact,  even  though  the  half  of  the  face  is 
paralyzed  and  cannot  be  moved  voluntarilj-.  It  is  also  likely  that  some 
of  the  fibers  of  the  optic  tract  terminate  in  the  posterior  portion  of  the 
thalamus  known  as  the  ptilvinar,  while  most  of  the  fibers  go  to  the  corpus 
geniculatum  externum,  and  possibly  some  to  the  anterior  colliculus  of  the 
corpora  quadrigemina.  Hence  destruction  of  the  hinder  part  of  the  thal- 
amus produces  complete  hemianopia  of  the  opposite  side,  usually  by  de- 
struction of  the  optic  radiations.     Focal  disease  of  the  thalamus  has  been 


CEREBELLAR  DISEASE  967 

supposed  to  cause  posthemiplegic  chorea  and  other  posthemiplegic  S3'mp- 
toms  of  irritation. 

It  would  appear  from  recent  experiments  that  the  lenticular  nucleus 
contains  centers  for  regulating  heat,  which  would  explain  certain  tempera- 
ture changes  in  cerebral  affections.  It  is  probable  that  a  lesion  strictly 
confined  to  the  lenticular  nucleus  causes  excessive  spasticity  and  partial 
paralysis  of  the  opposite  side  of  the  body. 

Beyond  this,  little  definite  is  known  of  the  effect  of  lesions  strictly 
limited  to  the  central  ganglia,  while  disorganization  of  these  ganglia  has 
been  found  unattended  by  any  symptoms  during  life. 

Corpora  Quadrigemina  and  Crura  Cerebri. — ^Lesions  of  the  corpora 
quadrigemina  are  rare.  Not  much,  therefore,  is  known  of  their  function. 
The  anterior  tubercles  are  connected  with  fibers  of  the  optic  tract,  but  the 
extent  of  the  connection  in  man  is  uncertain.  Unilateral,  or  even  bilateral, 
paralysis  of  the  oculomotor  nerve  has  been  observed  in  connection  with 
lesions  of  the  quadrigeminal  bodies,  as  have  also  nystagmus  and  immobility 
of  the  pupil.  But  this  is  because  the  nuclei  of  the  motor  nerves  of  the  eye- 
ball, except  the  sixth,  lie  very  close  to  the  tubercles,  and  may,  therefore,  be 
involved  in  such  a  lesion.  According  to  Nothnagel,  a  staggering  gait  with 
oculomotor  paralysis,  associated  with  general  symptoms  of  a  tumor,  points 
to  the  corpora  quadrigemina  as  its  site.  The  octdomotor  paralysis  is  often 
of  irregular  distribution,  involving  especially  upward  and  dowmward  move- 
ments of  the  eye,  and  should  be  an  early  symptom.  Tumor  of  the  corpora 
quadrigemina  often  causes  early  optic  neuritis. 

If  a  crus  of  the  cerebrum,  is  diseased,  there  often  result  characteristic 
symptoms — viz.,  paralysis  of  one  side  of  the  body  (arm,  leg,  and  face), 
and  on  the  side  opposite  the  hemiplegia  a  paralysis  of  the  motor  oculi,  or 
third  nerve — crossed  paralysis.  An  examination  of  Fig.  171  will  explain 
this.  A  lesion  on  the  right  side  at  p  in  the  right  pyramidal  tract,  might 
involve  the  oculomotor  nerve,  III,  on  that  side,  but  would  produce  a 
hemiplegia  on  the  left  side.  Since  the  cms  contains  sensory  fibers  from 
the  opposite  side,  a  lesion  in  one  crus  may  also  produce  hemianesthesia 
of  the  opposite  side  of  the  body.  Tegmental  lesions  should  also  produce 
sensory  paralysis. 

CEREBELLAR  DISEASE. 

The  cerebellar  lateral  lobes  may  occasionally  be  the  seat  of  extensive 
lesions  which  do  not  produce  symptoms.  The  trunk  and  lower  extremites 
are  chiefly  affected  in  cerebellar  ataxia.  The  patient  may  be  able  to  lie 
abed  and  move  his  legs  much  better  than  when  standing,  but  as  soon  as 
he  arises  he  begins  to  sway  back  and  forth  with  his  whole  body.  This  ten- 
dency is  increased  if  he  brings  his  feet  together,  but  is  diminished  while 
the  legs  are  widely  separated.  In  this  respect  cerebellar  ataxia  does  not 
differ  from  the  ataxia  of  posterior  sclerosis.  Closing  the  eyes  may  occasion- 
ally increase  the  ataxia,  but  usually  does  not  do  so  markedly,  because 
the  cutaneous  and  muscular  sensibility  of  the  lower  limbs  remains  normal. 
So,  too,  when  the  patient  tries  to  walk,  he  totters,  but  there  is  none  of  the 
stamping  gait  of  tabes  dorsalis.     It  is  more  the  true  drunkard's  reel,  at  one 


968  DISEASES  OF  THE  NERVOUS  SYSTEM 

time  forward,  rolling  now  to  one  side  and  now  to  the  other,  but  often  with 
a  distinct  tendency  toward  one  side  or  back\vard.  Unfortunately,  this  gait 
is  not  so  peculiar  to  cerebellar  disease  as  to  be  pathognomonic  of  it,  and 
we  can  only  suggest  that  the  cerebellum  or  its  peduncles  may  be  involved. 
The  upper  extremities  are  usually  less  affected  than  the  lower,  but  Hugh- 
lings  Jackson  has  called  attention  to  a  paresis  of  the  trunk  muscles  as 
the  result  of  which  the  movements  of  bending,  erection,  and  lateral  flexion 
of  the  trunk  caimot  be  performed.  The  head  is  sometimes  carried  much 
inclined  toward  one  side,  but  it  is  impossible  to  use  this  sign  to  determine 
with  certainty  the  side  on  which  the  lesion  is  situated. 

The  vertigo  of  cerebellar  disease,  if  severe,  is  one  of  the  most  distress- 
ing symptoms  with  which  one  can  be  afflicted.  It  varies  greatly  and  is  not 
constant,  while  it  may  be  the  only  symptom.  It  occurs,  however,'  under 
the  same  circumstances  as  the  ataxia — that  is,  when  the  patient  stands  or 
moves  about,  disappearing  when  he  lies  down.  The  vertigo  and  ataxia  are 
not  necessarily  associated,  and  either  may  be  present  and  the  other  absent. 

Headache  is  a  frequent  symptom  in  cerebellar  disease,  having  been 
present  in  83  out  of  100  cases  collected  by  W.  C.  Krauss.  Most  frequently  it 
is  occipital ;  more  rarely  there  may  be  pain  in  the  side  of  the  head  or  in  the 
forehead.  Vomiting  is  also  a  result  of  chronic  disorders  of  the  cerebellum, 
being  present  in  69  of  Krauss'  cases.  So  is  visual  disturbance  due  to  optic 
neuritis,  which  was  found  in  66  cases.  None  of  these  symptoms  is  pathog- 
nomonic, and  each  one  may  be  a  symptom  of  disease  elsewhere  in  the  brain. 
The  most  valuable,  perhaps,  is  the  cerebellar  gait.  It  might  be  expected 
that  retained  reflexes  would  be  a  distinctive  sign  as  contrasted  with  their 
absence  in  tabes  dorsalis;  but,  in  fact,  they  are  sometimes  absent,  this  being 
the  case  no  less  than  12  times  in  Krauss'  100  cases. 

Other  symptoms  which  suggest  cerebellar  disease,  but  are  not  dis- 
tinctive, are  neuralgic  pains  in  the  region  of  the  neck  and  occiput;  blocking 
of  the  venae  Galeni  and  dilatation  of  the  lateral  ventricles  producing  hydro- 
cephalus in  children;  pressure  on  the  medulla  oblongata,  causing  paralysis 
of  the  cranial  nerves,  glycosuria,  or  even  sudden  death,  incoordination  and 
asynergy  of  movements;  finally  bilateral  rigidity  from  pressure  on  the  motor 
paths.  On  the  other  hand,  there  may  be  cerebellar  disease  without  any 
symptoms  whatever,  especially  as  long  as  the  middle  lobe  is  not  involved^. 

Form  of  Lesion. — By  far  the  most  frequent  cerebellar  lesion  is  tumor — 
in  fact,  some  sort  of  tumor  was  fotmd  by  W.  C.  Krauss  in  88  out  of  100 
cases,  of  which  ten  were  abscess,  and  there  was  one  each  of  softening  and 
hemorrhage.  The  remainder  were:  sarcoma  and  tubercle,  each  22;  glioma, 
18;  nature  of  tumor  unspecified,  13 ;  cyst,  seven;  and  one  case  each  of  endo- 
thelioma, cyst  and  sarcoma,  cancer,  gumma,  and  fibroma.  It  is  probable 
that  some  of  those  tumors  classed  as  sarcoma  were  glioma.  The  tumor 
occupied  one  or  the  other  hemisphere  32  times;  the  middle  lobe,  17  times. 

Disease  of  the  middle  cerebellar  peduncles  may  be  accompanied  by  the 
so-called  forced  positions  and  forced  movements.  As  a  result  of  the  former, 
the  subject  may  lie  in  bed  upon  a  partic\ilar  side,  w^hether  conscious  or  uncon- 
scious; and  if  put  on  the  other  side,  may  reassume  his  former  position  invol- 
untarily. Sometimes  this  is  accompanied  by  a  corresponding  forced  position 
of  the  head  and  eyebaUs,  the  extremities  being  seldom  affected.     The 


CEREBELLAR  DISEASE  969 

Jorced  movements  are  less  frequent.  They  consist  either  in  oft-repeated 
rotations  of  the  body  on  its  longitudinal  axis  or,  if  the  patient  can  walk, 
in  involuntary  circular  movements.  There  is  no  guide  by  which  to  deter- 
mine which  of  the  two  peduncles  is  affected  under  these  circumstances, 
while  in  a  few  cases  of  brain  disease  the  same  symptoms  have  been  observed 
without  involvement  of  the  cerebellum. 

The  following  very  convenient  summary  from  Strumpell's  "Text- 
book," somewhat  altered,  American  edition  of  19 lo,  contains  the  most  im- 
portant facts  bearing  on  the  localization  of  cerebral  disease,  and  will  be 
found  useful  for  reference : 

"i.  The  most  frequent  cause  of  ordinary  hemiplegia  is  a  lesion  of  the 
pyramidal  tract  in  the  posterior  limb  of  the  internal  capsule.  If  the  hemi- 
plegia be  persistent,  then  this  tract  is  actually  destroyed;  if  temporary,  the 
tract  has  been  functionally  deranged  for  a  time  bj'  focal  disease  in  neighbor- 
ing parts  of  the  brain. 

"  2 .  Monoplegic  cerebral  paralysis  is  usually  due  to  affections  of  the 
cort?x  of  the  brain — that  is,  the  anterior  central  convolution  and  the  paracen- 
tral lobule.  Monoplegia  of  the  face  and  tongue  is  the  result  of  lesions  in 
the  lower  extremity  of  the  anterior  central  convolution.  Monoplegia  of 
the  arm  is  referable  principally  to  some  lesion  of  the  middle  third  of  the 
anterior  central  convolution.  Monoplegia  of  the  lower  extremity  implies 
some  affection  of  the  upper  portion  of  the  anterior  central  convolution  and 
the  paracentral  lobule. 

"3.  Hemiplegia  or  raonoplegia,  if  associated  wdth  epileptiform  convul- 
sions affecting  either  one-half  or  one  particular  portion  of  the  body,  is  almost 
always  caused  by  cortical  lesions  or  lesions  near  the  cortex.  These 
same  symptoms  of  motor  irritation  without  accompamdng  paralysis  are 
likewise  to  be  ascribed  to  some  irritation  of  the  above-mentioned  regions  of 
the  cortex. 

"4.  Hemiplegia  with  crossed  paralysis  of  the  oculomotor  nerve  develop- 
ing at  the  same  time  indicates  a  lesion  of  a  crus  cerebri.  Co-existing  tactile 
hemianesthesia  implies  that  the  tegmentiim  is  involved. 

"5.  Hemiplegia  with  crossed  facial  paralysis  implies,  provided  that 
the  paralysis  of  the  limbs  and  opposite  side  of  the  face  occurred  at  the 
same  time,  that  the  lesion  is  situated  in  the  pons. 

"6.  Posthemiplegic  chorea  {vide  infra)  seems  to  occur  especially  when 
there  is  focal  disease  in  the  neighborhood  of  the  posterior  part  of  the  internal 
capsule.     It  is  a  rare  phenomenon. 

"  7 .  Hemianesthesia  of  the  skin,  associated  wdth  hemiplegia  on  the 
side  of  the  anesthesia  and  hemianopia  developing  at  the  same  time,  is  due 
chiefly  to  lesions  of  the  most  posterior  portion  of  the  internal  capsule. 

"8.  Hemianopia  maj^  be  due  to  a  lesion  of  the  cuneus  and  neighbor- 
ing parts  in  the  occipital  lobe.  Probably,  also,  a  lesion  of  the  posterior  ex- 
tremity of  the  internal  capsule  may  cause  it,  in  which  case  it  is  usually 
associated  with  hemianesthesia.  Finally, .it  may  be  produced  by  affections 
of  the  pidvinar  of  the  optic  thalamus,  of  the  lateral  geniculate  body,  or  of 
one  of  the  optic  tracts. 

"9.  Genuine  motor  aphasia  indicates  disease  of  the  foot  of  the  third 
left  frontal  convolution.     Unless  we  accept  the  teaching  of  Marie. 


970  DISEASES  OF  THE  NERVOUS  SYSTEM 

"  10.  Word-deafness  (loss  of  understanding  of  speech)  is  due  to  dis- 
ease of  the  first  left  temporal  convolution  or  of  the  posterior  convolutions 
in  the  island  of  Reil;  word-blindness  (loss  of  understanding  of  writing)  is 
due  to  disease  of  the  left  lower  parietal  lobe  (angular  gyrus) — supramarginal 
gyrus  also,  according  to  Ferrier. 

"  1 1.  Difficulty  in  articulation  implies  disease  of  the  medulla  oblongata, 
as  does  also  dysphagia. 

"  1 2 .  Staggering  gait  and  vertigo  are  the  most  constant  symptoms  of 
cerebellar  disease,  but  they  may  also  occur  in  diseases  of  the  corpora  quad- 
rigemina  and  of  the  frontal  lobe  {vide  supra).  Forced  positions  and  forced 
movements  perhaps  indicate  lesions  of  the  crura  cerebelli  ad  pontem  or  of 
the  optic  thalamus. 

"13.  Staggering  gait  and  ocular  paralysis  implicating  the  third  and 
fourth  ner\'es  are  indicative  of  lesions  of  the  corpora  quadrigemina." 


DISEASES    OF    THE    CRANIAL    NERVES. 

OLFACTORY  NERVE. 

The  olfactory  fibers  may  be  affected  in  their  intracerebral  course  in 
the  rhinencephalon  or  in  their  distribution  to  the  olfactory  region  of  the 
nose.  There  are  probably  nerve  cells  in  the  frontal  lobe  belonging  to 
the  rhinencephalon,  and  nerve  tracts  belonging  to  the  rhinencephalon  pass 
through  the  frontal  lobe. 

Morbid  Anatomy. — The  lesions  may  be  tuniors  oj  the  brain,  instances 
of  which  have  been  found  in  the  hippocampal  gyri,  or  disease  in  the  hemi- 
spheres. There  may  be  congenital  defect  of  the  olfactory  center  or  atrophy 
of  the  ner\^e,  which  may  explain  the  occasional  anosmia  in  tabes  dorsalis. 
There  may  be  inappreciable  changes,  caused  by  injuries  to  the  head  or  by 
concurrent  disease,  such  as  epilepsy,  the  aura  of  which  is  sometimes  mani- 
fested by  parosmia.  The  area  of  distribution  of  the  olfactory  nerve  in  the 
nose  may  be  destroyed  by  chronic  nasal  catarrh  or  by  polypi.  Hysterical 
neuroses  of  the  olfactory  nerve  are  not  infrequent.  The  sense  of  smell  is 
sometimes  impaired  in  cases  of  tumor  situated  in  portions  of  the  brain 
remote  from  the  olfactory  area.  This  possibly  may  be  caused  by  increased 
intracranial  pressure. 

Symptoms. — ^Lesions  in  any  of  these  localities  may  produce  subjective 
sensations  of  smell,  or  parosmia,  of  which  various  foul  odors  are  illustrations; 
hypersensitiveness  of  the  normal  sense,  or  hyperosmia,  in  certain  highly 
developed  degrees  of  which  the  patient,  generally  a  highly  sensitive  woman, 
can  distinguish  one  person  from  another  b}'  the  sense  of  smell ;  or  loss  of  the 
sense  of  smell,  anosmia. 

Diagnosis. — The  nasal  region  should  be  carefully  explored  by  the  rhino- 
scope  and  the  sense  of  smell  should  be  tested.  For  this  purpose  the  essen- 
tial oils,  such  as  anise-seed,  clove^,  or  peppermint,  in  various  degrees  of  dilu- 
tion are  employed.  Cologne  water,  musk,  or  asafetida  may  be  used  for  the 
same  purpose.  Pungent  substances  should  be  avoided,  as  thej^  stimulate 
the  fifth  nerve  in  the  nasal  mucous  membrane,  and  thus  the  subject  perceives 
what  he  does  not  smell.     By  such  agents  the  fifth  nerve  is  tested.     No 


DISEASE  OF  OPTIC  NERVE  971 

conclusion  can  be  drawn  as  to  anatomical  differences  on  the  two  sides  with- 
out a  rhinoscopic  examination. 

Treatment  is  useless,  unlesss  the  condition  be  due  to  curable  or 
removable  polypi  or  other  nasal  condition. 

OPTIC  NERVE  AND  TRACT. 

There  may  be  derangement  of  the  retina,  of  the  optic  nerve,  of  the 
chiasm,  and  of  the  optic  tract. 

I.   Affections   of   the   Retin.\. 
These  may  be  organic  or  Junctional. 

(a)  Organic  Diseases  of  the  Retina. 

The  organic  affections  include  hemorrhage  and  inflammation,  or  both. 

Hemorrhage  into  the  retina  (arterial  sclerosis)  occurs  as  a  cause  or 
result  of  Bright's  disease,  most  commonly  chronic  interstitial  nephritis,  in 
gout  profoundly  affecting  the  system,  in  leukemia,  anemia,  syphilis,  pur- 
pura, and  in  ulcerative  endocarditis,  and  other  forms  of  septicemia.  The 
hemorrhages  are  in  the  layer*  of  the  nerve-fibers.  At  first  bright  red,  and 
then  becoming  darker  and  'eventually  lighter  in  color,  they  ultimately 
assume  a  diffuse  cloudiness,  dwing  to  serous  infiltration.  The  hemorrhages 
vary  in  extent,  and  often  follow  the  course  of  the  vessels.  In  septicemia 
they  are  due  to  capillary  septic  embolism,  and  often  have  white  spots  in  the 
center,  owing  to  the  massing  of  leukocytes.  Other  white  spots  are  due  to 
fibrinous  exudate,  fatty  degeneration  of  the  retinal  elements,  or  localized 
sclerosis  of  the  same.  Similar  hemorrhages  sometimes  occur  in  the  pia 
mater  in  the  same  cases. 

Retinitis  occurs  under  the  same  circumstances  as  hemorrhage,  espe- 
cially in  chronic  nephritis,  syphilis,  anemia,  leukemia,  and  also  malaria; 
and  in  diabetes  mellitus  and  chronic  lead-poisoning. 

Albuminuric  retinitis  may  occur  in  all  forms  of  chronic  nephritis,  more 
frequently  in  the  interstitial  variety,  of  which  disease  it  may  be  the  earliest 
symptom  recognized.  It  is  characterized  in  general  by  the  presence  of 
white  spots  of  various  extent  and  distribution,  as  seen  by  the  opthalmo- 
scope.  They  are  caused  by  degenerative  processes  and  hemorrhages. 
Gowers  recognizes  three  forms : 

1.  A  degenerative  form,  which  is  the  most  common,  in  which  there  is 
retinal  changes,  but  scarcely  any  alteration  of  the  optic  disk. 

2.  An  infiammatory  form,  in  which  there  is  much  swelling  of  the 
retina  with  obscuration  of  the  optic  disk. 

3.  A  hemorrhagic  form,  in  which  there  are  many  hemorrhages,  but 
little  evidence  of  inflammation. 

In  some  instances  of  the  second  type  the  inflammatory  changes  in  the 
optic  nerve  predominate  over  those  of  the  retina,  producing  an  optoneuritic 
form,  in  which  the  appearances  are  more  closely  allied  to  those  of  papillitis 
or  choked  disk,  such  as  is  caused  by  intracranial  disease. 


972  DISEASES  Of  THE  NERVOUS  SYSTEM 

Syphilitic  retinitis  is  a  rare  affection  in  acquired  and  conji;enital  disease. 
In  the  latter  it  is  called  retinitis  pigmentosa.  Syphilitic  choroiditis  is  less 
rare.  Retinitis  is  not  uncommon  in  chronic  anemia,  especially  in  the  per- 
nicious form.  After  excessive  loss  of  blood  the  patient  often  becomes  blind, 
either  suddenly  or  in  the  course  of  one  or  two  days.  In  such  cases  a  neuro- 
retinitis  has  been  found  quite  sufficient  to  explain  the  blindness,  which,  in 
rare  instances,  may  be  permanent  and  complete.  A  rare  variety  of  anemic 
retinitis  is  malarial  retinitis,  first  described  by  Stephen  MacKenzie.  It 
may  be  associated  with  hemorrhage.  In  leukemic  retinitis  the  retinal 
veins  are  large,  and  hemorrhage  may  also  occur,  with  white  and  yellow 
areas.  Tumor  of  the  brain,  especially  of  the  cerebellum,  has  been  found 
in  some  instances  to  cause  a  condition  of  the  retina  like  that  of  abuminuric 
retinitis. 

{h)  Functional  Disturbance  of  the  Retina,  or  Amaurosis. 

This  may  be  toxic.  Of  this,  the  most  strildng  and  best  known  variety 
is  uremic  amaurosis.^  Its  suddenness  is  its  most  strildng  feature,  and  it  is 
very  frequently  the  forerunner  of  uremic  convulsions,  although  it  may  occur 
without  them.  It,  too,  may  be  the  first  symptom  noted  in  Bright's  disease. 
The  retina  is  free  from  any  changes  visible  by  the  ophthalmoscope,  and  the 
condition  is  probably  due  to  the  action  of  the  poison  on  the  nerve  centers. 
It  generally  disappears,  not  quite  so  suddenly  as  it  comes  on,  but  compara- 
tively quickly,  while  the  impaired  vision  of  retinitis  albuminurica  is  a  more 
or  less  permanent  condition.  Similar  are  the  amauroses  from  lead-poisoning 
and  from  massive  doses  of  quinin.  Hysterical  amaurosis  is  more  frequently 
a  dimness  of  vision — ambl^'opia — but  true  blindness  may  occur  in  one  or 
both  eyes.  Tobacco  amblyopia  is  usually  gradual  in  its  appearance,  and 
affects  more  especially  the  center  of  the  field  of  vision.  There  may  be  con- 
gestion of  the  optic  disk  and  if  the  use  of  tobacco  is  persisted  in,  there  may 
be  a  permanent  organic  change,  with  atrophy  of  the  disks.  A  scotoma  for 
red  and  green  is  invariably  present. 

In  nyctalopia,  or  night-blindness,  objects  are  clearly  seen  by  the  daj^  or 
by  strong  artificial  light,  but  are  invisible  in  the  shade  or  at  twilight.  In 
hemeralopia  the  reverse  state  of  affairs  exists,  objects  being  seen  with  dis- 
comfort in  bright  daylight  or  by  strong  artificial  light,  but  being  easU}'  seen 
in  deep  shade  or  twilight.  Retinal  hyperesthesia  is  sometimes  met  in 
hysterical  women. 

2.  Affections  of  the  Optic  Nerve. 

Those  which  are  of  medical  significance  are  optic  neuritis,  or  choked  disk, 
and  optic  atrophy. 

(a)  Intracranial  Trunk. 

The  intracranial  trunk  of  the  nerve  is  rarely  affected,  by  reason  of  its 
shortness.  It  may,  however,  be  compressed  by  a  tumor  in  adjacent  parts, 
as  of  the  pituitary  body  or  of  the  bone ;  by  aneurysm  of  the  ophthalmic  artery 

1  Amaurosis  is  a  vague  term  usually  defined  as  partial  or  tetal  loss  of  vision.  For  partial  loss  of 
vision  amblyopia  is  now  commonly  applied,  while  the  less  obscure  term  blindness  is  best  used  for  total 
loss  of  vision. 


DISEASE  OF  OPTIC  NERVE  973 

within  the  orbit,  or  of  the  internal  carotid  within  the  skull.  The  trunk  may 
also  be  the  seat  of  inflammation,  which  may  extend  from  carious  bone  or 
meningitis , 

(b)  Optic  Neuritis,  Papillitis,  Papillo-edema,  or  Choked  Disk. 

Definition. — Inflammation  of  the  intraocular  end  of  the  optic  nerve. 

Anatomical. — It  will  be  remembered  that  the  optic  ner\'e  pierces  the 
sclerotic  and  choroid  coats  about  i/io  inch  (2.5  mm.)  to  the  nasal  side  of  the 
center  of  the  retina,  which  is  occupied  by  the  yellow  spot  of  Sommering. 
In  this  spot  the  sense  of  vision  is  most  nearly  perfect,  while  the  optic  papiUa 
or  disk  is  the  only  part  of  the  retina  from  which  the  power  of  vision  is  absent. 
A  central  depression,  or  "cup,"  is  due  to  the  separation  of  the  nerve  fibers, 
pale  because  of  the  absence  of  blood-vessels,  while  the  periphery  of  the  disk 
has  a  rosy  tint  from  the  presence  of  the  minute  blood-vessels  that  lie  among 


Fig.  172.— Commencing  UpliL  Aeuritit  trom  a  Caee  oi  Caries  ui  the  bphcuoid  Bone  with 
Secondary  ileningitis — {after  Growers). 
The  left-hand  figure  shows  the  normal  right  optic  disk  with  clear  outline  and  deep  central 
cup.  The  right-hand  figure  of  the  left  papilla  shows  well-marked  neuritis;  the  edge  of  the 
disk  is  concealed  by  a  swelling  which  extends  beyond  the  normal  limits  of  the  disk.  The  central 
cup  is  encroached  upon,  but  not  quite  obliterated.  Some  of  the  vessels  are  partly  concealed 
at  their  points  of  emergence,  and  the  veins  lose  their  central  reflection. 

the  nerve  fibers.  The  ' '  cup ' '  varies  in  size,  and  may  be  absent,  the  vascular 
portion  of  the  disk  at  times  extending  over  it.  The  tint  of  the  vasctilar 
portion  of  the  disk  also  varies,  and  differences  are  of  significance  only  when 
noted  at  successive  examinations  of  the  same  case. 

Morbid  Anatomy. — It  is  by  swelling  and  diminished  transparency 
rather  than  by  recognizable  signs  of  congestion  that  the  first  stage  of  optic 
'  netiritis  is  characterized.  Then  there  follows  lessening  of  the  sharpness  of 
the  edge  of  the  disk,  and  finally  its  total  obscuration,  as  seen  in  the  right 
half  of  Fig.  172  as  contrasted  with  the  left  half.  It  is  to  be  remembered 
that  the  normal  contrast  is  sometimes  diminished  within  the  limits  of  health, 
with  this  difference :  that  the  pathological  indistinctness  is  better  seen  with 
the  direct  method  of  examination,  while  the  indistinctness  sometimes 
normally  present  is  more  evident  to  the  indirect.  The  abnormal  change 
is  earlier  recognized  on  the  nasal  side,  because  there  are  more  nerve  fibers 


974  DISEASES  OF  THE  NERVOUS  SYSTEM 

there  than  at  the  temporal  edge.  In  the  second  stage  the  swcUing  rapidly 
increases  and  the  whole  circumference  of  the  disk  disappears,  though  the 
cup  is  still  represented  by  a  slight  depression.  The  swelling  extends  even 
beyond  the  normal  disk,  becoming  two  or  three  times  as  wide.  The  swollen 
disk  assumes  a  red  or  grayish-red  color  to  the  indirect  examination,  but 
by  the  direct  a  fine  striated  appearance  is  noted,  the  striae  radiating  from 
the  center  of  the  disk  in  the  direction  of  the  fibers.  White  spots  may 
appear  on  its  surface,  due  to  degeneration  of  the  nerve  fibers,  and  may  be 
seen  in  the  illustration.  As  the  swelling  increases  the  retinal  vessels,  at 
first  unaffected,  become  affected  by  the  compression,  the  veins  becoming 
wider  and  more  tortuous,  the  arteries  being  narrowed  or  remaining  normal, 
while  hemorrhages  may  occur.  The  retina  ma}'  also  be  invaded,  producing 
a  neuro-retinitis. 

In  very  slight  degrees  of  inflammation  the  swelling  subsides  and  re- 
covery takes  place.  In  high  degrees  it  remains  for  a  long  time,  owing  to 
the  presence  of  inflammatory  products,  which  gradually,  however,  undergo 
the  usual  contraction  of  cicatricial  tissue;  a  condition  of  "consecutive 
atrophy"  resulting,  in  which  the  disk  is  white  and  atrophied. 

Etiology. — Most  commonly  optic  'neuritis  is  caused  by  intracranial 
disease;  especially  in  , nine-tenths  of  all  cases  tumor  is  said  to  be  present. 
It  gives  no  information  as  to  the  seat  of  the  tumor.  It  is  ascribed  by  some 
to  a  descending  neuritis;  by  others,  to  intracranial  pressure.  In  over  go 
per  cent,  of  cases  the  neuritis  is  bilateral,  though  often  unequal  in  the  two 
eyes.  Unilateral  neuritis  is  generally  due  to  disease  within  the  orbit  or  at 
the  optic  foramen,  but  may  also  be  due  to  intracranial  tumor.  Meningitis, 
either  tuberculous  or  simple,  is  the  next  most  frequent  cause.  It  is  said 
to  be  rather  more  common  in  meningitis  of  the  base  than  of  the  convexity. 
Such  optic  neuritis  is  less  severe  than  that  caused  by  tumor.  Cerebral 
abscess  may  cause  it;  so  may  difuse  cerebritis.  In  thrombotic  softening  and 
hemorrhage  optic  neuritis  is  rare,  but  in  embolic  softening  it  is  more  common. 

Optic  neuritis  may  result  from  Bright's  disease,  chlorosis,  anemia  or 
lead-poisoning,  and  may  occur  after  acute  fevers,  especiaUj^  scarlet  and 
typhoid.  In  the  latter  it  may  be  associated  with  brain  symptoms,  espe- 
cially headache.  About  6  per  cent,  of  all  cases  of  multiple  sclerosis  are 
accompanied  by  optic  neuritis,  due  to  inflammatory  or  sclerotic  patches 
in  the  nerve,  usually  slight  and  of  short  duration,  often  one-sided  in  conse- 
quence of  unilateral  involvement  of  the  nerve  by  a  sclerotic  patch. 

Symptoms. — Mild  degrees  of  optic  neuritis  may  be  -without  symptoms, 
except  such  as  are  revealed  by  the  opthalmoscope.  With  higher  degrees, 
acuity  of  vision,  color  vision,  and  the  \nsual  field  all  become  affected  and 
may  be  lost.  Its  severest  effect  on  \nsion  may  not  appear  until  contraction 
sets  in,  because  it  is  at  this  peirod  that  the  nerve  elements  suffer  most  in 
integrity.  The  defective  sight  is  not,  however,  necessarily  due  to  changes 
in  the  disk  or  retina;  it  may  be  due  to  intense  inflammation  in  the  nerve 
behind  the  eye  or  to  intracranial  disease. 

Prognosis. — Even  in  severe  cases  there  may  be  some  improvement  of 
vision  ^\^th  subsidence  of  the  inflammation.  On  the  other  hand,  \ision 
may  be  permanently  lost. 


DISEASE  OF  OPTIC  NERVE  975 

(c)  Optic  Atrophy. 

There  are  three  varieties  of  atrophy  of  the  optic  nerve; 
(i)   Primary;  (2)  secondary;  (3)  consecutive. 

1.  Primary  or  simple  atrophy  is  that  form  which  is  not  preceded  by 
any  recognizable  inflammatory  change  in  the  papilla  or  surrounding  struc- 
tures. It  occurs  in  degenerative  diseases  of  the  brain  and  spinal  cord, 
more  frequently  in  multiple  or  disseminated  sclerosis  and  tabes  dorsalis. 
It  is  present  in  about  40  per  cent,  of  all  cases  of  multiple  sclerosis,  and, 
in  various  degrees,  in  at  least  15  per  cent,  of  those  of  tabes.  In  dementia 
paralytica  it  is  present  in  about  5  per  cent.  Primary  atrophy  is  some- 
times hereditary,  occurring  in  the  males  of  a  family  after  puberty.  Other 
causes  to  which  the  condition  has  been  ascribed  are  cold,  alcoholism,  lead- 
poisoning,  sexual  excesses,  diabetes,  and  the  specific  fevers. 

2.  Secondary  atrophy  is  the  result  of  damage  to  the  optic  nerve  behind 
the  eye  or  at  the  chiasm.  It  is  characteristic  of  it  that  demonstrable  signs 
of  atrophy  follow,  instead  of  accompany,  the  deranged  vision;  of  which, 
too,  hemianopsia  may  be  a  form. 

.3.  Consecutive  atrophy  is  that  form  of  atrophy  which  succeeds  neuritis 
or  papillary  neuritis.  It  has  the  same  causes  and  the  same  significance. 
Only  secondary  and  consecutive  atrophy  are  the  result  of  uncomplicated 
intracranial  diseases;  for  although  primary  atrophy  accompanies  dissemi- 
nated sclerosis,  tabes  dorsalis,  and  general  paralysis  of  the  insane,  it  is  not 
caused  by  the  associated  brain  disease,  but  is  the  result  of  the  same  wide- 
spread tendency  to  degeneration. 

The  ophthalmoscopic  appearances  in  primary  atrophy  differ  somewhat 
from  those  of  the  consecutive  and  secondary  forms,  the  disk  being  gray- 
tinted — whence  the  name  gray  atrophy — with  its  edges  well  defined,  while 
the  arteries  appear  almost  normal.  In  secondary  and  consecutive  atrophy 
the  disk  has  an  opaque,  white  appearance,  with  irregular  outline,  and  the 
arteries  are  small. 

The  symptoms  of  optic  atrophy  are  the  defects  of  vision  already  detailed 
when  treating  of  optic  neuritis. 

As  to  prognosis,  in  primary  atrophy  the  ultimate  result  is  usually 
blindness,  but  in  secondary  consecutive  atrophy  some  vision  remains, 
even  in  severe  cases,  while  in  mild  cases  recovery  is  not  impossible. 

3.  Lesions  of  the  Chiasm  and  Tract. 

Anatomical. — The  decussation  of  the  optic  tracts  at  the  chiasm  is 
peculiar.  As  it  reaches  the  chiasm  each  tract  divides  and  sends  a  portion 
— the  smaller — of  its  fibers  to  the  temporal  half  of  the  corresponding  retina, 
and  the  remaining  portion  to  the  nasal  half  of  the  opposite  retina.  Thus 
the  right  tract  supplies  the  right  or  temporal  half  of  the  right  retina  and  the 
right  or  nasal  half  of  the  left  retina;  the  left  tract  supplies  the  left  or  tem- 
poral half  of  the  left  retina  and  the  left  or  nasal  half  of  the  right  retina.  The 
decussating  fibers  occupy  the  middle  of  the  chiasm,  and  the  direct  fibers 
the  corresponding  side.     (See  p.  173.) 

Ejffect  of  Lesion  of  the  Chiasm :  Hemianopia. — (a)  If  the  central  portion 
of  the  chiasm,  composed  of  decussating  fibers  only,  is  involved  (lesions  b 


976  DISEASES  OF  THE  XERVOUS  SYSTEM 

and  c,  Fig.  1 73),  the  result  will  be  anesthesia  of  the  inner  half  of  each  retina 
and  blindness  of  the  outer  half  of  each  field  of  vision,  it  being  remembered, 
of  course,  that  the  half  field  which  is  blind  is  the  reverse  of  the  half  of  the 
retina  which  is  anesthetic,  since  the  picture  formed  on  each  half  of  the  retina 
is  projected  from  the  opposite  half  of  the  field  of  vision.  Such  half  blindness 
is  known  as  hemianopia,  and  the  form  just  described,  in  which  outer  or 
temporal  half  of  each  field  is  blind,  is  known  as  hi-temporal  hemianopia. 

(6)  If  the  whole  chiasm  is  involved,  as  is  not  infrequently  the  ease  as 
the  result  of  pressure  by  tumor,  there  will,  of  course,  be  total  blindness. 

(c)  If  the  lesion  is  intermediate,  involving  the  direct  fibers  on  one  side 
of  the  chiasm  as  well  as  the  central  fibers,  there  will  then  be  blindness  in 
one  eye  and  temporal  hemianopia  in  the  other. 

{d)  The  rarest  of  all  forms  of  hemianopia  is  bi-nasal  hemianopia.  due 
to  a  symmetrical  lesion  involving  only  the  direct  fibers  passing  to  the  tem- 
poral half  of  each  retina,  whence  results  blindness  in  the  nasal  field  only. 
It  may  be  caused  by  tumors  involving  the  outer  part  of  each  tract,  or  of 
each  optic  nerve,  but  the  more  common  lesion  is  inflammation. 

Effect  of  Unilateral  Lesion  of  the  Tract. — If  there  be  a  lesion  involving 
the  left  tract  at  d  (Fig.  173),  the  left  or  temporal  half  of  the  left  retina  and 
the  nasal  half  of  the  right  retina  become  anesthetic  and  useless,  the  right 
half  of  each  field  of  vision  is  blotted  out,  and  there  results  a  right  lateral 
hemianopsia  which  is  called  homonymous  hemianopia.  The  reverse  is  the 
case  if  the  lesion  is  in  the  right  tract.  The  number  of  cases  involving  the 
right  side  is  about  equal  to  the  number  involving  the  left.  When  the  left 
half  of  one  field  and  the  right  half  of  another  is  blind,  or  the  reverse,  the  con- 
dition is  known  as  heteronymous  hemianopia. 

In  the  usual  forms  of  bi-temporal  hemianopia  the  obscure  fields  are  by 
no  means  always  exact  demi-fields,  which  would  be  the  case  if  the  dividing 
line  passed  exactly  through  the  fixing  point,  or  macula  lutea.  It  may  diverge 
to  temporal  side  so  as  to  leave  a  small  area  around  this  \Adthin  the  seeing  half. 
These  differences  are  due  to  peculiarities  in  the  decussation  rather  than  to 
the  lesion.  The  half  fields  which  remain  frequently  are  contracted.  This 
is  usually  due  to  an  inflammatory  affection  of  the  peripheral  fibers  of  the 
optic  nerves  in  front  of  the  chiasm. 

There  are  other  differences  in  the  dividing-line,  such  as  obliquity,  want 
of  sharpness,  etc.,  due  to  the  same  cause,  but  minute  description  of  these 
belongs  to  special  works  on  nervous  diseases.  Since  vision  remains  intact 
in  the  central  region,  equally  in  right  and  left-sided  hemianopia,  it  follows 
that  there  must  be  a  passage  of  fibers  from  the  macular  region  to  the  optic 
tract  of  each  hemisphere,  else  this  region  woxild  be  blinded  by  disease  of  one 
or  the  other  tract.  There  is  usually  the  same  loss  of  vision  for  color  in  the 
half  field,  but  half  vision  for  color  may  be  lost  in  central  disease  without  any 
change  in  the  field  for  white.     This  is  knowTi  as  hemiachromatopia. 

4.  Lesion  of  the  Tract  and  Cortical  Centers. 

The  optic  tract  on  each  side  crosses  the  crus  cerebri  backward  and  sends 
fibers  to  the  external  geniculate  body,  to  the  pulvinar  of  the  optic  thalamus, 
and  to  the  anterior  collieulus  of  the  quadrigeminal  body.     From  these  so- 


DISEASE  OF  OPTIC  NERVE 


977 


called  primary  optic  centers  fibers  pass  bacla\'ard  through  the  posterior 
part  of  the  internal  capsule,  forming  the  fibers  of  the  optic  radiation  in  the 
white  substance  of  the  occipital  lobe,  into  the  visual  area  of  the  cortex, 
of  which  the  area  about  the  calcarine  fissure  is  the  chief  cortical  center, 


i}U<if^^_ 


■^iitUti 


Exiejrujl  ffe/7zcalate  6ody      y^O^^^^^w— ,C^^^^^ 


Ocdpi/aZ  certea: 


Fig.  173. — Diagram  of  Course  of  Optic  Nerve-fibers  from  the  Cortex  to  the  Retina — {ajler 
Sahli,  Modified  and  Extended). 


though  other  parts  of  the  occipital  cortex  possibly  also  receive  and  store  up 
visual  impressions. 

Whence  it  is  plain  that  vision  may  be  influenced  by  lesions  in  anj^  of 
the  following  situations: 

1.  In  the  tract  itself. 

2 .  In  the  external  geniculate  body. 


978  DISEASES  OF  THE  XERVOUS  SYSTEM 

3.  In  the  pulvinar  of  the  optic  thalamus  and  in  the  anterior  colhciiUis 
of  the  corpora  quadrigemina. 

4.  In  the  fibers  passing  from  the  primary  optic  centers  to  the  occipital 
lobe,  as  at  e  (Fig.  173),  in  the  hinder  part  of  the  optic  radiation. 

5.  In  the  area  about  the  calcarine  fissure. 

The  effect  of  lesion  in  any  one  of  these  situation  is  to  produce  anesthesia 
of  that  half  of  the  retina  corresponding  to  the  affected  side  and  a  homony- 
mous hemianopsia  of  the  opposite  half  of  the  visual  field. 

Morbid  States  Affecting  the  Optic  Nerve,  Chiasm,  Tract,  and  Centers. — 
Outside  of  the  affections  of  the  retina,  which  concern  the  ophthalmologist 
chiefly,  and  outside  of  optic  neuritis  or  papillitis  as  a  result  of  intracranial 
disease,  already  considered,  the  affections  of  the  optic  nerve  which  concern 
the  physician  are  tumors  springing  from  the  pituitary  body  or  the  bone, 
aneurysm  of  the  ophthalmic  artery  within  the  orbit  or  of  the  carotid  within 
the  skull,  and  interstitial  inflammation  from  an  adjacent  focus,  or  rarely 
from  rheumatism  and  injury. 

The  optic  chiasm  is  encroached  upon  by  tumors  in  the  neighborhood, 
especially  of  the  pituitary  body;  by  tuberculous  or  syphilitic  growths  in  its 
substance,  or  by  inflammation  invading  it  from  the  adjacent  dura  mater 
or  from  carious  bone;  by  internal  hydrocephalus,  the  distended  infmi- 
dibulum  of  the  third  ventricle  pressing  on  the  middle  of  the  chiasm ;  by  inter- 
stitial inflammation  of  a  possible  gouty  origin  or  associated  v.nth  tabes  dor- 
salis;  and,  finallj^  by  interstitial  hemorrhage. 

The  optic  tract  may  be  invaded  or  compressed  by  tumors  springing  from 
the  inner  part  of  the  temporosphenoidal  lobe,  bj^  softening  after  throm- 
bosis of  the  internal  carotid,  or  by  disseminated  sclerosis.  Primary  soft- 
ening in  the  tract  is  rare,  as  is  also  hemorrhage. 

The  cortical  visual  centers  may  be  invaded  b}-  hemorrhage,  softening, 
tumors,  pressure  by  depressed  bone  in  fracture,  and  other  traumatic 
conditions. 

Symptoms  of  Lesions  of  the  Optic  Nerve,  Chiasm,  Tract,  and  Cortex: 

I.  Visual  Effects. — (o)  Lesions  of  the  optic  nerve  cause  defects  of  vision 
on  the  same  side,  with  lessening  of  the  reflex  action  of  the  pupil  propor- 
tionate to  interference  with  vision.  The  impairment  of  x-ision  includes 
extent  of  field  of  vision  as  well  as  degree.  There  may  be  concentric  limita- 
tion of  the  visual  field  because  the  peripheral  layer  of  nerve-fibers  near  the 
optic  foramen  is  damaged  by  processes  external  to  it.  In  other  cases  there 
is  irregular  defect,  and  in  others  still  the  loss  of  sight  is  total  and  lasting. 

To  the  ophthalmoscope  there  may  be  at  first  no  change,  but  if  the  lesion 
is  considerable,  the  atrophic  condition  soon  makes  its  appearance  ' '  second- 
ary" to  changes  in  the  nerve  as  distinguished  from  "consecutive"  atrophy, 
which  succeeds  papillitis.  There  may  be  slowly  superv^ening  atrophy  with- 
out recognizable  papillitis.  Central  loss  of  vision,  due  to  axial  neuritis, 
is  less  common,  but  occurs  sometimes  in  tobacco  amblj'opia. 

(6)  In  lesions  of  the  chiasm  the  characteristic  symptom  is  bitemporal 
hemianopia,  or  loss  of  the  outer  half  of  each  field  of  ^dsion;  this  is  because 
the  lesions  mainly  affect  the  chiasm  at  its  central  portion,  where  the  fibers, 
after  decussating,  pass  to  the  nasal  half  of  each  retina.     Usually,  however, 


DISEASE  OF  OPTIC  NERVE  979 

the  process,  be  it  tumor  or  inflammation,  which  causes  temporal  hemianopia 
extends  laterally,  involving  the  non-decussating  fibers  of  one  side  of  the 
chiasm,  causing  total  blindness  of  the  corresponding  eye;  or,  if  extending 
to  both  sides,  blindness  of  both  eyes.  The  different  stages  may  often  be 
traced  in  a  single  case  as  the  disease  progresses.  The  term  "oscillating 
bitemporal  hemianopia"  is  applied  to  a  rapid  and  frequent  variation  of  the 
dark  fields,  and  is  regarded  as  more  or  less  clearly  diagnostic  of  basal 
syphilis,  such  as  gumma  or  syphilitic  meningitis.  More  rarely  we  have  the 
binasal  hemianopia  already  described.  Slight  variations  in  the  extent 
of  the  dark  fields  have  been  referred  to  as  the  result  of  peculiarities  in  decus- 
sation rather  than  of  lesion  or  seat  of  lesion. 

(c)  In  lesions  of  the  optic  tract  between  the  chiasm  and  the  external 
geniculate  body  there  is  bilateral  hemianopia. 

{d)  Bilateral  hemianopia  is  also  a  result  of  lesion  of  the  central  fibers 
of  the  nerve  between  the  primary  visual  centers  and  the  cerebral  cortex. 

ie)  Lesions  of  the  cuneus  cause  bilateral  hemianopsia.  A  lesion  in 
each  hemisphere,  destroying  the  visual  paths  back  of  the  chiasm,  will  cause 
a  double  hemianopsia,  with  total  loss  of  vision  in  both  eyes.  Such  a  result 
has   followed   successive   lesions   in   the   two   occipital    lobes. 

if)  Hemianopia  may  be  due  to  functional  disease.  Transient  hemian- 
opia is  sometimes  a  symptom  of  migraine,  either  as  an  isolated  sjinptom 
apart  from  headache  and  gastric  disturbances  or  associated  with  them.  It 
majr  affect  now  one  half  of  the  field  and  now  another. 

Hemianopia  has  been  reported  as  a  symptom  of  hysteria,  but  the 
occurrence  of  true  hemianopia  in  hysteria  is  questioned. 

2.  Other  Symptoms  Associated  with  Hemianopia. — In  about  one-half 
the  cases  of  hemianopia  there  is  transient  or  permanent  hemiplegia,  the 
result  of  the  same  lesion,  the  hemiplegia  being  on  the  side  of  the  loss  of 
vision,  so  that  the  patient  cannot  see  on  the  paralyzed  side.  Hemianesthesia 
may  also  be  associated,  and  defects  in  speech  are  sometimes  found  when  the 
paralysis  is  on  the  right  side. 

Hemiachromatopia  has  been  mentioned.  In  this  condition  there  is  no 
change  in  the  field  for  ordinary  objects,  but  all  colors  appear  gray  as  soon 
as  the  vertical  line  is  passed.  The  symptoms,  according  to  Gower,  probably 
depend  on  disease  of  one  part  of  the  occipital  lobe,  and  is  proof  of  a  separate 
center  for  color  not  yet  precisely  located,  perhaps  in  some  part  of  the  oc- 
cipital cortex  in  front  of  the  apical  region. 

The  limitation  of  the  remaining  functionally  active  half  fiield  and  the 
isolated  loss  for  colors  are  the  best  known  differences  in  the  features  of 
hemianopia  due  to  variations  in  the  seat  of  the  lesion  in  the  optic  path 
behind  the  chiasm;  the  limitation  of  the  active  half  field  indicating  a  lesion 
in  the  optic  radiation  near  the  thalamus,  the  isolated  loss  for  colors  pointing 
to  a  lesion  in  the  occipital  lobe. 

3.  Amblyopia. — Amblyopia  is  another  form  of  sight  defect  due  to  brain 
disease.  The  term  is  used  to  indicate  a  partial  loss  or  blurring  of  vision. 
There  is  concentric  limitation  of  the  visual  field,  different  in  different  cases, 
and  along  with  it  the  color  fields  are  also  reduced. 

Similar  eye  defects,  associated  with  hemianesthesia,  occur  sometimes 
in  hysteria,  with  which  it  may  be  confounded.     Since  a  simple  functional 


980  DISEASES  OF  THE  NERVOUS  SYSTEM 

loss  of  vision  may  rarely  result  as  a  reflex  from  irritation  of  the  fifth  nerve 
or  from  hysteria,  so  a  functional  amblyopia,  aflecting  both  eyes,  may  also 
result  from  such  causes — indeed,  is  more  common  than  the  organic  form. 
A  carious  tooth  may  act  in  this  way.  Amblyopia  from  errors  of  refraction 
must  not  be  confounded  with  the  amblyopia  due  to  brain  disease. 

Diagnosis. — How  shall  we  interpret  these  phenomena  of  vision  con- 
cerned with  the  optic  nerve  and  tract  ?  Some  conclusions  are  easy ;  others 
are  difficult,  because  of  our  limited  knowledge.  Accurate  investigation 
of  fields  of  vision,  with  a  view  to  the  study,  of  hemianopia  and  other  de- 
fects in  the  visual  fields  variously  caused,  is  made  by  means  of  the  perim- 
eter, for  directions  concerning  the  use  of  which  instrument  the  student  is 
referred  to  works  on  ophthalmology.  Herman  Sahli  suggests  an  easy, 
rough  method,  quite  sufficient  for  recognizing  marked  difference  in  the  field 
of  vision,  performed  as  follows:  The  physician  seats  himself  opposite  the 
patient,  whose  right  eye — supposing  this  to  be  the  one  to  be  tested — is 
opposite  the  physician's  left,  the  other  eye  of  each  being  closed.  The  two 
open  eyes  being  thus  fixed  opposed,  the  physician  passes  his  finger  to  and 
fro  across  the  field  of  vision  exactly  midway  between  the  two  eyes.  In  this 
way  he  can  compare  his  own  field  of  vision  with  that  of  the  patient,  noting 
at  what  moment  the  finger  is  seen  approaching  from  the  peripherj-  of  each. 
Care  must  be  taken  that  the  finger  is  kept  exactly  midwaj^  between  the 
physician  and  patient,  and  in  order  to  do  this,  the  examiner  ma}^  from  time 
to  time  open  his  closed  eye. 

Defective  sight  in  one  eye  with  diminished  reflex  action  of  pupil  pro- 
portionate to  the  defect,  the  function  of  the  remaining  eye  being  intact, 
usually  means  disease  of  one  optic  nerve.  In  some  rare  cases  of  functional 
disease  in  which  the  sight  of  one  eye  only  is  involved,  the  perfect  respon- 
siveness of  the  pupil  distinguishes  it  from  organic  disease  of  the  nerve. 
Total  loss  of  sight  in  both  eyes  may  mean  chronic  atrophy,  damage  to  the 
chiasm,  or  disease  of  both  tracts  or  in  both  hemispheres.  In  these  cases 
the  s^Tmptoms  are  at  first  partial,  and  in  this  way  the  diagnosis  is  aided. 

Central  scotoma  means  damage  to  nerve  fibers  in  the  center  of  the 
trunk  of  the  optic  nerve,  either  inflammator)'  or  the  result  of  hemorrhage. 
Peripheral  limitation  of  vision  means  damage  to  fibers  running  in  the 
periphery  of  the  nei^e.  Sectorial  blindness  in  one  eye  means  disease  of 
the  nerve,  decided  in  degree  but  limited  in  extent. 

Bitemporal  hemianopia  means  disease  of  the  chiasm,  while  the  combi- 
nation of  complete  blindness  of  one  eye  with  temporal  hemianopia  in  the 
other  means  disease  of  the  chiasm  which  has  extended  to  the  outer  fibers, 
and  even  to  the  optic  tract  or  optic  nerve,  on  the  side  on  which  blindness 
is  complete. 

Bilateral  hemianopia  may  be  due  to  disease  back  of  the  chiasm,  and 
the  detennination  of  the  spot  involved  in  the  tract  between  the  chiasm  and 
the  occipital  area  which  is  the  cortical  center  of  vision,  stimulates  diagnostic 
acumen.  The  most  that  can  be  attempted  is  the  settling  of  the  question  as 
to  whether  the  disease  is  in  the  tract  between  the  chiasm  and  the  external 
geniculate  body  or  in  the  fibers  beyond  in  the  visual  center  of  the  hemi- 
sphere. To  this  end  the  hemianopsic  pupillary  reaction  of  Wernicke  is 
sought.     A  perfect  pupil  reflex  requires  the  integrity  of  the  retina,  of  the 


LESIONS  OF  THE  MOTOR  NERVES  981 

fibers  of  the  optic  nerve  and  tract,  of  the  nuclei  and  fibers  of  the  third 
nerve,  and  of  the  iris.  When  the  light  is  thrown  on  the  blind  half  of  the 
retina  the  pupil  contracts  as  much  as  if  it  is  thrown  on  the  seeing  half,  if 
the  disease  is  in  the  hemisphere;  but  if  the  disease  is  in  the  tract,  it  does 
not  contract  because  the  path  to  the  third  nucleus  below  the  corpora  quad- 
rigemina  is  interrupted.  The  employment  of  the  test  requires  much  care 
and  experience.  Seguin  directs  that  the  patient,  being  in  a  darkened  room 
with  a  light  behind  his  head  in  the  usual  position,  be  directed  to  look  to  the 
other  side  of  the  room,  so  as  to  eliminate  accommodation  movements. 
Then  a  faint  light  is  thrown  upon  the  eye  from  a  plane  or  large  concave 
mirror,  held  well  out  of  focus,  and  the  size  of  the  pupU  is  noted.  With 
the  other  hand  a  beam  of  light,  focused  by  an  ophthalmoscope  mirror,  is 
then  thrown  directly  into  the  optical  center  of  the  eye,  then  laterall}-  in 
various  positions  and  from  above  and  below  the  equator  of  the  eye,  noting 
the  reaction  at  all  angles  of  incidence.  According  or  not  as  a  response  is 
obtained  in  the  pupil  the  inference  is  drawn. 

Amblyopia  with  concentric  reduction  of  the  field,  decided  in  one  eye 
and  slight  in  the  other,  may  be  due  to  atrophy  of  the  nerve,  to  disease  of 
the  distal  visual  center  in  one  hemisphere,  or  to  hysteria.  If  atrophy,  the 
ophthalmoscope  recognizes  the  lesion  and  the  responsiveness  of  the  pupil 
is  diminished.  If  disease  of  one  hemisphere,  the  nerve  is  normal  to  the 
ophthalmoscope,  the  pupil  contracts  perfectly  under  the  action  of  light, 
and  the  onset  is  sudden  or  accompanied  with  other  signs  of  organic  brain 
disease.  Mind-blindness,  may  also  be  a  result  of  lesion  in  this  locality.  In 
hysteria  the  symptoms  are  the  same  as  in  disease  of  the  higher  visual  center, 
and  the  diagnosis  depends  on  the  presence  or  absence  of  signs  of  organic 
or  functional  disease.  In  hysterical  blindness  the  loss  of  sight  is  rarely 
complete.  In  hysterical  and  neurotic  defects  of  vision  there  may  be  a 
derangement  of  the  natural  relation  in  color  fields.  Thus,  while  normally 
the  blue  field  is  most  conspicuous  in  the  last-named  conditions,  it  is  often 
overshadowed  by  other  colors. 

LESIONS  OF  THE  MOTOR  NERVES  OF  THE  EYEBALL. 

Anatomical. — The  third  cranial  nerve  (oculomotor)  supplies  the  levator 
palpebras  superioris,  the  superior,  inferior  and  internal  recti,  the  obliquus 
inferior,  the  sphincter  of  the  iris,  and  the  ciliary  muscle.  The  foiu-th  cranial 
nerve  (the  trochlear)  supplies  the  superior  oblique;  the  sixth  cranial  nerve 
(the  abducens),  the  rectus  extemus.  The  functions  of  the  muscles  to 
which  these  nerves  are  distributed  are  sufficiently  indicated  by  their  names. 

Third  Nerve. — ^Lesions  may  involve  the  nerve  at  its  nuclear  origin  or 
in  its  course.  Lesion  of  the  third  nerve  at  its  origin  involves  also  usuallj^ 
the  origin  of  the  fourth  nerve,  as  a  result  of  which  the  eyeball  is  motion- 
less, except  for  outward  movement,  and  an  object  moved  about  in  front  of 
it  can  be  followed  only  by  moving  the  entire  head.  The  nerve  may  be  in- 
vaded in  its  course  by  traumatic  causes,  meningitis,  gummata,  aneurysm, 
or  neuritis,  frequently  rheumatic,  and  may  also  be  affected  in  diphtheria, 
tabes  dorsalis,  and  diabetes  mellitus.     The  effect  may  be  spasm  or  paralysis. 

The  results  of  spasm  of  the  muscles  supplied  by  the  third  nerve  are 


982  DISEASES  OF  THE  XERVOUS  SYSTEM 

manifested  in  nystagmus,  although  nystagmus  is  not  invariably  indicative 
of  spasm.  This  consists  in  an  involuntary,  clonic,  rhythmical,  oscillatory 
movement  of  the  eyeball,  usually  horizontal,  but  sometimes  rotary,  more 
rarely  vertical.  It  is  seen  in  congenital  or  acquired  brain  lesions,  and  is 
often  a  striking  feature  in  albinism.  In  meningitis  and  hysteria  there 
is  also  sometimes  spasm  of  the  muscles  supplied  by  the  third  nerve,  espe- 
cially the  internal  rectus  and  the  levator  palpebrae,  the  antagonist  of  the 
orbicularis.^ 

Paralysis  of  those  muscles  supplied  by  the  third  nerve,  which  include 
all  the  eye  muscles  except  the  external  rectus  and  the  superior  oblique, 
results  in  outward  squint;  ptosis,  or  drooping  of  the  upper  eyelid;  the 
absence  of  contracting  power  in  the  pupil,  which  remains  of  medium  size; 
loss  of  accommodation;  double  vision,  or  diplopia.  Such  paralysis,  in- 
volving all  the  branches  of  the  nerve,  may  be  recurrent,  especially  in  women, 
rarely  at  the  menstrual  period,  and  usually  at  wider  intervals. 

It  is  sometimes  associated  with  pain  in  the  head  and  at  other  times 
with  migraine.  The  individual  attack  lasts  a  few  days,  or  as  many  weeks. 
Partial  involvement  of  the  third  nerve  may  include  the  levator  palpebrae. 
the  superior  rectus,  the  ciliary  muscle,  and  the  iris,  while  the  external 
muscles — that  is,  the  internal  and. inferior  recti  and  the  inferior  oblique — 
may  escape. 

Ptosis  only,  due  to  paralysis  of  the  levator  palpebras,  complete  or  partial 
may  occur  under  various  conditions.  It  maj'  be  congenital  and  incurable, 
or  due  to  cerebral  lesion;  or  it  may  be  hysterical,  when  it  is  apt  to  affect 
both  eyes  and  is  associated  with  other  symptoms  of  hysteria.  It  may  be 
caused  by  disease  of  the  sympathetic  nerve  (pseudoptosis),  and  ma}'-  be 
associated  with  symptoms  of  vasomotor  palsy — viz.,  elevation  of  tempera- 
ture on  the  affected  side,  redness  or  edema  of  the  skin,  and  contraction  of 
the  pupil  on  the  same  side.  Finally,  it  is  seen  in  weak,  delicate  women  as 
a  transient  event,  especially  in  the  morning.  When  ptosis  is  the  result  of 
a  definite  lesion  of  the  third  nerve,  at  its  nucleus  or  in  its  course,  it  ma}-  also 
be  associated  with  a  paralysis  of  the  superior  rectus  alone,  or  of  the  internal 
and  inferior  recti  in  addition. 

Condition  of  the  Pupil. — The  condition  of  the  pupil  should  be  studied 
with  light  of  moderate  intensity,  and  in  doubtftd  states  the  pupil  under 
examination  should  be  compared  with  that  of  the  eye  of  a  healthy  individual 
about  the  same  age. 

Miosis,  or  contraction  of  the  pupil,  is  found  physiologically  during 
sleep,  especially  in  elderl}-  persons;  pathologically,  as  an  early  sj^mptom  in 
tabes  dorsalis,  in  progressive  paralysis  of  the  insane,  and  as  an  effect  of 
eserin,  pilocarpin,  morphin,  and  in  complete  chloroform  narcosis. 

Mydriasis,  or  dilatation  of  the  pupil,  occurs  in  deep  unconsciousness, 
during  extreme  pain,  in  dyspnea,  in  peripheral  blindness,  especially  from 
optic  atrophy,  in  oculomotor  paralysis,  rarely  in  tabes  dorsalis  and  pro- 
gressive paralysis  of  the  insane.  It  is  also  an  effect  of  atropin,  duboisin, 
and  cocain,  and  of  the  early  stage  of  chloroform  narcosis. 

The  pupil  maj'  be  unduly  large  from  palsy  of  the  sphincter  (third  pair) 

*  Blepharospasm  is  a  spasm  of  the  orbicularis  muscle,  which  is  supplied  by  the  facial  nerve.  It 
amounts  usually  only  to  twitching  of  the  eyelids,  but  may.  be  so  severe  as  to  close  them  completely,  so 
that  it  is  not  in  the  power  of  the  patient  to  open  them. 


LESIONS  OF  THE  MOTOR  NERVES  983 

fibers  or  from  spasm  of  the  radiating  (sympathetic)  fibers ;  or  the  pupil  may 
be  abnormally  small  from  the  opposite  conditions. 

Other  limited  paralyses  due  to  third  nerve  disease  are  cycloplegia  and 
iridoplegia.  Cycloplegia  is  paralysis  of  the  cUiary  muscle,  producing  loss  of 
the  power  of  accommodation.  In  this  state  of  affairs  distant  vision  is  good, 
but  near  objects  cannot  be  seen  distinctly.  It  may  occur  in  one  or  both  eyes, 
being  in  the  latter  event  more  usually  due  to  disease  of  the  nuclear  origin  of 
the  third  nerve.  It  is  one  of  the  earliest  manifestations  of  diphtheritic 
paralysis,  and  is  a  symptom  also  of  tabes  dorsalis.  It  may  be  corrected  by 
the  use  of  eye-glasses. 

Iridoplegia  is  paralysis  of  the  iris,  and  its  three  forms  are  thus  classified 
by  Gowers,  one  associated  and  two  reflex: 

1.  Accommodative  iridoplegia  is  a  .form  in  which  the  pupil  does  not 
diminish  in  size  during  accommodation.  It  is  tested  by  having  the  patient 
look  at  a  distant  object  and  then  at  a  near  one  in  the  same  line  of  vision,  so 
as  to  avoid  any  change  in  the  amount  of  light  entering  the  eye.  It  is  usually 
associated  with  paralysis  of  accommodation,  but  the  ciliary  muscle  may 
be  efficient  and  yet  the  associated  action  of  the  iris  be  lost,  or  the  reverse. 
This  loss  is  less  common  than  that  of  reflex  action.  It  is  the  result  of  the 
same  cause  as  cycloplegia. 

2.  Reflex  Iridoplegia,  or  Argyll  Robertson  Pupil. — The  path  for  the 
optic  reflex  is  along  the  optic  nerve  and  tract  to  the  mucleus  of  the  third 
nerve ;  thence  to  the  ciliary  ganglion,  and  through  the  ciliary  nerves  to  the 
eye.  In  testing  for  this  condition  each  eye  should  be  tried  separately, 
the  other  being  covered,  but  not  closed.  The  patient  is  asked  to  look 
toward  a  dark  part  of  the  room,  when  a  bright  light  is  thro\vn  suddenly  in  front 
of  the  eye  at  a  distance  of  three  or  four  feet,  so  as  to  avoid  the  effect  of  ac- 
commodation. The  pupil  will  not  contract  under  these  conditions.  There- 
fore there  is  loss  of  reaction  to  light.  If  the  patient  is  now  directed  to  look 
at  some  object  in  the  distance  and  then  at  an  object  near  to  the  eye  the 
pupil  will  react.     This  is  the  Argyll  Robertson  pupil. 

3.  Skin  Iridoplegia. — ^Loss  of  skin  reflex.  If  the  skin  of  the  neck  is 
pinched  or  pricked,  or  stimulated  by  an  electric  shock,  the  pupil  dilates 
reflex!}'.  Since  active  dilatation  of  the  pupil  is  through  the  sympathetic 
nerve,  the  motor  path  for  this  action  must  be  along  the  cervical  sympathetic, 
and  along  the  fibers  connecting  this  with  the  cord,  at  the  lowest  part  of  the 
cervical  region. 

These  reactions  are  lost  when  the  path  is  interrupted  or  the  center  is 
damaged.  Thus,  the  light  reflex  is  lost  or  impaired  in  disease  of  the  optic 
nerve  including  the  retina,  or  in  disease  of  the  third  nerve.  Disease  of  one 
optic  tract  does  not  lessen  the  action  unless  the  light  falls  on  the  blind  half 
of  the  retina,  because,  as  already  stated,  the  fibers  from  the  central  and  most 
sensitive  region  of  each  retina  pass  through  both  optic  tracts,  whence  dis- 
ease of  one  does  not  abolish  the  reflex.  The  skin  reflex  is  lost  in  disease  of 
the  cervical  sympathetic  and  sometimes  of  the  cervical  spinal  cord  espe- 
cially when  there  is  associated  loss  of  sensibility.  Thus,  tumor  of  the  cord 
sometimes  produces  this  symptom. 

When  the  eye  reflexes  are  lost  without  disease  of  the  sympathetic  or 
cervical  cord,  it  is  generally  due  to  degenerate  disease  of  the  centers      Tabes 


984 


DISEASES  OF  THE  NERVOUS  SYSTEM 


dorsalis,  in  which  it  is  a  common  and  an  early  symptom,  is  a  conspicious 
instance.  Less  frequent  is  general  paralysis  of  the  insane,  and  other  degen- 
erative processes  less  definite.  It  may  occur  also  without  other  nen-e  symp- 
toms. In  most  of  the  cases  in  which  it  has  come  under  Gowers'  observation 
thus  isolated,  the  patient  had  suffered  from  constitutional  syphilis  for  years. 
The  two  palsies,  that  of  the  sldn  reflex  and  that  of  the  light  reflex,  are  com- 
monlj'-  associated,  but  not  always.  The  pupils  are  often  small,  reduced  to 
two  millimeters,  or  even  one  millimeter,  in  diameter. 

Inequality  of  pupils,  or  anisocoria,  is  also  a  symptom  of  progressive 
paresis  and  tabes  dorsails,  but  occurs  also  in  healthy  persons. 


Fig.  174. — Situation  of  the  Cranial  Ner\-e  Roots — {after  Edinger). 
Cranial  nerve  nuclei,  oblongata,  and  pons  represented  as  transparent.     Motor  nuclei,  black; 
sensitive  nuclei,  red. 

Fourth  Nerve. — The  fourth  cranial  nerve,  (trochlear),  as  it  passes 
around  the  outer  surface  of  the  cms  into  the  orbit,  is  liable  to  be  compressed 
by  ttunors,  by  aneurysm,  or  by  the  exudation  of  basal  meningitis.  Its 
nucleus  below  the  aqueduct  of  Sylvius  may  be  involved  in  tumors  or  may 
undergo  degeneration  with  other  octilar  nuclei.  As  the  superior  oblique 
muscle,  supplied  by  it,  acts  in  such  a  way  as  to  direct  the  eyeball  downward 
and  rotate  it  slightly,  paralysis  causes  retardation  of  downward  and  inward 
movement,  often  so  sHght  as  not  to  be  noticeable.  The  head  is  inclined 
somewhat  for^-ard  and  toward  the  sound  side,  and  there  is  double  vision 
when  the  patient  looks  down,  as  in  descending  stairs.  Paralysis  of  this 
nerve  is  seldom  met  with  alone,  except  in  nuclear  disease. 

Sixth  Nerve. — The  sixth  nerve  (abducens),  emerging  at  the  junction 
of  the  pons  and  medidla  oblongata,  passing  forward  and  entering  the  orbit, 
is  liable  to  be  affected  by  meningitis  at  the  base,  or  by  tumors,  especially 
fibromata.  The  external  rectus  being  alone  supplied  by  it,  the  effect 
of  its  paralysis  is  to  produce  internal  squint,  and  the  eye  cannot  be  turned 
outward.  There  is  diplopia  when  looking  toward  the  paralyzed  side. 
It  is  a  frequent  ocular  palsy,  because  the  ner\'e  has  a  long  intracranial  course. 

If  the  nucleus  of  the  sixth  nerve  is  affected,  a  very  interesting  condition 
restilts,  which  was  first  studied  by  Beevor.  In  consequence  of  paralysis 
of  the  external  rectus  the  eye  of  that  side  is   turned  inward  while  at  the 


LESIONS  OF  THE  MOTOR  NERVES  985 

same  time  the  internal  rectus  of  the  eye  of  the  opposite  side  has  lost  the 
power  to  turn  its  eye  inward.  Consequently,  both  eyes,  are  turned  to  the 
side  opposite  and  away  from  that  of  the  injury.  Thus,  if  the  nucleus  of  the 
right  sixth  nerve  is  involved,  both  the  right  and  the  left  eye  are  turned  to- 
ward ,the  left.  Such  opposite  deviation  away  from  the  side  of  lesion  is 
known  as  "conjugate  deviation."  It  is  due  to  the  fact  that  the  nucleus 
of  the  third  nerve,  supplying  the  internal  rectus,  is  connected  by  fibers  with 
the  nucleus  of  the  sixth  of  the  other  side;  whence  in  lesion  of  the  nucleus 
of  the  sixth  nerve  there  is  paralysis  of  the  internal  rectus  nerve  in  associated 
movements,  even  though  the  nucleus  of  the  third  nerve  is  not  involved 
while  the  power  of  convergence  is  not  affected. 

In  consequence  of  the  proximity  of  the  nucleus  of  the  sixth  nerve  to 
that  of  the  seventh  or  facial,  disease  of  the  former  is  likely  to  involve  the 
latter.  Whence,  say  if  there  is  lesion  of  the  left  nerve  there  follows  con- 
jugate deviation  of  both  eyes  to  the  right,  with  a  complete  paralysis  of  the 
left  Ihalf  of  the  face. 

Diabetes  insipidus  is  sometimes  associated  with  paralysis  of  the  sixth 
nerve.  Such  a  case  was  seen  at  the  Philadelphia  Hospital  with  J.  Hendrie 
Lloyd ;  The  paralysis  of  the  sixth  nerve  was  subsequently  substituted  by 
paralysis  of  the  third,  the  polyuria  remaining.  A  similar  condition  may 
be  caused  by  syphilitic  meningitis.  Basal  meningitis,  involving  the  vas- 
cular supply  to  the  floor  of  the  fourth  ventricle,  may  be  suspected.  Other 
cases  of  polyuria  associated  with  paralysis  of  the  sixth  nerve  are  reported, 
notably  Maguire's,  but  it  should  be  recognized  that  both  polj'uria  and  ocular 
palsy  may  be  caused  by  syphilis. 

Phenomena  in  General  of  Paralysis  of  Motor  Nerves  of  the  Eye. — 
These  include,  first,  limitation  of  movement  and  strabismus,  referred  to.     In 
addition  to  these  certain  derangements  of  vision,  known  as  secondary  devia- 
tion, erroneus  protection,  double  vision,  occur. 

Secondary  deviations  are  thus  demonstrated:  After  covering  the  sound 
eye,  let  the  paretic  eye  fix  itself  upon  a  point  which  it  cannot  reach  at  all,  or 
can  reach  only  after  extreme  exertion.  Then  remove  the  covering  hand 
from  the  sound  eye,  and  it  will  be  found  that  the  latter  has  been  moved 
much  too  far  in  the  same  direction,  the  abnormal  attempt  at  innervation  of 
the  affected  eye  passing  over  to  the  associated  muscle  of  the  healthy  eye 
and  causing  in  it  too  great  a  contraction. 

Erroneus  projection  furnishes  the  idea  that  an  object  at  which  we  are 
looking  is  further  on  one  side  than  it  really  is  or  that  the  movement  of  the 
eye  in  following  it,  when  moving,  is  greater  than  it  is.  Under  these  circum- 
stances, in  an  attempt  to  touch  the  object  with  the  fingers  the  latter  may 
go  beyond  it.  This  grows  out  of  the  fact  that  when  the  eyes  are  at  rest 
in  the  mid  position,  an  object  at  which  we  are  looking  appears  directly 
opposite  the  face.  Turning  the  eye  to  one  side,  the  object  appears  to  the 
side  of  its  former  position ;  and  if  the  object  moves,  we  estimate  the  extent 
of  its  motion  by  the  amount  of  movement  of  the  eyeball  following  it. 
Now,  when  one  muscle  is  weak,  the  increased  innervation  required  to  contract 
it  gives  the  impression  of  a  degree  of  movement  greater  than  actually  takes 
place.  This  is  erroneous  projection.  Now,  as  the  equilibrium  of  the  body 
is  largely  maintained  by  a  knowledge  of  the  relation  of  external  objects 


986  DISEASES  OF  THE  NERVOUS  SYSTEM 

to  it,  obtained  by  the  action  of  the  eye  muscles,  the  erroneous  projection 
due  to  paralysis  disturbs  the  harmony  of  visual  impressions  and  may  produce 
dizziness  known  as  ocular  vertigo. 

Double  vision  results  from  the  fact  that  if  one  eye  is  paralyzed  the  axes 
of  the  two  eyes  do  not  coincide,  nor  do  the  images  in  the  two  retinae.  The 
image  produced  in  the  sound  eye  is  called  the  true  image ;  that  is  the  affected 
eye,  the  false  image.  In  simple  or  homonymous  diplopia  the  false  image  is 
on'the  same  side  as  the  paralyzed  eye;  in  crossed  diplopia  it  is  on  the  other 
side.  It  is  one  of  the  most  annoying  symptoms  of  paralysis  of  the  eye 
muscles. 

Ophthalmoplegia. — Ophthalmoplegia  is  a  term  applied  to  a  chronic 
progressive  paralysis  of  the  ocular  muscles,  supposed  to  be  due  to  disease 
of  the  ocular  nuclei,  but  frequently  the  nerves  are  affected  at  the  base  of 
the  brain,  especially  when  the  sixth  nerves  escape.  It  is  called  internal 
when  the  internal  muscles  only  are  involved — i.e.,  the  iris  and  ciliary 
muscles,  external,  when  the  external  muscles  are  affected  more  or  less 
completely.  When  both  internal  and  external  muscles  are  irivolved, 
it  is  known  as  total  ophthalmoplegia. 

Symptoms. — These  varying  according  to  the  position  and  character  of 
the  lesion,  which  may  be  degenerative,  hemorrhagic,  or  the  result  of  pressure 
by  tumors  or  the  product  of  basilar  meningitis.  They  are  bilateral,  except 
in  the  instance  of  the  sixth  nerve,  with  resulting  conjugate  paralysis. 
Gowers  describes  three  modes  of  onset — chronic,  sudden,  and  acute. 

The  chronic  form  is  the  most  common,  due  to  nuclear  degeneration,  or 
more  rarely  to  tumor  and  embolic  obstruction,  and  still  more  rarely  to 
hemorrhage.  In  this  form  there  is  a  great  variety  of  combination  and 
degree.  Thus,  there  may  be  internal  ophthalmoplegia  only,  or  external, 
or  both.  In  the  internal  form  there  may  be  loss  of  the  iris-reflex  only  or 
of  the  ciliary  muscle  action  only.  In  the  external  variety  the  levator  and 
superior  recti  are  commonly  first  involved,  the  other  muscles  gradually. 
There  may  be  loss  of  the  upward  and  downward  movement  of  the  eye, 
ptosis,  and  conjugate  lateral  palsy.  There  may  be  double  vision.  In  the 
total  form  the  eye  is  fixed  and  immovable.  Each  variety  may  be  associated 
with  tabes  dorsahs,  general  paralysis  of  the  insane,  progressive  muscular 
atrophy,  and  bulbar  palsy,  often  with  syphilis.  It  is  more  common  in 
males,  and  occurs  occasionally  in  the  young.  There  is  a  form  occurring  in 
children,  known  as  infantile  oculo-facial  palsy,  which  may  be  congenital  or 
acquired ;  rarely,  it  occurs  as  a  sequel  of  diphtheria,  late  and  permanent.  The 
disease  may  be  very  slow  in  developing,  and  may  require  years.  Sometimes 
one  eye  is  more  affected  than  the  other. 

In  sudden  nuclear  palsy,  the  second  in  frequency,  the  onset  may  take 
but  a  few  minutes  or  an  hour  or  two.  The  causes  in  such  such  cases  are  com- 
monly obstruction  to  the  basilar  arterial  branches,  rarely  embolic  obstruc- 
tion, and  still  more  rarely  hemorrhage.  The  obstruction  is  usually  bilateral. 
The  lesions  are  irregular,  and  the  symptoms  are  correspondingly  irregular 
and  unsymmetrical ;  the  tendency  is  to  recover.  In  these  respects  it  differs 
from  the  chronic  form  also  in  that  hemiplegia  is  a  frequent  accompaniment, 
generally  on  the  side  opposite  the  greater  eye  palsy.     When  hemorrhage 


LESIONS  OF  THE  MOTOR  NERVES  987 

is  a  cause,  the  resulting  ocular  palsy  lasts  but  a  few  hours,  provided  the 
hemorrhage  acts  on  the  ocular  centers  only  by  pressure,  while  the  other 
phenomena  of  pressure  by  effused  blood,  which  is  apt  to  spread,  make  their 
appearance. 

Acute  nuclear  palsy  is  rare.  It  develops  in  a  few  days  or  weeks,  and  is 
possibly  of  inflammatory  or  toxic  origin  whence  called  by  Wernicke  poliomy- 
elitis superior;  but  toxic  cases  may  occur  without  inflammation.  This 
form,  according  to  Gowers,  may  be  due  to  peripheral  neuritis  and  not  to  nu- 
clear disease.  Alcohol  may  be  a  toxic  cause.  The  eye  muscles  are  invaded 
irregularly,  and  it  is  common  for  the  internal  muscles  to  escape.  In  fatal 
cases  the  causal  influence  extends  to  the  centers  of  other  nerves  and  possibly 
to  the  cortex.  In  cases  that  survive  there  is  improvement,  various  in 
degree. 

Treatment  of  Ocular  Palsies. — The  cause  should  be  sought  and  if 
found,  treated.  Although  syphilis  probably  is  the  chief  cause  of  this 
disease  and  of  tabes  dorsalis,  with  which  it  is  so  frequently  associated, 
disappointment  follows  the  syphilitic  treatment  in  the  majority  of  cases 
because  of  destructive  lesions.  Yet  mercury  or  salvarsan  perhaps  accom- 
plishes more  than  any  other  remedy.  Arsenic,  potassium  iodid,  strychnin, 
and  iron  are  sometimes  used,  strychnin  hypodermicallj^  In  acute  cases,  when 
there  is  pain,  hot  fomentations,  leeches,  and  counterirritation  may  be  used. 
In  chronic  forms  electricity  has  been  extensively  used,  galvanism  being  pre- 
ferred. Benedikt  recommended  placing  the  anode,  or  positive  pole,  on  the 
forehead  and  the  cathode,  or  negative  pole,  on  the  margin  of  the  orbit  near 
the  affected  muscle.  If  the  faradic  current  is  used  the  orbital  pole  is  held 
still ;  if  the  voltaic,  is  kept  moving  over  the  skin  or  the  current  is  broken  by 
the  commutator.  To  overcome  the  ptosis,  electric  stimulus  is  applied  to 
the  third  nerve,  as  the  muscle  is  not  accessible. 

The  diplopia  is  removed  by  a  prism  not  strong  enough  to  fuse  the  two 
images  completely,  but  of  sufficient  force  to  approximate  them,  so  that  the 
fusion  may  be  completed  by  muscular  action.  Such  action  may  be  practised 
for  an  hour  each  day.  The  dizziness  due  to  erroneous  projection  can  be  re- 
moved only  by  throwing  the  eye  out  of  use  by  an  opaque  glass.  Operative 
treatment  is  not  recommended. 

Periodical  Oculomotor  Paralysis. — The  organic  lesion  at  the 
bottom  of  these  paralyses  is  not  yet  settled.  Mobius,^  who  was  one  of  the 
first  who  have  contributed  largely  to  the  subject,  regarded  nuclear  degenera- 
tion as  the  cause,  while  other  contributors  consider  that  the  majoritj^  of 
cases  have  a  basal  cause,  by  which  is  meant  a  basal  meningitis,  tumor  or 
other  cause  compressing  the  trunk  of  the  nerve  at  the  base  of  the  cranium. 
A  recent  paper  on  this  subject  is  "  Migraine  ophthalmoplegique,"  Bomstein, 
Monatsschrift  fur  Psychistrie  und  Neurologic,  vol.  xxv,  No.  3,  March,  1909. 

Treatment. — Because  of  syphilitic  origin,  in  many  of  these  cases  mer- 
curial treatment  proved  promptly  efficient,  while  at  times  the  symptoms 
subsided  spontaneously. 

1  Mobius,  "TJeber  periodische  wiederkehrende  Oculomotoruslahmung." 
1884,  Nr.  30  u.  38,  S.  604;  and  "Arch.  £.  Psych,  u.  Nervenkrankh.,"  xiv., 


988  DISEASES  OF  THE  NERVOUS  SYSTEM 

LESIONS  OF  THE  TRIFACIAL  OR  FIFTH  NERVE 
(TRIGEMINUS). 

Anatomical. — This  important  mixed  nerve  of  the  face  suppHes  by  its 
motor  trunk  the  muscles  of  mastication ;  by  its  sensory  portion,  the  skin  of 
the  face,  the  mucous  membrane  of  the  mouth  and  nasal  cavity,  the  conjunc- 
tiva, and  the  comua;  also,  according  to  some  physiologists,  the  anterior 
part  of  the  tongue  with  gustatory  fibers.  The  gustatory  fibers  are  supposed 
to  reach  the  lingual  fibers  of  the  fifth  nerve  by  the  chorda  t},-mpani  nerve. 
Recent  studies  of  Harvey  Gushing  make  this  doubtful. 

Lesions. — i.  There  may  be  lesions  of  the  pons,  especially  hemorrhage, 
or  areas  of  sclerosis  invading  the  trigeminus  nucleus. 

2.  Injury  or  disease  at  the  base  of  the  skuU,  especially  acute  and  chronic 
meningitis  and  caries  of  the  bone,  tumors,  syphilis,  new  formations  com- 
pressing the  trunk  or  the  Gasserian  ganglion.  Fracture  of  the  base  rarely 
affects  this  nerve. 

3.  Tumors  or  aneurj^sms  pressing  on  the  first  division  (ophthalmic)  of 
the  nerve  through  the  cavernous  sinus,  on  the  second  division  (superior 
maxillary)  and  on  the  third  division  (inferior  maxillary)  by  invasion  of  the 
sphenomaxillary  fossa. 

4.  There  may  be  inflammation  of  the  nerve,  which  is  rare. 

5.  The  sensory  division  may  also  be  affected  in  hysteria. 

6.  The  gustatory  fibers  of  the  trigeminus  may  be  influenced  b}'  per- 
ipheral lesions  of  the  facial,  whence  the  chorda  t\Tnpani  is  derived. 

Symptoms. — Paralysis  of  the  Sensory  Portion. — The  distribution  of 
the  anesthesia  varies  according  as  the  whole  trigeminus  or  only  a  part  is 
involved.  In  total  anesthesia  there  is  loss  of  sensation  in  half  the  corre- 
sponding side  of  the  head,  including  the  conjunctiva  and  cornea,  mucosa  of 
the  lips,  tongue,  hard  palate,  and  nose  of  the  same  side.  Hence  on  the 
tongue  or  mucous  membrane  there  are  often  ulcers  which  come  from  un- 
conscious lacerations  by  the  teeth.  There  is,  according  to  the  views  of 
many,  loss  of  the  senses  of  taste  and  smell.  The  loss  of  the  sense  of  smell  is 
probably  due  to  drying  of  the  mucous  membrane,  as  it  is  not  probable  that 
the  fifth  nerve  contains  olfactory  fibers.  The  so-called  trophic  phenomena 
are  also  observed,  and  among  them  the  much-discussed  neuroparalytic  oph- 
thalmia, an  vdcerative  keratitis,  beginning,  also,  always  in  the  lower  seg- 
ment of  the  cornea,  and  passing  over  into  ptrrulent  inflammation  of  the 
whole  eyeball.  It  seems,  on  the  whole,  more  likely  that  the  inflammation 
is  primarily  due  to  the  action  of  irritants  which  in  health  are  excluded  by 
the  proper  closure  of  the  eyelids,  though  the  inflammatory  process  itself 
may  be  trophically  influenced.  The  salivary,  lacrymal,  and  buccal  secre- 
tions may  be  diminished  and  the  teeth  may  become  loose.  Herpes  is  a 
trophic  result  which  may  develop  in  the  course  of  the  nerve,  is  painful,  and 
may  last  a  long  time.  So,  too,  the  anesthesia  may  be  preceded  by  tingling. 
The  skin  of  the  face  is  sometimes  swollen. 

Paralysis  of  the  motor  portion,  which  supplies  especially  the  muscles  of 
mastication,  the  masseters,  temporals,  and  pterygoids,  is  not  common.  It 
is  most  frequent  in  diseases  of  the  base  of  the  skull,  compressing  this  branch. 
Difficultj^  in  chewing  is  the  restdt.     If  on  one  side,  the  patient  can  chew  only 


LESIONS  OF  THE  FACIAL  NERVE  989 

on  the  other;  if  on  both  sides,  he  cannot  chew  at  all.  The  lower  jaw  hangs 
down  and  cannot  be  moved  from  side  to  side  because  of  the  paralysis  of  the 
pterygoids.  If  on  one  side,  the  external  pterygoid  cannot  push  the  jaw 
toward  the  sotmd  side,  and  when  depressed,  the  jaw  is  pushed  by  the 
muscle  of  the  sound  side  toward  the  paralyzed  side.  Cases  have  occurred 
associated  with  cortical  lesion;  and  paralysis  of  the  muscles  of  mastication 
occurs  sometimes  in  hemiplegia,  but  is  not  likely  to  be  persistent. 

Spasm  of  muscles  of  mastication  is  found  in  connection  with  muscular 
cramp,  the  muscular  contraction  of  tetanus  (trismus),  sometimes  in  menin- 
gitis, and  reflexly  through  painful  affections  of  the  jaw  or  teeth,  or  from 
irritation  near  -the  motor  nucleus.  It  is  also  sometimes  hysterical.  Clonic 
spasm  occurs  in  muscles  supplied  by  the  fifth  nerve,  constituting  "chattering 
teeth."  It  occurs  generally  in  connection  with  general  conditions,  such  as 
paralysis  agitans,  but  it  may  happen  as  a  local  symptom  late  in  life. 

Diagnosis. — This  is  not  difficult.  Sensibility  is  tested  in  the  ordinary 
way.  The  preliminary  pain  must  not  be  mistaken  for  neuralgia.  Gustatory 
sense  is  tested  in  the  anterior  end  of  the  tongue  by  applying  weak  acid  or 
salt  solutions  and  comparing  the  effect  on  the  two  halves.  The  motor  power 
is  tested  by  biting  on  a  piece  of  wood  or  cork  or  by  moving  the  jaws  against 
resistance. 

Treatment. — This  must  depend  upon  the  cause,  which  should  be  care- 
fully sought.  Syphilitic  new  formations  are  the  lesions  most  commonly 
amenable  to  treatment.  In  the  absence  of  such  causes  the  treatment  must 
be  symptomatic.  Stimulating  liniments  send  faradization  through  the 
electric  brush  are  often  useful.  Galvanism  may  also  be  used,  brushing  the 
part  with  the  cathode.  The  anesthetic  part  should  be  carefully  protected 
against  irritamts. 

In-  the  absence  of  tangible  cause,  systemic  treatment  is  not  indicated, 
except  to  build  up  the  general  health  of  the  patient. 

LESIONS  OF  THE  FACIAL  NERVE,  OR  SEVENTH  PAIR. 

The  seventh  pair  (portio  dura  of  the  seventh,  old  classification)  is  the 
motor  nerve  of  the  face,  and  is  subject  to  paralysis  ofm  otion  and  to  spasm. 

Paralysis  of  the  Facial  Nerve. 

Synonyms. — Mimetic  Facial  Paralysis;   Bell's  Palsy;  Monoplegia  facialis. 

Monoplegia  facialis  may  be  caused  by  lesions  in  the  cortical  center  of 
the  nerve,  in  the  brain  between  the  cortex  and  the  nucleus,  in  the  nucleus 
itself,  and  in  the  nerve  trunk. 

Supranuclear  Paralysis. — The  cortical  center  resides  in  the  foot  of  the 
central  convolution,  probably  the  anterior  central,  from  which  pass  out 
fibers  along  with  the  pyramidal  fibers  through  the  internal  capsule  to  the 
facial  nucleus  in  the  tegmentum  of  the  pons  on  the  opposite  side.  Accord- 
ingly, the  nerve  is  commonly  involved  in  hemiplegias.  Such  a  paralysis, 
due  to  lesion  above  the  facial  nucleus,  is  known  as  supranuclear . 

In  such  a  palsy  the  voluntary  muscles  of  the  lower  half  of  the  face 
are  paralyzed,  while  the  secretory  and  gustatory  functions  of  the  facial 


990  DISEASES  OF  THE  NERVOUS  SYSTEM 

are  not  affected;  nor  are  the  orbicularis  and  forehead  muscles,  except  in 
some  cases  in  the  beginning  of  the  hemiplegia,  these  being  innervated  by 
the  upper  branch  of  the  facial.  These  features,  together  with  the  normal 
electrical  excitability  of  both  nerve  and  muscle,  the  intact  reflexes  and  taste 
sense,  all  point  to  a  central  facial  paralysis  as  distinguished  from  a  per- 
ipheral. The  limitation  of  the  paralysis  to  the  lower  half  of  the  face  is  due 
to  the  fact  that  the  lower  portion  only  of  the  face  receives  almost  exclusively 
crossed  innervation,  while  the  upper  part,  like  the  ocular  muscles  and  the 
motor  trigeminus,  is  innervated  more  from  both  hemispheres,  so  that 
a  lesion  in  one  may  be  overbalanced  by  the  other.  This  will  be  understood 
by  an  examination  of  the  schematic  drawing  (Fig.  175),  from  which  it  is 
plain  that  a  one-sided  brain  lesion  at  a  paralyzes  only  the  inferior  and  not 
the  upper  facial,  because  the  upper  facial  is  also  inner\'ated  from  the  sound 
side.  Recent  investigations  show  that  the  upper  and  lower  branches 
of  the  facial  nerve  have  not  separate  nuclei,  although  they  may  be  repre- 
sented in  different  parts  of  the  same  nucleus.  That  they  are  functionally 
distinct  is  further  shown  by  the  fact  that  in  bulbar  paralysis,  also  a  disease 
of  the  nerve  nuclei  of  the  medulla  oblongata,  usually  only  the  inferior  facial 
is  involved.  That  the  upper  face  muscles  are  totally  uninvolved  in  central 
facial  paralysis  is  not  quite  true,  for  careful  examination  will  show  that  the 
function  is  not  quite  so  perfect  as  in  health;  the  patient  cannot  close  the 
eye  of  the  paralyzed  side  by  itself,  as  in  the  normal  state ;  whence  it  follows 
that  the  upper  half  of  the  face  is  innervated  from  both  hemispheres,  as  is 
also  shown  in  Fig.  175.     The  crossed  influence  is,  however,  the  larger. 

Cortical  facial  paralysis,  monoplegia  facialis,  usually  with  some  weak- 
ness of  the  upper  limb  on  the  side  of  the  face  paralysis,  has  been  found 
associated  with  lesions  in  the  center  for  the  face  muscles  in  the  lower  Rolan- 
dic  region,  but  isolated  facial  paralysis  due  to  involvement  of  the  nerve- 
fibers  in  their  path  from  the  cortex  to  the  nucleus  is  extremely  rare. 
Cortical  or  capsular  facial  paralysis,  as  already  explained,  is  on  the  same 
side  as  that  of  the  arm  and  leg. 

Nuclear  Paralysis. — Paralj^sis  may  also  be  caused  by  lesions  of  the 
nucleus,  but  is  not  common.  The  sjrmptoms  are  essentially  the  same  as 
those  of  paralysis  of  the  trunk  of  the  nerve,  or  peripheral  facial  palsy, 
although  there  is  no  loss  of  taste  in  the  nuclear  palsy. 

Infraniiclear  Paralysis,  or  Peripheral  Facial  Paralysis. — This  includes 
all  cases  due  to  involvement  of  the  nerve  trunk.  The  distinctive  features 
of  this,  as  compared  with  cortical  paral^-sis,  have  already  been  stated.  It 
still  remains,  however,  to  determine  the  affected  segment  of  the  ner\-e,  to 
be  again  referred  to  when  treating  of  diagnosis. 

Etiology. — Cortical  paralyses  are  usually  due  to  compression  or  de- 
struction of  the  cortical  center,  as  by  traumatism,  hemorrhage,  tumor,  men- 
ingitis, or  embolism.  Nuclear  paralysis  may  be  caused  by  tumors,  chronic 
softening,  hemorrhage,  or  the  diphtheritic  toxin,  while  rarely  anterior 
poliomyelitis  may  involve  the  facial  nucleus. 

The  most  frequent  cause  of  peripheral  paralysis.  Bell's  palsy,  is  exposure 
to  cold,  as  to  a  cold  wind  or  draft  from  an  open  window.  Such  cases  in- 
clude so-called  rheumatic  paralysis,  and  may  be  due  to  neiuitis.  Disease 
of  the  middle  ear  and  caries  of  the  petrous  portion  of  the  temporal  bone 


PARALYSIS  OF  THE  SEVENTH  NERVE 


991 


are  relatively  frequent  causes,  which  have  evident  explanation  in  the  course 
of  the  facial  through  the  Fallopian  canal  adjacent  to  the  tympanic  cavity, 
whence  it  may  be  invaded.  At  the  base  of  the  brain,  tumors,  syphilitic 
new  formations  and  inflammatory  processes  also  involve  the  facial.  Rarely 
swelling  of  the  parotid  gland  is  a  cause  of  pressure. 

Symptoms. — The  symptoms  vary  with  the  exact  seat  at  which  the 
nerve  is  invaded.  Paralysis  of  the  facial  muscles  of  expression  produces 
the  most  striking  change  of  physiognomy.  The  homely  description,  imder- 
stood  by  everyone,  is  that  the  face  is  drawn  to  one  side;  and  it  appears  to 
be  drawn  to  the  sound  side,  except  in  old  cases  after  contracture  has  oc- 


Portion  of  the  facial  Nucleus  f( 
the  Upper  Facial  Distribut: 


Portion    of    the    Facial  Nu- 
for  'he   Upper  Facial 
Distribution. 


Portion  of  the 
Nucleus  for  the 
Lower  Facial 
Distribution. 


Fig.  175. — Schema  and  Central  Innervation  of  the  Facial  Nerve — {A^ier  Sahli). 
The  nucleus  o£  the  upper  branch  is  innervated  from  both  hemispheres,  though  mostly 
from  the  opposite  side,   while  the  nucleus  of  the  lower  branch  is  innervated  almost  totally 
from  the  opposite  side. 


curred.  The  appearance  of  the  face  being  drawn  to  the  sound  side  is 
deceptive,  and  is  caused  by  the  flattening  of  the  face  on  the  paralyzed  side 
and  the  contrast  afforded  by  the  two  sides.  Examination  discloses  that  on 
the  opposite  and  paralyzed  side  there  is  a  remarkable  smoothness  of  face, 
the  wrinkles  have  disappeared  from  the  forehead,  the  labionasal  fold  is  gone, 
and  this  half  of  the  face  is  quite  expressionless.  The  comer  of  the  mouth 
on  the  paralyzed  side  is  lowered,  while  saliva  frequently  flows  from  it;  the 
eye  is  wider  open  than  natural,  and  can  be  only  partly  closed,  even  during 
sleep — lagophthalmos — and  the  eye  waters.  These  symptoms  are  rendered 
still  more  striking  on  effort  at  smiling,  talking,  or  whistling,  at  turning  up 
the  nose,  wrinkling  the  forehead,  inflating  the  cheeks,  or  closing  the  eyes. 
On  attempting  the  latter  the  upper  lid  drops  as  though  heavy,  the  eye  is 


992  DISEASES  OF  THE  NERVOUS  SYSTEM 

turned  upward,  the  pupil  covered,  but  quite  a  space  remains  "uncovered." 
The  so-called  "corneal"  and  "optical"  reflexes,  by  which,  through  closure 
of  the  lid,  the  eye  protects  itself  from  the  entrance  of  foreign  bodies  seen 
approaching,  are  lost,  and  a  tendency  to  conjunctivitis  results. 

In  complete  facial  paralysis  winking  is  impossible.  Whistling  is  also 
impossible,  and  speech  may  be  interfered  with,  owing  to  the  difficulty  in 
forming  labial  sounds.  The  proper  muscles  of  mastication  are  not  para- 
lyzed, but,  owing  to  paralysis  of  the  buccinator  muscle,  food  collects 
between  the  teeth  and  cheek  on  the  paralyzed  side,  and  an  attempt  to  sniff 
reveals  paralysis  of  the  nasal  muscles.  The  upper  teeth  cannot  be  un- 
covered, and  an  attempt  to  drink  is  only  partly  successful,  because  the  lips 
cannot  be  kept  close  to  the  glass.  The  tongue  is  sometimes  described  as 
protruding  toward  the  paralyzed  side,  but  this  appears  to  have  been  an 
error.  The  organ  is  really  central,  when  examined  in  its  relation  to  the 
incisors,  and  the  erroneous  impression  arises  from  the  fact  that  the  lips 
are  drawn  to  the  sound  side.  ]\Iany  authorities  speak  of  a  paralysis  of 
the  soft  palate  on  the  affected  side,  since  facial  fibers  pass  through  the  su- 
perficial petrosal  nerve  to  the  sphenopalatine  ganglion.  It  is  described 
as  drooping,  while  effort  at  phonation  raises  the  soft  palate  obliquely  to  the 
sound  side.  Both  Gowers  and  Hughlings  Jackson,  however,  deny  this 
symptom  in  most  cases.  The  innervation  of  the  soft  palate  is  not  definitely 
known. 

.  Derangement  of  taste  also  occurs  in  the  anterior  two-thirds  of  the  tongue 
on  the  paralyzed  side  in  cases  where  the  facial  is  involved  in  that  part 
of  its  course  in  which  it  contains  the  chorda  tympani  nerve — that  is,  in  the 
Fallopian  canal  between  the  genu  and  the  union  of  the  chorda  tympani 
with  the  facial.  When  the  nerve  is  affected  outside  of  the  skull,  the  sense 
of  taste  is  intact.  Salivary  secretion  is  diminished,  producing  drj'ness  of 
the  mouth.  Hearing  may  be  more  acute,  especially  for  low  notes,  because 
of  paralysis  of  the  stapedius  muscle,  antagonized  by  the  tensor  tympani, 
which  is  innervated  from  the  trigeminus.  Hence  results  a  greater  sensi- 
tiveness of  the  membrana  tympani.  Other  disturbances  of  hearing  are 
also  present,  but  they  are  generally  due  to  associated  aural  trouble.  Herpes 
is  also  an  occasional  symptom,  and  is  ascribed  to  the  presence  of  trigeminal 
filaments  among  those  of  the  facial. 

Facial  paralysis  usually  sets  in  suddenly,  rareh'  gradually.  Some- 
times there  are  prodromata,  consisting  in  abnormal  sensations  of  taste, 
pain  in  the  ear  and  face,  and  ringing  in  the  former,  all  from  inflammation 
of  the  nerve.     With  this  exception,  pain  is  not  common. 

Diagnosis. — The  recognition  of  the  presence  of  paralj'sis  of  the  facial 
is  for  the  most  part  easy.  More  difficult,  and  proportionately  important,  is 
it  to  ascertain  the  modifications  due  to  lesions  in  different  parts  of  its  course. 
This  is  rendered  easy  by  the  appended  schematic  drawing  of  the  distri- 
bution of  the  facial  nerve,  after  Sahli.     (Fig.  176.) 

The  phenomena  vary  in  accordance  with  the  following: 

(a)  Lesion  at  A,  trunk  of  the  facial,  affecting  onlj'  the  mimetic 
branches.  Paralysis  of  all  the  facial  muscles;  taste,  secretion  of  saliva, 
hearing,  and  palate  normal. 

(b)  Lesion  at  B,  within  the  styloid  foramen.     Paralysis  of  facial  mus- 


FACIAL  PARALYSIS 


993 


cles,  and  auricular  muscles  innervated  by  the  posterior  auricular  nerve.' 
Taste,  secretion  of  saliva,  hearing,  and  soft  palate  normal. 

(c)  Lesion  at  C.  Paralysis  of  the  facial  muscles,  derangement  of 
taste,  diminished  secretion  of  saliva;  hearing  and  soft  palate  normal. 

(d)  Lesion  at  D.  Paralysis  of  the  facial  muscles,  derangement  of 
taste,  diminished  secretion  of  saliva,  abnormal  acuteness  of  hearing,  and 
paresis  of  soft  palate. 

(e)  Lesion  at  E,  above  geniculate  ganglion.  Paralysis  of  the  facial 
muscles,  diminished  secretion  of  saliva,  abnormal  acuteness  of  hearing, 
paresis  of  soft  palate,  but  no  disturbance  of  taste. 


0^ 


Fig.  176. — Simplified  Drawing  of  thePeripheral  Distribution  of  theFacial  Nerve — {after  Sahli) . 


(/)  Lesions  at  F,  in  Fallopian  canal,  often  associated  with  a  lesion  of 
the  auditory  nerve  in  consequence  of  its  proximity  to  it.  Paralysis  of 
facial,  diminished  secretion  of  saliva ;  hearing  may  be  influenced  by  common 
lesions  to  auditory;  palate  normal,  taste  normal. 

The  student  is  referred  to  what  has  previously  been  said  as  to  the 
modification  rendered  necessary  by  the  observations  of  Gowers  and  others 
on  the  non-involvement  of  the  soft  palate  in  facial  palsy. 


1  Since  the  auricular  muscle  is  in  most  men  not  under  control  of  the  will,  its  paralysis  ( 
only  by  the  electrical  test  (reaction  of  degeneration). 


1  be  ascertained 


994  DISEASES  OF  THE  NERVOUS  SYSTEM 

We  are  aided  also  in  recognizing  precise  forms  by  the  causes,  if  known, 
like  the  presence  of  ear  disease,  or  a  history  of  exposure  to  cold  or  of  trau- 
matism. Coexisting  symptoms  of  brain  or  bulbar  disease  must  also  be 
considered.  Reaction  of  degeneration  can  occur  in  true  cerebral  facial 
palsy,  only  in  peripheral  palsy  or  in  such  bulbar  paralysis  as  affects  the 
facial  in  or  below  the  nucleus  itself.  In  the  cortical  facial  paralysis  the 
frontal  distribution  of  the  facial  nerve  and  the  ocular  muscles  are  not 
seriously  affected  except  in  the  early  stages;  in  the  peripheral  paralysis  they 
usually  are. 

The  existence  of  bilateral  facial  paralysis — diplegia  facialis — points 
almost  invariably  to  an  intracranial  lesion,  which  may  be  within  the  pons. 
Simultaneous  involvement  of  both  nerves  in  their  peripheral  distribution  is 
rare,  though  its  possibility  cannot  be  denied.  Syphilitic  meningitis  is  a  com- 
mon cause  of  facial  diplegia. 

Prognosis  and  Course. — The  prognosis  varies  with  the  etiology  and  with 
the  degree  of  severity.  In  some  cases  recovery  is  rapid,  in  others  it  is  only 
partial.  The  following  division  of  forms  with  their  probabilities,  according 
to  Erb,  will  be  helpful : 

1.  The  Mild  Form  of  Facial  Paralysis. — To  this  many  rheumatic  cases 
belong.  The  affection  is  usually  one  of  facial  muscles  only.  Electrical 
excitability  in  the  paralyzed  muscles  remains  normal,  and  there  are  no 
severe  and  deep-seated  changes  in  nerves  or  muscles.  Recover}^  is  rapid, 
usuall}^  taking  place  in  two  or  three  weeks. 

2.  Middle  Form. — There  is  partial  reaction  of  degeneration,  the  ex- 
citability of  nerve  being  diminished  but  not  lost;  in  the  muscles,  however, 
in  two  or  three  weeks,  there  is  decided  increase  of  galvanic  excitability  to 
direct  excitement,  the  anodal  closure  contraction  being  greater  than  the 
cathodal  while  contractions  are  slow.  Recovery  may  still  be  quite  rapid, 
usiially  in  from  four  to  six  weeks. 

3.  Severe  Form. — Complete  reaction  of  degeneration  in  ncr\-e  and 
miiscles — i.e.,  loss  of  faradic  and  galvanic  excitability  of  nerve,  loss  of 
faradic  excitability  of  muscle,  and  quantitative  and  qualitative  changes  in 
galvanic  excitability  of  muscle.  In  this  form  there  is  always  degeneration 
of  nerve  and  muscle,  so  that,  if  recovery  takes  place  at  all,  it  is  only  after 
two  or  six  months  or  longer. 

In  these  cases  there  often  inter\'ene  sj^mptoms  of  motor  irritation, 
consisting : 

1.  In  a  marked  tonic  contraction  of  the  paralyzed  muscle,  sometimes 
very  striking. 

2.  Single  spasmodic  contraction  of  muscles.  This  is  usually  the  move- 
ment described  under  the  following  heading. 

3.  Special  associated  movements.  Thus,  if  the  patient  closes  his  ej^es 
or  winks,  there  always  follows  a  marked  distortion  of  the  comer  of  the 
mouth,  which  cannot  be  restrained. 

4.  An  increased  reflex  irritability,  as  the  result  of  which,  on  pricking 
or  blowing  on  the  skin,  vigorous  muscular  contractions  follow. 

These  symptoms  last  for  a  long  time — for  years  in  incurable  or  imper- 
fectly cured  cases. 

Further  points  bearing  on  prognosis  have  reference  to  the  nature  of 


FACIAL  SPASM  995 

the  primary  disease.  Paralysis  caused  by  tumors  of  the  base  of  the  brain 
and  caries  of  the  petrous  bone  is  almost  always  incurable.  If  the  paralysis 
is  due  to  middle-car  disease,  the  prognosis  depends  on  the  curability  of  the 
ear  disease.  The  electrical  examination  affords  helpful  data.  If  at  the  end 
of  two  weeks  electrical  excitability  still  remains  normal,  a  rapidly  favorable 
termination  may  be  predicted.  If,  on  the  other  hand,  the  reaction  of  de- 
generation is  present,  a  much  longer  course  and  delayed  recovery,  if  any, 
may  be  expected.     Relapses  may  occur,  but  are  rare. 

Treatment. — The  treatment  is,  of  course,  that  of  the  lesion  which 
lies  at  the  bottom  of  the  paralysis.  If  it  is  a  syphilitic,  inflammator\'  prod- 
uct, mercury  or  salvarsan  should  be  given  or  the  iodids  should  be  adminis- 
tered in  the  usual  ascending  doses.  Middle-ear  disease  should  receive  the 
promptest  and  closest  attention,  as  some  of  the  most  unfortunate  cases 
are  caused  by  this.  Any  possible  cause  of  pressure  should  be  sought  and 
removed. 

When  cold  is  the  cause,  and  the  case  comes  early  under  observation, 
warmth,  either  dry  or  moist,  should  be  applied  to  the  distribution  of  the 
nerve  in  the  face,  while  mild  counterirritation  at  the  pes  anserinus  is  useful. 
Decided  blistering  is  of  questionable  utility,  but  it  is  harmless  and  probably 
does  good. 

For  the  paralysis  remaining  after  the  removal  of  the  cause  electricity 
is  indicated,  and  more  especially  the  constant  current.  A  weak  current 
should  be  used  for  from  three  to  five  minutes  at  a  time,  interrupting  from 
four  to  six  times  a  minute,  placing  first  the  anode  and  then  the  cathode  in 
the  auriculo-mastoid  fossa,  the  other  pole  in  front  of  the  ear.  Galvanism 
and  faradization  may  be  applied  to  the  muscles  themselves,  including  the 
oribicularis,  the  direct  effect  of  the  electricity  on  which  is  shown  by  an 
increased  power  to  close  the  eye  immediately  after  the  application  of  the 
current.     Massage  of  the  muscles  may  be  used. 

Sulphate  of  strychnin  is  a  drug  which  has  some  reputation  in  facial 
paralysis,  although  it  is  difficult  to  trace  the  results  of  its  use.  Its  admin- 
istration by  subcutaneous  injection,  daily  or  on  alternate  days,  is  recom- 
mended. The  salicylate  may  be  used  with  advantage  in  some  cases. 
Massage  of  the  facial  muscles  is  advisable. 

Facial  Spasm. 

Definition. — By  facial  spasm  in  meant  a  real  spasm  confined  to  the 
mechanism  of  motor  innervation  of  the  face  as  contrasted  with  mimetic 
facial  tic  or  convulsive  tic,  all  usually  unilateral,  sometimes  bilateral. 

Etiology. — No  cause  can  be  found  for  most  cases.  Possible  causes  are 
exposure  to  cold,  lesions  at  the  base  of  the  skull,  or  irritation  of  the  facial 
center  in  the  cerebral  cortex.  Other  cases  may  be  explained  by  reflex 
causes,  such  as  irritation  by  ocular  disease,  carious  teeth,  intestinal  worms, 
or  disease  of  the  sexual  organs.  Others  have  been  ascribed  to  violent 
mental  excitement. 

Symptoms. — Hugh  T.  Patrick'  thus  contrasts  facial  spasm  with  facial 
tic,  tic  convulsif,  or  habit  spasm.     First,  as  to  points  of  resemblance:  Both 

1  Patrick,  "Journal  of  Nervous  and  Mental  Disease,"  January,  1909. 


996  DISEASES  OF  THE  XERVOUS  SYSTEM 

facial  tic  and  facial  spasm  arc  hyperkinesias.  Both  present  intermittent 
painless  twitching  and  contraction  of  facial  muscles,  both  tend  to  become 
chronic  and  both  cease  during  sleep  with  rare  exceptions  in  case  of  spasm. 
Here  resemblances  cease. 

On  the  other  hand,  tic  is  much  more  common  than  spasm,  and  invari- 
abl'y  develops  in  a  nervous  or  neuropathic  person.  Temperament  has 
nothing  to  do  with  spasm.  Second,  facial  spasm  is  a  real  spasm  confined 
to  the  mechanism  of  motor  innervation  of  the  face.  Tic  is  not  a  spasm, 
but  a  movement  of  volition. 

3.  Spasm  is  totally  beyond  voluntary  or  involuntary  control,  while  tic 
is  always  to  some  extent  under  voluntary  control  and  always  to  involuntary 
control  as  by  strong  emotional  or  mental  preoccupation. 

4.  Spasm,  according  to  Patrick,  is  an  "anatomical,  tic  a  physiological 
disorder."  A  good  idea  of  facial  spasm  may  be  obtained  by  faradizing  the 
facial  nerve,  and  no  one  would  mistake  such  resulting  contraction  for  a 
voluntary  movement.  Tic  is  a  reproduction  of  a  perfectly  natural  and 
normal,  though  it  may  be  unusual  movement.  Voluntary  imitation  of 
facial  spasm  is  impossible,  but  the  patient  or  even  another  person  may 
imitate  the  tic  movements. 

5.  In  its  incipiency  spasm  is  confined  to  a  part  of  a  muscle  and  ulti- 
mately extends  to  the  entire  distribution  of  the  facial  nerve,  no  less,  no 
more,  and  is,  moreover,  strictly  unilateral.  Tic  never  affects  a  part  of  a 
muscle,  because  voluntary  fascicular  contractions  are  impossible.  On  the 
other  hand,  all  the  facial  muscles  are  rarely  included  in  one  movement.  In 
tic  one  physiologically  associated  group  of  muscles  may  contract  one 
moment,  and  another  group  the  next.  Tic  is  apt  to  be  bilateral  either 
simultaneously  or  alternately,  and  it  is  peculiarly  liable  to  be  associated 
with  tic  of  adjacent  or  remote  muscle  groups. 

6.  The  contraction  of  facial  spasm  is  very  like  that  produced  by  farad- 
ism  when  the  vibrator  is  not  running  smoothly.  While  the  general  effect 
is  tonic,  there  is  also  a  flickering  or  quivering,  or  rapid  slight  irregular 
twitching  such  as  never  occurs  in  voluntary  movement  or  tic  and  cannot  be 
imitated.  Each  spasm  begins  with  this  flickering  contraction,  generally 
of  a  part  of  a  muscle  and  most  frequently  in  the  orbicularis  palpebrarum. 
The  preliminary  quiver  may  be  very  brief  or  may  last  several  seconds, 
and  even  in  a  fully  developed  case  one  may  see  abortive  spasms.  This 
never  occurs  in  facial  tic. 

7.  Facial  spasm  may  not  look  worse  than  facial  tic,  but  it  is  more  un- 
comfortable and  much  more  disabling.  The  subject  of  tic  may  talk  and 
sing  as  he  pleases,  and  though  his  talk  may  be  interspersed  with  grimaces 
his  sentences  are  not  interrupted  by  them.  The  speech  of  a  person  with 
spasm  may  be  cut  short  at  any  time. 

Blepharospasm. — A  variety  of  the  partial  form  is  blepharospasm,  a 
tonic  or  clonic  spasm  of  the  orbicularis  muscle.  In  the  clonic  form  it  is 
apt  to  be  associated  with  spasm  of  the  lateral  facial  muscles,  and  there  is 
constant  twitching  of  the  side  of  the  face,  with  partial  closure  of  the  eye.  In 
another  clonic  variety  there  is  constant  contraction  of  the  eyelids  and  conse- 
quent winking. 

The  tonic  form  is  usually  reflex  in  origin,  bilateral,  and  may  last  for 


LESIONS  OF  THE  AUDITORY  NERVE  997 

days  or  weeks,  with  occasional  interruptions.  The  reflex  cause  is  commonly 
some  afliection  of  the  eye,  producing  photophobia,  or  it  may  reside  in  some 
other  point  in  the  distribution  of  the  trigeminus.  The  clonic  form  may 
also  sometimes  be  traced  to  a  reflex  act  as  a  cause. 

Very  interesting  in  connection  with  blepharospasm  is  the  discovery 
by  V.  Graefe  of  certain  so-called  "pressure  points."  These  are  points  at 
which  pressure  causes  the  spasm  to  cease,  so  that  the  eyelids  "fly  up  as 
if  by  a  spring."  These  are  commonly  found  at  points  of  exit  of  the  tri- 
geminus, but  have  also  been  found  on  the  vertebral  column  and  elsewhere. 

For  other  forms  of  spasm  of  the  facial  nerve  see  Choreiform  Affections, 
page  1086. 

Prognosis. — This  in  all  forms  is,  as  a  rule,  unfavorable.  There  are 
intervals  of  suspension,  sometimes  of  considerable  length,  but  the  spasm 
recurs,  and  the  disease  generally  remains  incurable. 

Treatment. — The  treatment  by  drugs  is  correspondingly  unsatisfactory, 
but  a  number  of  things  may  be  done.  Causes  of  reflex  irritation  should 
be  sought  and  removed,  such  as  carious  teeth  nasal  polypi  and  ophthalmia. 
Paquelin's  cautery  may  be  applied  to  the  trunk  of  the  nerve,  or  to  pressure 
points,  if  they  exist.  Nerve  section  of  the  supra-orbital  nerve  has  been 
practiced  in  blepharospasm.  Nerve  stretching  has  been  followed  by  relief, 
at  least  as  long  as  the  paralysis  continues,  which  is  commonly  a  welcome 
substitute  for  the  twitching.  The  constant  current  may  be  used,  seeking 
also  for  pressure  points,  to  which  the  anode  is  to  be  applied.  If  there  are 
none,  this  pole  should  be  applied  to  the  trunk  of  the  nerve  and  to  the  different 
branches  of  the  pes  anserinus.  Weir  Mitchell  recommends  the  freezing 
of  the  cheek  every  day  or  every  other  day  with  the  rhigolene  spray;  at 
least  transient  relief  follows.  The  injection  of  a  small  amount  of  alcohol 
into  and  about  the  nerve  is  a  new  and  promising  method  of  treatment.  It 
has  been  successful  in  a  number  of  cases.  Paralysis  of  the  facial  distribu- 
tion occurs,  and  after  it  has  disappeared  the  spasm  may  not  reappear. 

As  to  medicines,  those  usual  in  nervous  affections  should  be  tried — ■ 
bromid  of  potassium,  strychnin  by  hj^podermic  injection,  arsenic,  iron, 
oxid  of  zinc,  atropin,  curare. 

The  treatment  of  convulsive  tic  is  that  of  hysteria. 

LESIONS  OF  THE  AUDITORY  OR  EIGHTH  NERVE. 

The  eighth  pair  (portio  mollis  of  the  seventh  in  the  older  classification 
of  Willis)  may  be  affected  in  its  nucleus  at  the  junction  of  the  pons  with 
the  medulla  oblongata,  or  at  the  base  of  the  brain  after  it  passes  out  of  the 
pons  into  the  internal  auditory  meatus  to  its  distribution  in  the  cochlea 
and  vestibule.  The  proximity  of  this  nerve  to  the  facial  at  the  base  of  the 
brain  and  in  the  internal  auditory  meatus  is  to  be  remembered.  As  indi- 
cated by  its  name,  it  is  softer  and  more  vulnerable  than  the  facial,  so  that 
equally  acting  causes  may  affect  it  and  leave  the  facial  intact. 

Cortical  deafness  from  a  unilateral  lesion,  apart  from  word  deafness, 
cannot  be  regarded  as  well  established. 

The  auditory  nerve  should  be  regarded  as  t^vo  nerves — the  cochlear 
and  the  vestibular;  the  former  having  to  do  with  hearing  and  the  latter 
with  co-ordination. 


998  DISEASES  OF  THE  XERVOUS  SYSTEM 

Symptoms  directly  due  to  disease  of  the  auditory  nerve  are  limited 
to  some  derangement  of  hearing,  and  it  is  their  association  with  others 
which  widens  their  significance  in  the  study  of  nervous  diseases.  The  de- 
rangements of  hearing  resulting  from  such  lesion  are  six : 

1.  Loss  of  hearing,  or  deafness. 

2.  Increased  sensitiveness,  auditory  hyperesthesia,  or  hyperacusis. 

3.  Symptoms  of  irritation,  causing  subjective  aural  sensations — tinnitus 
aurium  and  allied  symptoms. 

4.  Disturbances  of  equilibrium  or  sensation  of  such,  due  to  irritation 
of  the  fibers  in  the  semicircular  canals — Meniere's  disease. 

5.  Certain  rare  instances  of  involuntary  movements,  due  to  disease  of 
the  nerve  within  the  ear,  as  oscillatory  motions  of  the  head. 

6.  Purely  functional  derangements  of  hearing,  occurring  especially  in 
connection  with  hysteria  and  with  anemia  following  large  hemorrhage. 

I.  Loss  OF  Function;  Nervous  Deafness. 

Etiology. — Deafness  may  be  congenital  when  it  is  due  to  labyrinthine 
defect.  According  to  Gowers,  80  per  cent,  of  deaf  mutes  are  congenitally 
deaf.  The  remaining  20  per  cent,  become  so  from  disease  in  early  life.  Of 
congenital  cases  it  is  said  that  the  intermarriage  of  relations  having  similar 
defects  is  responsible  for  some,  while  such  intermarriage,  even  where  there 
is  no  such  defect,  is  held  responsible  for  a  smaller  number.  Partial  as  well 
as  total  deafness  may  be  congenital. 

Of  the  cases  of  acquired  nervous  deafness,  disease  of  the  labyrinth, 
either  primary  or  secondary  to  that  of  the  middle  ear,  causes  most.  The 
labyrinth  is  subject  to  inflammation,  acute  or  chronic,  to  syphilitic  disease, 
to  degeneration,  and  to  hemorrhage.  It  may  be  invaded  by  meningitis, 
cerebrospinal  or  tuberculous.  Its  membrane  may  undergo  degeneration, 
due  to  gout  or  simply  to  old  age.  The  product  of  all  these  may  be  fibrous 
or  calcareous  new  formation.  The  deafness  caused  by  certain  drugs,  as 
quinin,  has  been  ascribed  to  congestion  of  the  internal  ear,  and  that  by 
loud  noise,  as  the  explosion  of  artillery,  to  hemorrhage. 

Lesions  of  the  nerve  trunks  are  less  common  causes.  They  may  be  of 
the  same  character  as  those  of  the  labyrinth,  except  primary  infiammation, 
although  even  this  is  said  to  be  a  cause.  Primary  degeneration  may  occur 
in  tabes  dorsalis.  The  nerve  may  be  compressed  by  thickening  of  the 
cranial  bones,  calcareous  nodules,  tumors,  or  extravasated  blood. 

The  nuclei  wdthin  the  pons  may  be  damaged  by  hemorrhagic  extrava- 
sations and  tumors.  Above  the  nuclei  there  may  be  a  lesion  encroaching 
on  the  superficial  layer  of  the  tegmentum. 

Symptoms. — Since,  as  already  stated,  derangement  of  hearing  consti- 
tutes the  only  essential  symptom  of  nervous  deafness,  any  enlargement 
of  the  subject  can  be  made  only  by  considering  the  modifications  and  condi- 
tions of  this  system,  and  by  reviewing  such  methods  of  determining  the 
precise  seat  of  the  lesion  as  exist. 

The  ability  to  hear  through  the  bone  while  the  air  conduction  is  im- 
paired implies  that  the  function  of  the  labyrinth  is  intact,  and  that  deaf- 
ness is  due  to  obstruction  of  the  meatus  or  to  disease  of  the  middle  ear  and 


LESIONS  OF  THE  AUDITORY  NERVE  999 

not  to  nerve  deafness.  This  is  further  confirmed  if  the  bone  conduction  is 
intensified  by  closing  the  meatus,  since  in  this  way  the  vibrations,  which 
ordinarily  pass  out  by  the  meatus,  are  retained.  On  the  other  hand,  if 
there  is  diminished  bone  conduction,  it  does  not  necessarily  follow  that 
the  labyrinth  is  diseased,  because  there  may  be  ankylosis  of  the  stapes, 
which  will  diminish  bone  conduction,  although  no  amount  of  disease  of 
the  middle  ear  will  extinguish  it  if  the  labyrinth  be  intact.  Further,  in 
health  air  conduction  is  heard  after  bone  conduction  ceases.  This  is  the 
basis  of  Rinne's  test,  in  which  the  vibrating  tuning-fork  is  first  placed  upon 
the  mastoid  process  and  allowed  to  remain  until  the  sound  dies  away  to 
the  patient,  when  the  fork  is  suddenly  transferred  to  the  external  auditory 
meatus  of  the  same  ear.  If  the  air-conducting  apparatus  is  normal,  the 
vibration  of  the  fork  s,hould  again  be  heard.  Again,  there  may  be  a  moder- 
ate impairment  of  hearing  and  maintenance  of  the  relative  delicacy  of  the 
air  conduction.  Absence  of  bone  conduction  is,  however,  the  character- 
istic symptom  of  nervous  deafness.  So,  to  a  less  degree,  is  deafness  to 
short  and  high-pitched  sounds,  whence  the  high-pitched,  short  sounds  of 
the  ticking  of  a  watch  are  a  delicate  test  of  the  ability  to  hear  through  the 
bone.  Simple  senile  labyrinthine  degeneration  may  be  responsible  for  in- 
ability to  hear  the  ticking  through  bone  in  persons  sixty  years  old  or  more. 

Can  we  distinguish  between  labyrinthine  disease  and  disease  of  the 
nerve  before  its  terminal  distribution  ?  Given  the  absence  of  bone  conduc- 
tion, if  the  facial  nerve  is  paralyzed,  and  there  is  also  disease  of  the  middle 
ear  or  of  the  bone,  we  may  conclude  that  the  nerves  (facial  and  auditory) 
are  affected  at  the  base  of  the  brain  or  in  the  internal  meatus.  If  there  is 
disease  of  the  middle  ear  along  with  deafness  and  paralysis  of  the  facial,  it 
is  probable  that  the  facial  nerve  and  labyrinth  are  affected  by  extension  of 
the  disease  from  the  tympanum,  but  this  is  not  certain.  An  involvement 
of  the  trunk  of  the  nerve  at  the  base  is  also  probable  if  some  other  nerve 
near  it,  as  the  sixth,  is  involved.  The  fact  that  the  auditory  nerve  is  more 
sensitive  to  pressure  than  the  facial  has  already  been  mentioned,  whence 
an  agency,  such  as  an  inflammatory  product  or  tumor,  pressing  on  both 
nerves,  may  affect  the  auditory  and  leave  the  facial  intact. 

No  distinctive  symptorns  have  been  found  associated  with  lesion  of  the 
auditory  nuclei  in  the  medulla  oblongata.  Such  lesion  is  very  rare,  but  has 
been  found  associated  with  deafness  on  the  same  side,  while  it  has  also  been 
found  when  the  hearing  has  been  unaffected.  Sudden  deafness,  associated 
with  other  symptoms  of  a  lesion  of  the  pons  or  medulla  oblongata,  should 
excite  suspicion  of  nuclear  lesion,  especially  if  paresis  of  limbs  on  the  opposite 
side  be  one  of  those  symptoms. 

The  auditory  fibers  in  their  passage  through  the  tegmentum  may  also 
be  affected  and  may  produce  deafness.  Such  a  lesion  is  a  tumor  of  the  cor- 
pora quadrigemina. 

Lesions  of  the  cortical  center  are  very  rare,  though  they  have  been 
sufficiently  frequent  to  confirm  the  results  of  experiment  on  the  monkey, 
which  go  to  show  that  the  first  temporo-sphenoidal  gyrus  represents  the 
center  for  hearing,  since  the  destruction  of  this  gyinis  on  the  left  side  in 
man  has  been  attended  by  word-deafness.  It  is  possible  that  the  first 
temporal  gyrus  in  each  hemisphere  in  man  must  be  damaged  in  order  to 


1000  DISEASES  OF  THE  NERVOUS  SYSTEM 

produce  cortical  deafness  for  sound.     Hemorrhages,  softening,  and  pressure 
by  fractures  or  tumors  may  be  causative  lesions  in  this  situation. 

Treatment. — This  is  for  the  most  part  unsatisfactory,  at  least  from  the 
physician's  standpoint.  Careful  otoscopic  examination  should  be  made 
with  a  view  to  discovering  the  existence  of  disease  of  the  external  and 
middle  ear,  and  the  aural  surgeon  should  invariably  be  consulted  in  derange- 
ments of  hearing  of  more  than  brief  duration,  with  a  view  to  obtaining 
certainty  of  diagnosis  between  nerve  deafness  and  disease  of  the  middle 
or  external  ear.  Suspected  syphilitic  tumors  should  be  treated  by  iodids. 
A  blister  in  front  of  or  behind  the  ear  may  be  useful,  especially  in  acute 
cases;  but  deep  blistering  should  be  avoided  in  front  lest  it  cause  facial 
neuritis.     Electricity  has  been  employed  with  partly  satisfactory  results. 

2.  Auditory  Hyperesthesia. 

True  hyperesthesia,  or  hyperacusis,  is  a  condition  in  which  ordinary 
sounds  are  heard  with  more  than  normal  acuteness,  and  in  which  sounds 
inaudible  become  audible.  In  dysesthesia,  or  dysacusis,  ordinary  sounds, 
although  not  intensified,  produce  discomfort.  There  is  generalh'  present 
some  pre-existing  symptom,  as  a  headache,  during  which  sounds  usually 
without  effect  intensify  the  headache.  Both  these  conditions  occur  in 
functional  as  well  as  in  organic  brain  disease.  Of  the  former,  hysteria 
is  an  instance;  of  the  latter,  meningitis. 

Treatment. — The  treatment,  outside  of  the  removal  of  the  cause,  is  by 
nerve  sedatives,  as  the  bromids,  preparations  of  valerian,  and  asafetida. 

3.  Irritation  of  the  Auditory  Nerve. — Tinnitus  Aurium. 

Definition. — The  term  tinnitus  includes  almost  every  conceivable 
form  of  auditory  subjective  sensation,  of  which  the  most  common  is  ring- 
ing, roaring,  or  hissing.  The  tinnitus  may  inlcude  humming,  ticking,  the 
sound  of  rushing  steam,  the  roaring  of  machinery  and  the  like,  the  sound 
of  a  bell,  and  even  articulate  speech,  music,  or  the  sound  of  voices.  It 
may  be  persistent  or  intermittent,  with  rhythmical  intermissions — these 
commonly  corresponding  with  the  beating  of  the  pulse.  The  sounds  may 
be  so  slight  as  to  be  forgotten  when  the  attention  is  directed  to  something 
else,  or  they  may  be  heard  through  everything,  causing  the  sorest  distress 
and  misery.  In  fact,  their  victims  have  even  been  impelled  to  self-des- 
truction. The  clicking  symptom,  sometimes  aubible  to  those  standing 
near,  is  often  very  annoying,  and  may  be  due  to  clonic  spasm  of  the  muscles 
connected  with  the  Eustachian  tube  or  levator  palati.  The  so-called 
premonitory  "aura"  of  epileptic  seizures  may  be  a  variety  of  tinnitus. 

Etiology. — Beyond  what  is  conveyed  by  the  word  "irritation,"  it  is 
exceedingly  difficult  to  discover  the  cause  of  tinnitus.  Changes  in  the 
labyrinth  appear  to  be  the  most  common,  and  Gowers  tells  us  that  "evi- 
dence of  nervous  deafness,  mostly  due  to  changes  in  the  internal  ear,  is 
distinct  in  four-fifths  of  the  cases  which  come  under  the  phj-sician's  notice. 
Disease  of  the  middle  and  external  ear,  including  inflammation  and  wax 
accumulation,  is  also  a  fruitful  cause,  while  in  a  few  cases  the  process  may 
be  wholly  in  the  auditory  centers,  in  the  nucleus  of  the  nerve,  or  in  the  cor- 
tical area.     Blood  movement,  not  usually  audible,  may  become  so.     Inter- 


MENIERE'S  DISEASE  1001 

nal  aneurysm  is  a  possible  cause.  Tinnitus  is  common  in  anemia  and 
neurasthenia.  An  epileptic  aura  is  often  a  tinnitus.  A  systolic  murmur 
is  sometimes  heard  over  the  ear  in  children,  and  even  in  adults. 

Treatment. — This  is  generally  most  unsatisfactory.  The  ear  should  be 
explored  and  its  surgical  diseases  treated. 

The  gouty  diathesis  must  be  treated  by  the  administration  of  the  salic- 
ylates, colchieum,  and  purgatives,  and  by  regulation  of  the  diet;  anemia 
and  neurasthenia  by  iron,  arsenic,  nutritious  food,  and  rest.  Large  doses 
of  salicylic  acid  and  quinin,  it  is  known,  produce  ringing  in  the  ears — a 
fact  to  be  remembered  always. 

The  bromids  are  sometimes  beneficial,  and  a  few  drops  of  tincture  of 
belladonna  are  sometimes  added.  Nitro-glycerin  has  been  highly  com- 
mended. Beginning  with  doses  of  i/ioo  grain  (0.00066  gm.),  they  should 
be  rapidly  increased  until  the  physiological  effect  is  produced.  Our  ex- 
perience with  nitro-glycerin  is  that  the  physiological  effect  is  often  not 
attained  in  adults  even  by  doses  of  i/ioo  grain  (0.00066  gm.). 

Counterirritation  is  undoubtedly  useful  at  times.  It  should  be  applied 
behind  the  ear,  and  actual  vesication  is  the  most  efficient  form.  The  tem- 
porary effect  is  sometimes  striking,  while  permanent  results  may  be  pro- 
duced by  repeated  blistering. 

4.  Disturbance  of  Equilibrium  Associated  with  Defect  of  Hearing 
— ^Labyrinthine  Vertigo.     Meniere's  Disease. 

Definition. — The  term  Meniere's  disease  is  applied  to  a  vertigo,  usually 
sudden,  associated  with  deafness  and  noises  in  the  ear. 

Pathology  and  Etiology — In  1861  Meniere  described  some  cases  in 
which  vertigo  was  produced  by  a  sudden  lesion  of  the  labyrinth.  Since 
then  the  term  Meniere's  disease  has  come  to  be  applied  to  all  cases  of  sudden 
vertigo  associated  with  labyrinthine  disease.  Gowers  says  that  "in  nine 
cases  out  of  ten  in  which  there  is  definite  giddiness,  not  epileptic  in  nature  or 
obviously  due  to  organic  brain  disease,  it  is  due  to  a  morbid  state  of  the 
labyrinth  or  auditory  nerve  endings."  Thus  the  vertigo  becomes  the  result 
of  the  irritation  of  the  nerve. 

In  addition  to  clinical  sources  for  the  confirmation  of  this  view  there  is 
the  fact  that  experimentally  induced  lesions  in  the  semicircular  canals  of 
am'mals  result  in  vertiginous  movements.  In  point  of  fact,  aural  vertigo 
results  from  almost  any  one  of  the  morbid  processes  possible  to  the  labyrinth 
and  the  nerve  endings  it  contains,  but  not  from  disease  of  the  middle  ear. 
The  precise  nature  of  the  morbid  change  can  only  be  conjectured.  It  is 
twice  as  frequent  in  men  as  in  women,  and  four-fifths  of  all  cases  occur 
between  the  ages  of  30  and  60.  Cold,  gout,  and  syphilis  have  been  followed 
by  it,  probably  through  inflammation,  and  possibly  resulting  hemorrhage. 
The  slower  forms  may  be  due  to  degenerative  processes,  like  those  of  tab2s 
or  such  as  are  due  to  age.  Vasomotor  neuroses  of  the  vessels  of  the  laby- 
rinth have  been  held  responsible. 

Symptoms. — The  vertigo  is  usually  sudden  and  paroxysmal,  though 
there  may  be  light  continuous  dizziness  between  paroxysms,  which  occur  at 
intervals  of  from  a  few  days  to  as  many  weeks.     Occasionally  they  occur 


1002  DISEASES  OF  THE  XERVOUS  SYSTEM 

dail}'.  They  may  be  spontaneous  or  an  exciting  cause  of  trifling  character 
may  bring  them  on,  such  as  turning,  coughing,  or  sneezing.  Gastric  dis- 
turbances may  excite  them — a.  fact  to  be  remembered  in  the  diiTerential 
diagnosis  from  gastric  vertigo.  There  may  be  brief  unconsciousness.  The 
attacks  generally  pass  off  in  a  few  minutes,  leaving  the  patient  pale,  faint 
and  nauseated,  often  in  a  cold,  clammy  sweat.  Vertigo  may  or  may  not 
be  accompanied  by  a  tendency  to  fall  forward,  bacla\^ard,  or  to  one  side, 
and  the  victim  may  have  to  grasp  something  to  save  himself  from  falling. 
External  objects  may  appear  to  circle  about  him.  The  seeming  movements 
of  person  and  external  objects  are  usually  in  the  same  direction. 

The  auditory  symptoms — deafness  and  tinnitus — may  be  in  one  or 
both  ears,  and  more  marked  in  one  side  than  in  the  other.  In  the  latter 
case  the  sense  of  movement  may  be  toward  or  from  the  ear  most  afifected; 
but  when  the  subject  and  objective  movements  coincide  in  direction,  they 
are  more  often  toward  the  affected  side. 

The  deafness  is  nervous  and  always  partial.  The  tinnitus  is  usually 
roaring  or  throbbing.  There  may  be  ocular  symptoms ;  these  are  secondary, 
and  include  nystagmus  and  diplopia.  Pressure  on  the  drum  or  on  the 
meatus  may  bring  on  the  nystagmus,  and  sometimes  an  apparent  jerky 
movement  of  objects.  Diplopia,  nystagmus,  and  jerky  movements  may 
occur  together. 

Diagnosis. — The  essential  symptoms  of  Meniere's  disease  are  dizziness, 
tinnitus,  and  deafness.  Gastric  disturbance  is  not  peculiar  to  it.  The 
deafness  must  be  proved  to  be  nervous  and  not  the  result  of  defective  air 
conduction.  True  gastric  vertigo  is  not  associated  with  deafness,  while 
other  symptoms  of  dyspepsia  are  present  with  it. 

While  the  aura  of  epilepsy  is  sometimes  accompained  by  giddiness, 
there  is  no  impairment  of  hearing.  Moiecver,  in  Meniere's  disease  slight 
vertigo  is  more  or  less  constant,  che  tinnitus  is  persistent,  and  loss  of  con- 
sciousness, if  present,  is  very  brief.  It  is  the  petit  mal,  with  its  brief  uncon- 
sciousness, -ttdth  which  the  confusion  may  occur. 

The  vertigo  of  cardiac  valvular  disease,  especially  aortic  insufficiency, 
of  arteriocapillary  fibrosis,  and  of  chronic  interstitial  nephritis  is  unaccom- 
panied by  any  of  the  other  distinctive  signs  of  Meniere's  disease.  Gelier's 
vertigo,  characterized  by  attacks  of  paretic  weakness  of  the  extremities, 
ptosis,  and  profound  depression,  but  without  loss  of  consciousness,  occurring 
especially  among  laborers  in  the  canton  of  Geneva,  should  be  mentioned 
as  a  source  of  possible  error. 

Prognosis. — This  depends  upon  the  durability  of  the  lesion  causing  the 
malady.  In  cases  resulting  from  remedial  causes — such  as  gout  and  even 
syphilis — recovery  is  possible,  while  palliation  is  not  infrequently  attained. 
Other  cases  are  obstinate  and  incurable.  Relief,  however,  comes  to  the 
dizziness  when  the  deafness  becomes  total. 

Treatment. — When  traceable  to  gout  and  syphilis,  the  remedies  appro- 
priate to  these  diseases  should  be  prescribed.  The  salicylates  and  iodids 
are  most  frequently  useful,  but  the  lithium  salts  and  colchicum  are  to  be 
remembered.  The  salicj'lates  should  be  given  in  moderate  doses  rather  than 
large  ones,  which  produce  the  ringing  in  the  ears.  In  the  absence  of  knowl- 
edge of  a  definite  cause  the  bromids  are  the  remedies  to  be  most  relied  upon. 


LESIONS  OF  THE  PNEUMOGASTRIC  NERVE  1003 

From  20  to  30  grains  (1.3  to  2  gm.)  should  be  given  at  a  dose,  and 
Gowers  recommends  the  addition  of  a  few  minims  of  the  tincture  of 
belladonna.  Nitro-glycerin  has  been  recommended.  Suprarenal  extract 
may  be  beneficial  in  some  cases.  Where  the  tinnitus  is  intense  and  not 
amenable  to  drugs,  intracranial  division  of  the  auditory  nerve  may  be 
advisable.     The  general  healtfi  should  be  looked  after. 

Counterirritation  by  blistering  behind  the  ear  is  sometimes  promptly 
followed  by  favorable  results. 

LESIONS  OF  THE  NINTH  OR  GLOSSOPHARYNGEAL  NERVE. 

Anatomical. — This  triply  mixed  nerve  supplies  sensibilitj^  to  the  soft 
palate,  the  tonsils,  the  upper  part  of  the  pharynx,  the  Eustachian  tube,  and 
the  tympanic  cavity;  motor  impulses  to  the  stylopharyngeus  and  to  the 
middle  constrictor  of  the  pharynx;  and  the  sense  of  taste  to  the  posterior 
third  of  the  tongue  and  to  the  palate. 

The  study  of  the  precise  pathology  of  this  nerve  is  rendered  difficult 
by  its  numerous  communications  with  other  nerves,  notably  with  the  fifth, 
the  facial,  and  the  pneumogastric,  and  by  the  fact  that  it  is  rarely  involved 
alone.     Experimental  inquiry  with  it  also  is  difficult. 

The  nerve  may  be  invaded  by  meningitis,  tumors,  or  degenerations. 

Symptoms. — Symptoms  of  such  lesion  would  be  difficult  deglutition  and 
perversion  of  the  sense  of  taste — parageusia — or  complete  gustatory  anesthesia. 

Modifications  of  the  sense  of  taste  are  tested  by  means  of  sapid  sub- 
stances in  solution,  applied  to  the  anterior  and  posterior  parts  of  the  tongue 
by  a  glass  rod  or' a  brash,  suitable  substances  being  used  for  each  taste. 
Thus,  for  bitter  a  solution  of  quinin  may  be  used;  for  sweet,  a  solution  of 
sugar;  dilute  acetic  acid  or  vinegar  for  acid,  and  common  salt  for  the  saline 
taste. 

Ageusia  may  result  not  only  from  lesions  of  the  glossopharj-ngeal  nerve, 
but  also  from  those  of  the  gustatorjr  or  lingual  branch  of  the  fifth,  and  possi- 
bly of  the  fifth  itself  within  the  cranial  cavity ;  from  affections  of  the  chorda 
tympani  in  disease  of  the  middle  ear,  of  the  facial  between  the  entrance  of 
the  chorda  tympani  and  the  geniculate  ganglion,  and  in  lesions  of  the 
peripheral  organs  of  the  nerves  of  taste.  Disturbance  of  taste  may  possi- 
bly result  from  cerebral  lesions,  but  the  cortical  area  for  taste  is  not  definitelj' 
known.     It  is  probably  in  the  region  of  the  uncinate  gyrus. 

Perversion  of  the  sense  of  taste  is  known  as  "parageusia."  It  is  a  rare 
phenomenon,  found  in  patients  with  facial  palsy,  in  the  hysterical,  and  in 
the  insane,  in  whom,  also,  subjective  sensations  of  taste  may  be  present. 
The  latter  also  occurs  as  an  aura  in  epilepsy.  Hyperesthesia  of  taste  is 
even  more  rare,  and  is  purely  a  hysterical  symptom. 

LESIONS  OF  THE  PNEUMOGASTRIC  OR  VAGUS  NERVE— THE 
TENTH  PAIR. 

Anatomical. — This  nerve  has  by  far  the  widest  distribution  of  any  of 
the  cranial  set,  supplying  the  pharynx,  larynx,  lungs,  heart,  esophagus,  and 
stomach,  and  in  part  also  the  intestines  and  spleen.  The  symptoms  of  its 
involvement  are,  therefore,  numerous  and  varied. 


1004  DISEASES  OF  THE  NERVOUS  SYSTEM 

It  is  a  mixed  nerve  of  motion  and  sensation,  some  of  its  most  important 
motor  functions  being  performed  through  its  connection  with  the  accessory 
nerve.  It  is  the  chief  sensory  nerve  for  the  respiratory  center  in  the  medulla 
oblongata,  but  contains,  also,  accelerating  and  inhibitory  fibers  from  this 
center.  The  former  office  preponderates,  so  that  section  of  the  nerve 
renders  respirations  less  frequent,  though  deeper,  while  stimulation  of  the 
divided  central  end  accelerates  them,  and  acceleration  may  proceed  to 
tetanic  an-est.  The  inhibitory  fibers  are  contained  chiefly  in  the  superior 
laryngeal  nerve,  stimulation  of  which  arrests  breathing  with  the  muscles 
in  a  state  of  relaxation. 

It  is  also  the  inhibitory  nerv3  of  the  heart,  slight  stimulation  increasing 
the  length  of  diastole,  while  stronger  stimulation  arre.=;ts  its  action.  On 
dividing  the  nerve  cardiac  contractions  become  more  frequent.  It  is  also 
inhibitory  for  the  vasomotor  center,  and  its  stimulation  produces  relaxation 
of  the  arteries  throughout  the  body.  It  is  the  motor  and  sensory  nerve  for 
the  esophagus,  sensory  nerve  for  the  stomach,  and  partly  the  motor  ner\''e 
for  the  stomach  and  intestines. 

Lesions  Involving  the  Nucleus  and  Trunk  of  the  Pneumogastric 
AND  Branches. 

The  nucleus  in  the  medulla  oblongata  may  be  involved  in  softening, 
hemorrhage,  or  slow  degeneration,  but  adjacent  nuclei  are  also  affected  at 
the  same  time,  whence  resulting  effects  are  associated  and  are  especially 
seen  in  bulbar  palsy. 

The  trunk  of  the  nerve  near  its  origin  maj^  be  compressed  by  thickened 
meningitis,  tumors,  or  aneurysm  of  the  vertebral  art?ry.  In  its  course  it 
has  been  implicated  in  incised  wounds,  and  tied  in  ligation  of  the  carotid. 
Neuritis  and  fibroneuromata  are  possible.  The  results  of  such  lesions 
of  the  nerve  are  commonly  paralytic,  rarely  irritative.  The  parah^tic 
symptoms,  if  total,  are  diminished  breathing-rate,  "suffocation,"  frequent 
pulse-rate,  and  death.  According  to  Tratimann  and  others  unilateral 
division  of  the  vagus  in  experiments  on  animals  caused  few  pul- 
monary symptoms.  One  vagus  seems  to  be  sufficient  for  the  function  of 
both  lungs.  The  results  of  partial  paralysis  are  better  considered  in  con- 
nection with  lesions  of  the  separate  branches  of  the  pneumogastric,  some  of 
which  are  also  invaded  separately. 

Lesions  of  the  Pharyngeal  Branches. — These  branches  of  the  pneu- 
mogastric, together  with  branches  of  the  glossopharj^ngeal,  form  the  pharyn- 
geal plexus,  from  which  the  muscles  and  mucous  membrane  of  the  pharj^nx 
are  innervated. 

Etiology. — Nuclear  disease  is  a  most  common  cause  of  paralysis  of  the 
pharynx.  It  shares  with  disease  involving  adjacent  nuclei,  constituting 
bulbar  palsy,  already  considered;  but  it  may  also  be  caused  by  meningitis 
or  bone  disease  at  the  base  of  the  skull,  or  it  may  form  part  of  the  lesion  of 
dipthcritic  paralj'sis. 

Symptoms. — The  results  are  mainly  paralytic,  occasionally  irritative, 
producing  spasm.  The  symptoms  of  paralysis  are  difficulty  in  swallowing, 
food  lodging  in  instead  of  descending  into  the  esophagus.     A  most  frequent 


LESIONS  OF  THE  PNEUMOGASTRIC  NERVE  1005 

consequence  is  the  entrance  of  food  into  the  larynx,  causing  spasm  and  even 
choking.  Piilpy  food  is  better  swallowed  than  liquids,  the  latter  passing 
easily  into  the  posterior  nares  when  there  is  paralysis  of  the  soft  palate,  and 
even  when  the  paralysis  is  limited  to  the  superior  constrictor  of  the  pharynx 
owing  to  contraction  of  the  middle  constrictor.  When  the  nerv^ss  on  one 
side  only  are  involved,  the  difficulty  is  much  diminished.  vShould  there  be 
a  doubt  in  diagnosis  between  paralysis  of  the  pharynx  and  obstruction  or 
morbid  growth,  the  passage  of  a  bougie  will  clear  it  up. 

Spasm  of  the  pharynx  is  always  functional  in  origin,  chiefly  hysterical. 
The  so-called  "globus  hystericus,"  or  sensation  as  of  a  ball  in  the  throat 
which  has  to  be  swallowed  but  immediately  arises  again,  is  one  of  its  mani- 
festations; so  is  eminently  the  spasm  in  hydrophobia.  Extreme  degrees 
are  those  in  which  persons  cannot  swallow  their  food  in  the  presence  of 
others. 

Lesions  of  the  Laryngeal  Branches. — The '  laryngeal  branches  are 
two,  the  superior  and  inferior  or  recurrent  laryngeal.  The  former  supplies 
the  mucous  membrane  above  the  vocal  cords,  the  cricothyroid,  and  the 
depressors  of  the  epiglottis.  The  inferior  or  recurrent  laryngeal  on  the  left 
side  winds  around  the  arch  of  the  aorta;  on  the  right,  around  the  sub- 
clavian. The  nerves  then  pass  up  to  the  larynx  between  the  trachea  and 
the  esophagus,  supplying  all  the  laryngeal  muscles  except  the  cricothyroid 
and  epiglottic,  and  the  mucous  membrane  below  the  cords;  also  that  of 
the  trachea.  It  has  besn  supposed  that  the  motor  fibers  in  these  nerves 
come  from'the  spinal  accessory  nerve,  but  this  is  now  doubted.  Their  nu- 
cleus is  probably  a  part  of  the  pneumogastric  nucleus.  The  sensory  fila- 
ments of  laryngeal  branches  pass  to  the  meduUa  oblongata  in  the  roots  of 
the  pneumogastric. 

In  order  to  appreciate  the  phenomena  of  paralysis  of  the  larvnx  it 
should  be  remembered  that  the  glottis  is  opened  or  closed  only  by  the 
movement  of  the  posterior  extremity  of  the  cords,  the  anterior  remaining 
fixed,  and  that  this  movement  is  effected  chiefly  by  the  arytenoid  cartilages 
attached  to  the  cricoid  cartilage  by  an  articidation  which  permits  frie  move- 
ment. Each  arytenoid  is  shaped  like  an  irregular  pyramid  prolonged  at 
the  base  into  two  processes — an  anterior  or  vocal,  from  which  the  cord 
passes  to  the  thyroid  cartilage,  and  an  external  or  muscular,  to  which  the 
muscles  are  attached.  When  the  latter,  which  is  at  right  angles  to  the 
vocal  process,  is  moved  back,  this  process  moves  outward  from  its  fellow, 
the  cord  is  abducted,  and  the  glottis  opened.  If  the  muscular  process  is 
moved  forward,  the  vocal  process  is  moved  inward  toward  its  fellow,  the 
cord  adducted,  and  the  glottis  closed.  These  movements  are  further  aided 
by  movements  of  the  arytenoids  away  from  or  toward  each  other. 

Symptoms. — These  are  phonic  and  respiratory,  together  with  altered 
position  of  the  cords,  as  recoginzed  by  the  laryngeal  mirror.  The  voice 
may  be  changed  or  lost,  the  entrance  of  air  in  breathing  impeded,  while  the 
closure  of  the  glottis,  necessary  to  coughing,  is  usually  imperfect.  The 
voice  and  respiratory  functions  of  the  larynx  are  regulated  by  the  same 
muscles  and  nerves,  but  by  centers  that  differ  in  anatomical  connection,  if 
not  in  position. 


1006  DISEASES  OF  THE  NERVOUS  SYSTEM 

In  breathing  the  cords  arc  abducted  or  separated  during  inspiration, 
the  extent  being  proportionate  to  the  force  of  inspiration.  During  exi:)ira- 
tion  they  are  a  Httle  nearer  than  in  inspiration.  In  phonation  they  are 
made  tense  and  brought  together,  the  degree  of  adduction  and  tension 
varying  with  the  note  produced.  After  death  the  vocal  cords  assume  a 
position  of  slight  abduction  from  the  middle  line,  a  little  nearer  than  during 
ordinary  breathing,  known  as  the  cadaveric  position.  The  position  is  one 
of  partial  relaxation,  complete  relaxation  being  never  fully  attained  during 
life. 

The  symptoms  of  deranged  function  of  the  laryngeal  nerves  admit  of 
classification  into  those  of  paralysis  and  spasm. 

1.  Total  Paralysis  of  Both  Cords  or  of  One. — In  what  is  known  as  com- 
plete paralysis  of  the  laryngeal  muscles — which  does  not,  however,  usually 
include  the  cricothyroid — the  vocal  cords  assume  the  cadaveric  position 
previously  mentioned,  from  which  they  cannot  be  moved.  Hence 
vocal  sounds  cannot  be  produced.  In  deep  inspiration  the  current  of  air 
may  bring  them  a  little  closer,  and  there  may  be  slight  stridor,  and  instead 
of  the  natural  explosive  cough,  there  is  only  a  sudden  rush  of  air  through 
the  glottis.  If  one  cord  is  paralyzed,  it  alone  is  motionless  in  the  cadaveric 
position.  Phonation  may  still  be  possible,  because  the  unaffected  cord 
may  be  overadducted  beyond  the  middle  line,  but  the  voice  is  low-pitched 
and  often  hoarse.  During  inspiration  the  abduction  of  the  healthy  cord 
prevents  stridor,  while  an  explosive  cough  is  impossible  because  the  glottis 
is  not  closed  with  sufficient  firmness  to  produce  it,  unless  the  paralysis  is 
very  slight. 

The  causes  of  complete  paralysis  are  central  disease  and  disease  of  the 
trunk  of  the  vagus  or  of  the  recurrent  laryngeal. 

2.  Bilateral  Abductor  Paralysis. — In  abductor  paraly.sis  involving  the 
posterior  crico-arytenoids  the  cords  are  near  together — in  the  position  of 
phonation — and  cannot  be  abducted  even  as  far  as  the  cadaveric  position. 
They  can,  however,  be  brought  together  in  phonation  and  in  coughing,  at 
the  cessation  of  which  they  recede  a  little,  but  the  normal  wide  abduction 
of  inspiration  does  not  take  place.  This  slight  recession  is  due  to  the  elas- 
ticity of  the  attachment  of  the  cords.  The  adductors,  unopposed,  undergo 
secondarj'  contracture,  so  that  if  the  paralysis  is  of  long  duration,  the  chink 
of  the  glottis  becomes  pemanently  narrower.  The  tensors  are  still  active, 
as  well  as  the  adductors,  hence  the  voice  is  little  affected  The  chief  diffi- 
culty is  in  breathing,  since  the  normal  recession  of  the  cords  essential  to 
inspiration  does  not  take  place, while  they  are  even  brought  closer  together 
by  the  pressure  of  the  entering  air.  Hence  inspiration  is  accomplished  with 
stridor,  and  the  obstruction  to  the  entrance  of  air  brings  into  play  the  extra- 
ordinary muscles  of  respiration,  the  eflect  of  which  is  to  prolong  the  inspi- 
ratory act.  Expiration  is  unimpeded,  the  current  of  outward  air  tending 
to  open  the  cords.  The  absence  of  voice  involvement  and  of  cough  may 
cause  the  obstruction  to  be  referred  to  the  trachea,  but  the  absence  of  the 
expiratory  stridor  excludes  this,  while  the  movement  of  the  larynx  up  and 
down  during  breathing  is  greater  than  in  tracheal  stenosis.  The  added 
urgent  dyspnea,  the  loud  inspiratory  stridor,  livid  features,  and  cold  ex- 
termities  furnish  an  unmistakable  picture;  so  that  a  laryngoscopic  examina- 


LESIOXS  OF  THE  PXEUMOGASTRIC  NERVE  1007 

tion  is  therefore  not  necessarj^  to  complete  the  diagnosis.  In  bilateral 
palsy  there  is  even  great  danger,  as  a  slight  catarrhal  swelling  may  close 
the  larynx  nad  tracheotomy  may  be  necessary  to  save  life. 

The  causes  of  abductor  paralysis  are  central  disease  and  local  influence 
such  as  laryngeal  catarrh  and  degeneration  of  the  posterior  circothyroids, 
possibly  of  toxic  origin.  Disease  of  the  recurrent  laryngeal  has  produced 
such  paralysis,  although  this  nerve  supplies  fibers  to  the  adductors  as  well 
as  abductors.  On  the  other  hand,  the  abductors  have  been  found  degen- 
erated when  the  other  muscles  were  found  normal.  Paralysis  of  both  cords 
is  generally  due  to  disease  of  both  nerves,  and  may  be  produced  by  pressure 
on  both  vagi  or  both  recurrent  larjmgeal  nerves.  Central  causes  are  tabes 
dorsalis  and  bulbar  palsy.  Abductor  paralysis  is  also  a  rare  symptom  in 
hysteria,  when  it  is  bilateral,  with  characteristic  symptoms,  and  has  caused 
death. 

3.  Unilateral  Abductor  Paralysis. — In  this  the  affected  cord  is  near  the 
middle  line,  and  it  does  not  move  in  inspiration.  There  are  hoarseness  and 
roughness  of  voice  and  sometimes  dyspnea,  but  the  mobility  of  the  other 
cord  permits  the  function  of  the  larynx  to  be  carried  on  with  tolerable 
comfort.  If  the  adductors  become  involved,  as  is  sometimes  the  case, 
phonation  is  still  more  impaired. 

The  most  frequent  cause  is  aneurysm,  and  the  left  cord  is  most  fre- 
quently involved — though  other  tumors  may  cause  it — and  on  the  right 
side  the  nerve  may  be  involved  in  a  thickened  pleura. 

4.  Adductor  Paralysis  {Phonic  Paralysis;  Hysterical  Paralysis). — In 
adductor  paralysis  due  to  involvement  of  the  lateral  crico-arji;enoid  and  the 
arytenoid  muscles  the  cords  are  apart  and  cannot  be  approximated.  In 
true  adductor  paralysis  there  is  still  the  power  of  separating  the  cords 
on  deep  inspiration,  but  no  power  to  bring  the  cords  nearer  than  in  the 
cadaveric  position. 

The  causes  of  adductor  paralysis  are  rarely  organic  diseases  of  the 
nerves  or  centers.  It  is  the  condition  causing  the  oft-quoted  hysterical 
aphonia,  and  may  be  brought  on  by  overuse  of  voice  and  catarrhal  larjm- 
gitis.  The  patisnt  with  hysterical  aphonia  can  sometimes  sing,  though 
she  can  only  talk  in  a  whisper.  It  is  most  common  as  a  partial  paralysis. 
While  the  cords  cannot  be  approximated  for  phonation,  they  can  be  in 
coughing.  Hence  it  was  called  by  Turck  "phonic  paralysis."  Another 
partial  adductor  paralysis  is  due  to  the  loss  of  power  in  the  arj-tenoid 
muscle,  resulting  in  defective  closure  of  the  posterior  part  of  the  glottis 
and  hoarseness  or  loss  of  voice. 

5.  Tensor  Paralysis. — Little  is  known  of  this  except  that  palsy  of  the 
internal  fibers  of  the  thyro-arytenoideus  causes  the  edge  of  the  cord  to  be 
concave. 

Diagnosis. — The  laryngoscope  is  necessary  to  a  proper  diagnosis  of 
laryngeal  palsies,  but  symptoms  are  also  useful.  The  inability  to  produce 
explosive  cough  is  of  great  value  in  pointing  to  palsy  or  organic  orgin,  if 
there  is  no  local  lesion  to  prevent  it. 

(a)  Absence  of  cough  with  entire  loss  of  voice  points  to  bilateral  palsy 
of  organic  origin. 

(b)  No  cough,  voice  low-pitched  and  hoarse,  paralysis  of  one  cord. 


1008 


DISEASES  OF  THE  XERVOUS  SYSTEM 


(c)  Loud    inspiratory    stridor    without    loss    of    voice,   total  abductor 
paralysis. 

(d)  Little  change  of  voice  or  cough,  unilateral  abductor  paralysis. 

(e)  Perfect  cough,  no  voice,  no  stridor,  unimportant  adductor  palsy. 
The  following   table  from  Gowers  contains  in  separate  columns  the 

sj'mptoms,  laryngoscopic  picture,  and  lesions: 


(b)  Voice  low-pitched  and  hoarse; 
no  cough;  stridor  absent  or  slight 
on  breathing. 


One  cord  moderately  abducted  1  Total  ^ 
and  motionless,  the  other  mov- 
ing freely  and  even  beyond  the 
middle  line  in  phonation. 


(c)  Voice  little  changed;  cough  nor-     Both  cords  near  together  and  dur-     Total  abductor  palsy, 
mal;  inspiration  difficult  and  long,       ing   inspiration   not   separated.  , 
with  loud  stridor.  but  even  drawn  nearer  together. 


(d)   Symptoms    inconclusive;    little:  One  cord  near  the  middle  line,  not    Unilateral  abductor  palsy, 
affection  of  the  voice  or  cough.  moving  during  inspiration;  the 

other  normal. 


(c)No  voice;  perfect  cough;  no  stri- 
dor or  dyspnea. 


Cord  normal  in  position  and 
moving  normally  in  respiration, 
but  not  brought  together  on  an 
attempt  at  phonation. 


Adductor  palsy. 


Spasm  of  the  Larynx. — In  spasm  of  the  larynx  the  adductors  are  alone 
concerned.  The  closers  of  the  glottis  are  stronger  than  the  openers,  while 
reflex  mechanism  is  connected  chiefly  mth  those  muscles  because  of  the  im- 
portance in  guarding  against  the  entrance  of  foreign  bodies  into  the  laryrLX. 
Spasm  is  quite  common  in  children,  especially  in  the  ricket}^  and  is  not  rare 
in  adults  under  the  name  of  laryngismus  stridulus.  It  is  generally  reflex, 
although  the  reflex  cause  is  not  always  discoverable.  The  patient  com- 
monly wakes  up  at  night  in  an  attack  of  intense  dyspnea ;  but  it  may  occur 
at  any  time.     The  symptoms  are  like  those  of  ordinary  croup. 

The  paroxysm  differs  from  that  of  abductor  paralysis  in  that  stridor 
accompanies  expiration  as  well  as  inspiration.  The  attacks  occur  in  the 
so-called  laryngeal  crises  of  tabes  dorsalis,  in  tetany,  in  the  paroxysms 
of  hydrophobia,  sometimes  in  alteration  with  attacks  of  migraine,  and  in 
hysteria. 

Spasm  is  also  sometimes  excited  by  attempts  to  speak,  when  aphonia 
results.  The  condition  is  the  reverse  of  phonic  paralysis,  in  which  the 
cords  cannot  be  brought  together  in  speaking,  while  in  spastic  aphonia 
they  come  together  too  forcibly. 

Disturbances  of  the  sensory  innervation  of  the  larynx  are  chiefly  confined 
to  the  irritation  which  causes  cough  and  spasm. 


Lesions  of  Cardiac  Branches. — The  cardiac  plexus  is  made  up  of 
fibers  derived  in  part  from  the  pneumogastric  and  in  part  from  the  sympa- 
thetic.    The  vagus  fibers  are  motor,  sensory,  and  probably  trophic. 

The  motor  fibers  include  those  which  inhibit,  control,  and  regulate  the 
cardiac  action.  Their  irritation  inhibits  the  heart's  action  and  causes 
slowness  of  the  pulse,  or  bradj^cardia.  In  complete  paralysis  of  the  vagi 
the  inhibitory  action  is  abolished  and  the  accelerator  influence  is  unham- 


LESIONS  OF  THE  PNEUMOGASTRIC  NERVE  lOO'J 

pered,  producing  rapid  pulse,  or  tachycardia.  Yet  it  sometimes  happens 
that  complete  paralysis  of  one  vagus  is  followed  by  no  cardiac  symptoms. 

The  causes  of  these  effects  are,  unfortunately,  not  always  discoverable. 
Pressure  of  a  tumor,  accidental  ligation  of  one  vagus,  irritation  of  its 
nuclei,  anginal  attacks,  in  one  instance  associated  with  a  small  tumor  of  the 
vagus,  have  all  been  followed  by  bradycardia.  Toxic  blood  states  are 
also  held  responsible  for  it.  Some  persons  are  able  to  control  the  action  of 
their  own  hearts,  notably  a  Colonel  Townsend,  who  could  control  the  action 
of  his  heart  at  will.  The  heart  may  sometimes  be  slowed  by  pressure 
against  the  pneumogastric  in  the  neck 

The  opposite  condition,  tachycardia,  has  been  produced  by  diphtheritic 
neuritis,  tumors  of  the  vagus,  or  accidental  removal  of  the  vagus. 

Sensory  phenomena  in  connection  with  parts  supplied  by  the  cardiac 
branches  of  the  pneumogastric  are  unusual,  but  any  uncomfortable  sensa- 
tions arising  from  palpitation  or  irregularity  are  conveyed  by  branches  of 
the  pneumogastric. 

Trophic  influence  in  the  pneumogastric  is  inferred  from  the  fact  that  the 
heart  has  been  found  in  a  state  of  fatty  degeneration  after  injury  to  the 
nen^e. 

Lesions  op  Gastric  and  Esophageal  Branches. — Among  phenomena 
ascribed  to  effect  on  these  branches  are  spasm  of  the  esophagus  and  diffi- 
culty in  swallowing.  The  vagus  is  also  the  sensory  nerve  of  the  stomach, 
and  pain  in  this  organ  is  felt  through  this  nerve.  The  severe  gastric  crises 
which  occur  in  tabes  dorsalis  may  be  caused  by  irritation  of  the  vagus  nuclei. 
The  senses  of  hunger  and  thirst  are  also  believed  to  be  conveyed  through  it, 
and  have  been  lost  in  disease  involving  the  root,  but  appetite  is  not  always 
lost  after  section  of  the  nerve,  while  in  some  case  of  disease  of  the  nerve 
there  has  been  excessive  appetite.  On  the  other  hand,  loss  of  appetite  is 
from  so  many  causes  that  it  cannot  be  ascribed  to  pneumogastric  lesion 
without  careful  investigation. 

The  pneumogastric  is  also  the  motor  nerve  of  the  stomach,  though 
motion  of  the  organ  is  not  entirely  arrested  after  its  section.  Vomiting  is 
probably  produced  through  its  agency,  and  is  excited  by  central  and  reflex 
irritation.  Meningitis,  which  so  frequently  excites  vomiting,  does  so 
through  it ;  the  pressure  of  a  tumor  on  the  nerve  has  had  a  similar  effect, 
also  direct  pressure  on  an  exposed  ner^^e. 

Lesions  of  Pulmonary  Branches. — While  the  vagus  sends  branches 
to  the  lungs,  little  is  known  of  their  office.  They  are  supposed  to  go  to  the 
bronchial  muscles.  Irritation  of  the  afferent  pulmonary  fibers  certainly 
produces  spasm.  Stimulation  of  the  respiratory  center  also  causes  energetic 
respiratory  movements,  while  rapid  congestion  and  even  hemorrhage  have 
been  noticed  after  section,  though  these  effects  may  possibly  be  of  reflex 
origin  excited  through  the  sympathetic,  since  the  vasomotor  fibers  in  the 
vessels  of  the  lungs  are  derived  from  the  sympathetic.  After  section  of  the 
vagus  animals  die  of  broncho-pneumonia.  This  has  not  been  considered  the 
result  of  trophic  influence,  but  because  of  the  entrance  of  foreign  particles 
into  the  bronchi  in  consequence  of  paralysis  of  the  larynx  and  esophagus; 


1010  DISEASES  OF  THE  NERVOUS  SYSTEM 

this  was  shown  by  Traube  as  far  back  as  1871,  and  confirmed  by  Frey  by 
numerous  experiments  in  1877.  Such  broncho-pneumonia  has  also  been 
ascribed  to  paralysis  of  the  bronchial  musculature  and  of  the  vaso-constrictor 
fibers  which  causes  neuroparalytic  hyperemia  of  the  pulmonary  tissue. 
Spiller's  case'  has  some  bearing  on  the  subject.  This  patient  suffered  an 
injury  of  the  left  glossopharjmgeus  and  vagus  by  a  fracture  of  the  base  of 
the  skull.  He  died  46  days  after  the  accident  and  at  necropsy  numerous 
areas  of  bronchopneumonia  were  found.  It  seemed  improbable  that  the 
pulmonary  condition  was  caused  by  the  entrance  of  foreign  bodies  into  the 
lungs  in  this  case,  because  the  patient  was  unable  to  swallow.  Saliva, 
however,  doubtless  passed  into  the  trachea  and  carried  with  it  micro- 
organisms. The  patient  was  tested  with  a  glass  of  water  and  his  choking 
was  so  alarming  that  the  attempt  was  not  repeated.  He  was  nourished 
by  rectal  enemas  and  the  stomach  tube  was  passed  only  on  the  day 
before  his  death.  The  choking  was  probably  the  result  of  impaired 
function  of  the  epiglottis.  Spiller  thinks  it  reasonable  to  attribute  the 
pulmonary  condition  to  the  paralysis  of  the  vagus  nerve,  although  the 
pulmonary  lesions  were  not  recognized  until  the  necropsy  was  made. 

The  phenomena  of  hiccough  may  be  the  result  of  disease  of  this  nerve, 
as  it  is  also  the  result  of  disease  of  the  respiratory  center. 

Prognosis  in  Pneumogastric  Lesions. — This  varies  greatly.  In  cen- 
tral and  nuclear  disease  it  is  unfavorable;  it  is  unfavorable  also  when  it  is 
the  result  of  pressure  from  intrathoracic  tumors,  especially  aneurysm.  In 
hysterical  and  purely  local  affections  the  prognosis  is  more  favorable. 

Treatment. — This  is,  of  course,  that  of  the  casual  lesion,  if  it  can  be 
discovered.  Syphilis  is  the  more  curable  of  the  central  causes.  Other 
causes  of  central  disease  are  not  removable. 

Of  diseases  of  the  trunk,  neuritis  of  the  vagus  is  as  amenable  to  treat- 
ment as  the  polyneuritis  of  which  it  is  a  part.  The  larjmgeal  s^Tnptoms 
due  to  involvement  of  the  reclirrent  laryngeal  are  as  remediable  as  the 
causes  which  produce  them.  I;f  they  are  caused  by  aneurysm  of  the  aorta 
or  cancer,  treatment  is  useless ;  if  caused  by  syphilitic  and  scrofulous  growths, 
the  prognosis  is  more  hopeful. 

In  the  paralyses  of  more  purely  local  origin,  especially  the  hysterical, 
phonic,  and  diphtheritic  forms,  electricity  offers  the  most  promising  results. 
The  method  of  its  employment  will  be  found  detailed  under  diseases  of  the 
larynx.  Either  form  of  electricity  may  be  used.  Strychnin  is  a  useful 
remedy.  The  method  preferred  is  by  hypodermic  injection,  the  nitrate 
being  employed  in  doses  of  from  1/60  to  1/30  grain  (o.ooii  to  0.0022 
gm.)  daily. 

In  additon  to  strychnin,  other  tonics  should  be  used  to  restore  the 
general  health  of  the  patient.  Laryngeal  gj-mnastics  have  been  recom- 
mended and  used  with  some  success.  Thej^  consist  in  pressing  firmly 
with  the  thumb  and  forefinger  on  each  side  of  the  upper  and  hinder  part  of 
the  thyroid  cartilage,  the  patient  being  requested  to  make  a  simple  sound 
during  the  compression. 

The  treatment  of  laryngeal  spasm  demands  also  the  removal  of  the 
cause  if  possible,  in  addition  to  which  sedatives,  local  and  general,  especially 

1  "Univ.  of  Penn.  Med.  Bull.."  March,  1903. 


LESIONS  OF  THE  SPINAL  ACCESSORY  NERVE  1011 

the  bromids  and  cocain,  may  be  used.     Chloral,  chloroform,  and  nitrite  of 
amyl  by  inhalation  may  be  necessary  to  break  up  the  spasm. 

LESIONS  OF  THE  ELEVENTH  PAIR' OR  SPINAL 
ACCESSORY  NERVE 

Anatomical. — This  nerve,  purely  motor  in  its  function,  has  two  por- 
tions— an  internal,  which  passes  to  the  pneumogastric  and  innervates  the 
laryngeal  muscles,  and  an  external  or  spinal  portion.  The  former  has  been 
considered.  It  should  be  regarded  as  probably  a  part  of  the  vagus,  and  the 
eleventh  nerve  is  called  by  some  the  vago-accessory  nerve.  The  latter,  i.e., 
the  spinal  portion,  is  essentially  a  set  of  motor  fibers  from  the  cervical 
spinal  cord,  which  ascends  into  the  cranial  cavity  and  passes  out  again 
as  one  of  the  cranial  nerves  to  be  distributed  to  the  sternocleidomastoid 
and  trapezius  muscles,  whose  innervation  they  share  with  the  spinal  nerv^es. 
The  purpose  of  the  trapezius  is  chiefly  to  raise  the  shoulder;  that  of  the 
sternocleidomastoid  is  to  assist  in  turning  the  head  to  the  opposite  side, 
the  chin  being  at  the  same  time  raised.  This  is  accomplished  by  drawing 
the  occiput  toward  the  side  of  the  muscle  acting. 

Lesions. — The  nuclear  origin  of  the  nerve  may  be  involved  and  con- 
tribute to  the  phenomena  of  bulbar  palsy,  or  it  may  share  in  progressive 
central  degeneration,  causing  wasting  in  the  muscles  supplied,  which  may 
be  a  part  of  a  more  general  muscular  atrophy.  The  trunks  of  the  nerve  or 
both  nerves  may  be  compressed  in  the  foramen  magnum  by  meningitis  or 
tumor.  Outside  the  skull  there  may  be  wounds,  tumors,  caries  of  the  ver- 
tebrae, and  resulting  abscesses,  and  sometimes  abscesses  springing  from 
the  cervical  glands. 

The  resulting  conditions  are  paralysis  and  spasm.  Those  of  the  internal 
or  accessory  portion  have  been  described  under  lesions  of  the  pneumogastric. 
It  remains  to  consider  only  those  of  the  external  branch. 

Symptoms  of  Paralysis  of  the  External  Branch  of  the  Spinal  Acces- 
sory Nerve. — The  seats  of  the  paralysis  are  the  sternomastoid  and  trapezius 
muscles.  When  one  sternomastoid  is  involved,  the  head  may  still  be  moved 
to  the  opposite  side,  and  there  is  no  wry-neck,  or  torticollis,  though  in  some 
cases  the  head  is  held  obliquely.  The  trapezius  is  not  so  much  involved 
because  it  is  well  supplied  with  cervical  and  thoracic  nerves,  but  a  portion 
which  passes  from  the  acromion  to  the  occipital  bone  is  motionless.  The 
middle  portion  of  the  muscle  is  also  weakened,  the  shoulder  droops  down- 
ward and  forward,  and  the  inferior  angle  of  the  scapula  is  rotated  inward 
by  the  action  of  the  rhomboids  and  the  levator  anguli  scapulse.  Elevation 
of  the  arm  is  also  partial,  because  the  trapezius  does  not  fix  the  scapula  at  a 
point  whence  the  deltoid  can  work.  The  paralysis  is  well  seen  when  the 
patient  takes  a  deep  breath  or  tries  to  shrug  his  shoulders.  Wasting  almost 
always  accompanies  the  loss  of  power,  and  there  is  usually  reaction  of 
degeneration. 

In  bilateral  paralysis  the  power  of  holding  the  head  in  the  upright  posi- 
tion is  impaired.  If  both  sternocleidomastoids  are  affected,  the  head  tends 
to  fall  backward;  if  both  trapezii,  it  falls  forward  so  that  the  chin  rests  on 
the  sternum.  The  latter  is  the  characteristic  position  of  the  head  in  pro- 
gressive spinal  muscular  atrophy,  and  in  children  who  have  chronic  menin- 


1012  DISEASES  OF  THE  NERVOUS  SYSTEM 

gilis  about  the  foramen  magnum,  pressing  on  both  nerve  trunks,  and  in  cer- 
vical meningitis  the  result  of  caries.  A  peculiar  drooping  of  the  head  is 
sometimes  seen  during  the  first  year  of  life  in  children,  which  Gowers  says 
may  be  due  to  injury  to  the  spinal  accessory  nerves  in  difficult  labor.  In 
recent  cases  the  nerves  may  give  characteristic  reaction  of  degeneration.  In 
central  disease  the  reaction  varies,  as  it  does  in  progressive  spinal  muscular 
atrophy. 

Treatment. — This  must  have  for  its  object,  first,  the  removal  of  the 
cause,  or  the  morbid  process  which  produces  it.  After  this  the  weak 
muscles  are  to  be  treated  by  massage  and  electricity.  Faradization  is, 
perhaps,  most  efficient  for  this  purpose,  and  cither  form  of  current  will 
answer. 

Symptoms  of  Accessory  Spasm  (Torticollis;  Wry-neck). — Though  the 
muscles  supplied  by  the  spinal  accessory  are  not  the  sole  ones  responsible  for 
these  conditions,  they  are  the  ones  chiefly  concerned.  The  terms  are  applied 
to  unnatural  positions  of  the  head  resulting  from  contraction  of  these 
muscles.     There  are  two  principal  varieties: 

1 .  Fixed  wry-neck,  or  congenital  torticollis. 

2.  Spasmodic  wry-neck. 

These  two  may  be  regarded  as  true  torticollis,  and  are  to  be  distin- 
guished from  two  somewhat  similar  states  which  may  be  called  false  torti- 
collis. The  first  of  these  is  the  ordinary  "stiff  neck,"  which  is  really  a 
condition  due  to  exposure  to  cold,  and  characterized  by  pain  and  tender- 
ness, for  the  relief  of  which  the  position  is  assumed,  and  should  not  be  called 
wry-neck.  The  second  is  a  twist-neck,  not  due  to  muscles,  but  to  some 
other  cause,  most  frequently  disease  of  the  cervical  vertebrae.  This  devia- 
tion puts  the  sternocleidomastoid  muscle  on  the  stretch,  and  thus  may  give 
rise  to  the  impression  that  it  is  responsible. 

I.  Congenital  Torticollis,  or  Fixed  Wry-neck. — This  depends  on 
the  shortening  of  some  muscle,  commonly  the  sternocleidomastoid,  which 
is  also  often  atrophied,  hard,  and  firm.  It  is  met  most  frequently  in 
children,  and  is  thought  to  be  due,  in  some  cases  at  least,  to  injury  of  the 
muscle  produced  by  traction  during  birth.  In  others  it  is  ascribed  to  devel- 
opmental shortening  of  the  muscle,  due  to  the  inclined  position  of  the  child's 
head  in  the  pelvis.  It  is  not  always  noticed  immediately  after  birth  because 
of  the  natural  shortness  of  the  child's  neck.  A  similar  condition  may 
result  from  injury  to  the  muscle  during  life,  producing  inflammation  and 
tricial  contraction.  It  affects  the  right  side  almost  exclusively.  It  is 
more  or  less  constantly  associated  with  facial  asymmetry,  first  noticed 
by  George  Wilks  and  further  studied  by  Golding  Bird,  who  suggested  that 
the  two  conditions  are  parts  of  one  affection  which  has  a  central  origin. 
In  fixed  wry-neck  the  face  is  turned  toward  the  side  opposite  to  that  of 
the  contracted  muscle,  which  stands  out  conspicuously,  and  cannot  be 
turned  toward  the  latter.  While  the  sternocleidomastoid  is  the  muscle 
almost  invariably  responsible  in  these  cases,  the  trapezius  is  occasionally 
the  seat  of  similar  atrophy. 

Treatment. — The  treatment  is  by  section  of  the  contracted  muscle. 
Some  appliance  may  be  necessary  for  a  time  to  keep  the  head  in  proper 


LESIONS  OF  THE  PNEUMOGASTRIC  NERVE  1013 

position,  especially  when  secondary  changes  in  the  articulations  have  taken 
place.  In  simple  rheumatic  wry-neck  Tyson  has  used  an  appliance  consist- 
ing of  webbing  or  "saddle  girth"  about  three  inches  wide,  stretched  from  side 
to  side  of  the  bed  and  raised  a  few  inches  above  the  mattress — the  distance 
to  be  regulated  by  circumstances — on  which  the  patient  lay  at  night, 
instead  of  on  a  pillow  on  the  side  to  which  the  head  is  drawn.  This  expe- 
dient may  be  used  after  operation.  The  facial  asymmetry  is  likely  to  remain 
after  the  wry-neck  is  cured,  and  may  even  become  more  conspicuous. 

2.  Spasmodic  Wry-neck. — This  is  a  condition  analogous  to  the  facial 
spasm,  occurring  as  a  symptom  of  disease  of  the  facial  nerve.  There  are 
two  forms,  the  tonic  and  the  clonic,  which  may  alternate  in  the  same  case 
or,  as  is  most  usual,  occur  separately  and  remain  so. 

Etiology. — It  is  for  the  most  part  an  affection  of  adults,  and,  accord- 
ing to  Gowers,  is  more  common  in  females — that  is,  in  22  out  of  32  cases. 
While  this  must  be  true  of  England,  the  opposite  seems  to  be  the  case  in 
this  country,  since  of  eight  or  ten  cases  observed  by  Osier  in  Philadelphia 
and  Montreal,  all  were  men.  It  is  more  common  in  middle  life,  two-thirds 
of  all  cases  occurring  between  the  ages  of  30  and  50.  In  women  under  30 
it  is  likely  to  be  of  a  hysterical  origin ;  rarely  it  is  ascribable  to  the  same 
c;ause  in  boys.  It  is  prone  to  occur  in  neurotic  families  and  often  has  the 
characteristics  of  tic.  Very  rarely  it  occurs  in  the  first  year  of  infantile  life, 
ceasing  after  a  few  months  Cold  has  been  assigned  as  a  cause;  also 
traumatism. 

In  the  tonic  form,  when  the  sternocleidomastoid  is  responsible,  the  face 
is  continually  turned  to  the  opposite  side,  the  chin  is  raised,  and  the  occiput 
is  drawn  down  toward  the  affected  side — the  caput  obstipum  spasticuni. 
When  the  trapezius  is  involved,  the  head  is  still  more  depressed  toward  the 
same  side.  In 'combined  and  bilateral  spasm  of  these  muscles  the  head  is 
drawn  backward,  producing  the  retrocollic  spasm.  In  prolonged  cases  the 
muscles  involved  are  prominent  and  rigid,  and  there  may  be  spinalcurva- 
ture  with  the  convexity  toward  the  sound  side. 

In  the  clonic  form  there  are  paroxysmal  twitchings  of  the  head,  which 
may  be  very  severe  and  correspondingly  distressing.  When  there  is  pre- 
dominating unilateral  spasm  of  the  sternocleidomastoid,  the  head  is  turned 
to  the  opposite  side  and  the  chin  is  raised  with  every  contraction  of  the 
muscle.  In  unilateral  spasm  of  the  trapezius  the  head  is  drawn  more  back- 
ward with  each  contraction  and  toward  the  shoulder  of  the  affected  side.  In 
bilateral  and  combined  spasm  there  is  clonic  retrocollic  spasm,  with  shaking 
and  nodding  movements — the  so-called  "salaam  convulsions"  sometimes 
seen  in  children.  They  may  be  produced  also  by  contractions  of  the  other 
muscles  of  the  neck.  Tonic  and  clonic  spasm  of  the  splenius  may  occur 
either  alone  or  in  combination  with  that  of  the  trapezius  and  sternocleido- 
mastoid. In  splenius  spasm  the  head  is  also  drawn  backward  and  toward 
the  affected  side,  and  there  will  be  noticed  muscular  swelling  to  the  outside 
of  the  cervical  portion  of  the  trapezius.  The  splenius  is,  according  to 
Gowers,  associated  with  the  sternomastoid  about  half  as  often  as  the  trape- 
zius. The  retrocollic  spasm  is  commonly  associated  with  a  wrinkling  of  the 
forehead  in  both  the  tonic  and  clonic  forms. 


1014  DISEASES  OF  THE  NERVOUS  SYSTEM 

In  the  clonic  form,  the  contractions  may  come  on  suddenly  or  be  pre- 
ceded by  stiffness  and  irregular  pain.  The  movements  occur  every  few 
minutes,  and  the  head  cannot  be  kept  still,  although  the  movements  cease 
during  sleep.  They  are  increased  by  emotion,  excitement,  or  fatigue. 
vSometimes  there  is  pain,  but  at  other  times  there  is  merely  a  sense  of  fatigue. 
The  muscles  in  time  may  become  hypertrophied,  but  never  waste. 

Pathology. — This  is  very  obscure.  Reasoning,  rather  than  demonstra- 
tion, leads  to  the  conclusion  that  the  muscular  contractions  probably  depend 
on  the  overaction  of  nerve  cells,  and  not  on  irritation  of  nerve  fibers; 
the  movement  usually  involves  the  deep  rotators  on  one  side  of  the  neck 
and  the  sternocleidomastoid  muscle  on  the  opposite  side.  It  is  there- 
fore a  movement  of  associated  muscles,  and  this  suggests  a  cortical  origin, 
at  least  in  many  cases. 

Diagnosis. — The  distinction  lies  between  true  and  false  torticollis,  in 
which  there  is  deviation  of  the  head  from  some  other  cause  than  muscular 
contraction,  and  it  is  only  the  form  of  true  torticollis  due  to  shortening  of 
one  sternocleidomastoid  which  is  likely  to  be  confounded  with  the  false.  In 
the  spurious  form  the  sternomastoid  is  tense  on  the  side  toward  which  the 
face  is  turned,  and  in  the  true  form  the  tension  is  on  the  side  opposite.  In 
retrocollic  spasm  the  invariable  association  of  contraction  of  the  frontalis 
muscles,  producing  the  peculiar  wrinkling  of  the  forehead,  distinguishes  it 
from  simple  tremor.  The  hysterical  form  occurs  in  women  under  30, 
and  this  fact  is  presumptive  evidence  of  its  presence,  while  hysterical  spasm 
is  also  apt  to  spread  from  the  neck  to  the  trunk;  in  the  true  form  of  torticollis 
it  is  limited  to  the  neck. 

Prognosis. — The  prognosis  is  always  grave,  and  the  more  severe  and 
extensive  the  spasm,  the  more  unfavorable.  Relief  is  more  possible  in  the 
first  half  of  life  than  in  the  second.  Cases  do,  however,  occasionally  get 
well,  and  itemporary  relief  is  more  frequent. 

Treatment. — If  the  cause  can  be  found  which  is  responsible,  it  ought  to 
be  removed.  If  discovered  in  an  acute  stage,  absolute  rest  in  bed  and  fomen- 
tations or  dry  heat  are  indicated.  Electricity  has,  perhaps,  more  reputation 
than  any  other  remedy.  The  faradic  brush  may  be  applied  over  the  skin  of 
the  affected  muscles  and  to  the  swelling.  Gradually  increasing  faradic  cur- 
rents may  be  used.  If  the  galvanic  current  is  used,  a  weak  one  is  preferred, 
and  the  anode,  or  positive  pob,  is  placed  below  the  occiput  or  highest 
accessible  part  of  the  nerve,  and  the  negative  on  each  contracting  muscle, 
for  10  minutes  at  a  time. 

Sedatives  and  narcotics  have  also  some  reputation.  Among  these  the 
bromids  and  cannabis  indica  in  large  doses  are  included.  Five-minim  (0.3 
c.c.)  doses  of  the  fluid  extract  of  cannabis  indica  may  be  given,  rapidly 
increased.  The  drug  is  proverbially  unreliable.  The  hypodermic  use  of 
morphin  is  of  undoubted  value  in  relaxing  the  spasm,  but  the  dangers  of  its 
protracted  use  almost  preclude  it.  It  would  be  unfair  to  the  drug,  however, 
to  omit  the  statement  of  Gowers  that,  "continued  for  several  months  in 
doses  increased  gradually  to  1/2  or  i  gram  a  day,  it  has  entirely  removed 
the  spasm."  Naturally,  such  persons  are  weaned  from  the  drug  with  diffi- 
culty. The  hypodermic  use  of  atropin  in  the  affected  muscles  has  also 
been  recommended. 


LESIONS  OF  THE  HYPOGLOSSAL  NERVE  1015 

Mechanical  supports  for  fixing  the  head  are  recommended,  but  are  not 
weU  borne.  Surgical  measures  have  been  employed — such  as  section,  exsec- 
tion,  stretching  of  the  nerve,  and  section  of  the  muscle — with,  at  best,  but 
temporary  results.  Mention  should  be  made,  however,  of  the  deep-seated 
operation  of  W.  W.  Keen  and  Noble  Smith,  which  consists  in  dividing  the 
spinal  accessory  nerve  and  the  posterior  branches  of  two  or  three  cervical 
nerves  which  also  supply  the  splenius  and  complexus.  This  reduces  the 
spasms  that  reside  in  these  muscles  to  a  slight  degree,  while  the  otherwise 
paralyzing  effect  of  the  division  of  branches  of  the  spinal  nerves  is  compara- 
tively unimportant. 

LESIONS   OF   THE  TWELFTH  PAIR  OR  HYPOGLOSSAL  NERVE. 

Anatomical. — This  is  the  motor  nerve  of  the  tongue,  and  supplies  also 
the  depressors  of  the  hyoid  bone  and  the  hyoglossus  and  geniohyoid  of 
the  elevators.  It  arises  from  the  medulla  oblongata  behind  the  olivary 
body.  Its  cortical  center  is  probably  the  lower  part  of  the  ascending 
frontal  gyrus.     It  is  subject  to  paralysis  and  spasm. 

Etiology. — I.  Cortical  disease  is  frequently  responsible  for  paralysis 
of  the  tongue  on  the  opposite  side,  as  is  seen  in  the  nvunerous  cases  of  hemi- 
plegia associated  with  this  condition.  The  same  paralysis  occurs  when  the 
fibers  between  the  cortex  and  the  nucleus  in  the  medulla  oblongata  are  in- 
vaded, and  probably  this  is  the  most  frequent  cause  of  paralysis  of  the 
tongue.  Apoplexies  and  other  causes  of  compression,  softening,  throm- 
bosis, and  embolism,  are  agencies  operating  to  this  end. 

2.  Nuclear  disease  is  another  cause.  It  is  usually  degeneration,  rarely 
sudden  softening:  the  former  as  a  part  of  bulbar  palsy  and  tabes  dorsalis, 
and  the  latter  from  vascular  obstruction.  The  effect  is  almost  always 
bilateral,  the  nuclei  being  so  close  together  that  it  is  scarcely  possible  to 
involve  one  only,  although  such  isolated  result  has  occurred  in  sudden 
cases  and,  rarely,  in  slow  ones,  as  in  tabes  dorsalis  and  general  paralysis. 

3.  Infranuclear  disease  may  operate  at  various  sites — ■ 

(a)  Within  the  medulla  oblongata  the  root  fibers  may  be  invaded  by 
a  tumor  or  by  softening. 

(6)  Outside  the  medulla  oblongata  the  fibers  may  be  damaged  by  the 
products  of  meningitis,  simple  or  syphilitic,  and  by  new  formations.  The 
nerve  may  be  compressed  in  its  foramen  by  outgrowth  of  bone.  Outside 
the  skull  the  nerve  is  compressed  by  tumors,  by  inflammatory  products, 
or  injured  by  disease  communicated  from  caries  of  the  upper  cervical 
vertebrae  and  by  penetrating  wounds.  Hence  the  spinal  accessory  and 
vagus  nerves  are  often  implicated  coincidently  and  there  is  paralysis  of  the 
palate,  occasionally  of  the  vocal  cords,  with  or  without  wasting  of  the 
trapezius  and  sternomastoid.     The  hypoglossal  may  be  the  seat  of  neuritis. 

Symptoms,  i.  Of  Hypoglossal  Paralysis. — These  are  motor  only. 
When  there  is  supranuclear  disease  in  addition  to  the  palsy  of  the  tongue, 
there  is  hemiplegia,  but  no  wasting  of  the  tongue,  nor  change  in  electrical 
reaction.  The  tongue  is  usually  but  not  always  protruded  toward  the 
affected  side.  In  nuclear  disease  the  lesion  is  apt  to  be  bilateral  palsy. 
The  tongue  lies  motionless  in  the  floor  of  the  mouth,  and  is  usually  drawn 


1016  DISEASES  OF  THE  NERVOUS  SYSTEM 

away  from  the  paralyzed  side  and  speech  and  deglutition  are  seriously  im- 
paired. Mastication  is  interfered  with  mainly  because  the  tongue  cannot 
regulate  the  position  of  the  food,  the  proper  muscles  of  mastication  being 
intact.  There  are  atrophy  and  reaction  of  degeneration.  The  mucous  mem- 
brane is  thrown  into  folds.  The  condition  is  likely  to  be  a  part  of  bulbar 
palsy.  In  infranuclear  disease  only  one  nerve  is  afTected,  there  is  wasting 
with  reaction  of  degeneration  and  fibrillary  twitching.  Speech  is  not  much 
impaired,  nor  is  swallowing. 

2.  Of  Spasm. — Spasm  of  the  tongue  as  an  isolated  event  is  ver\^  rare. 
It  may  be  unilateral  or  bilateral.  It  commonly  occurs  as  a  part  of  some 
other  convulsive  affection,  as  epilepsy  or  chorea,  or  spasm  of  the  facial 
muscles.  It  may  occur  also  in  hysteria.  In  the  biting  of  the  tongue  in 
epilepsy  the  organ  is  thrust  between  the  teeth  by  spasmodic  contraction  of 
the  genioglossus  and  caught  by  the  jaws  through  a  spasm  of  masseters. 
Spasm  of  the  tongue  occurs  in  some  forms  of  stuttering,  the  spasm  often 
preceding  the  explosive  utterance  of  words.  In  other  cases  there  are  various 
protrusions  and  deviations  of  the  tongue,  produced  in  some  instances  by 
irritation  of  the  fifth  nerve,  variously  induced,  as  by  a  carious  tooth.  The 
spasm  may  be  clonic,  the  tongue  being  thrust  in  and  out  many  times  in  a 
minute,  at  others  more  slowly.  It  may  be  associated  wth  facial  spasm. 
It  may  occur  during  sleep. 

Diagnosis. — This  is  generally  easy.  If  there  are  hemiplegia  and  palsy, 
but  no  wasting  of  the  muscles  of  the  tongue,  no  reaction  of  degeneration, 
the  lesion  is  supranuclear.  If  there  is  paralysis  of  the  tongue  on  the  one 
side  and  of  the  limbs  on  the  opposite,  there  is  probably  a  unilateral  lesion  in 
the  medulla  oblongata,  involving  the  nucleus  or  the  fibers  arising  from  it. 
When  the  disease  is  on  the  surface  of  the  medulla  oblongata,  the  paralysis 
is  commonly  unilateral,  and  is  associated  with  paralysis  of  the  corresponding 
half  of  the  palate  and  vocal  cord,  because  of  the  involvement  of  the  vagus 
fibers  to  the  spinal  accessory  nerve. 

Prognosis. — The  prognosis  is  unfavorable  because  the  lesion  is  in- 
curable. 

Treatment. — The  treatment  embraces  that  of  the  disease  producing 
it.  The  lingual  paralysis  may  be  treated  with  electricitj^ — with  an  electrode 
in  the  shape  of  a  tongue  depressor. 

The  treatment  of  spasm  has  been  by  sedatives,  including  bromids,  by 
iodid,  and  by  electricity. 


DISEASES  OF  THE  SPINAL  NERVES  AND  BRANCHES. 

CERVICAL  PLEXUS. 

Affections  of  the  Phrenic  Nerve. — Paralysis  of  this  nerve  may  be 
the  result  of  a  lesion  in  the  anterior  horn  of  the  gray  matter  of  the  cord, 
at  the  level  of  the  third  and  fourth  cervical  nerves;  of  a  lesion  to  these 
nerve-roots  in  disease  of  the  membranes  of  the  cord  or  of  the  vertebrae; 
or  by  compression  by  aneurj'sms  or  other  tumors.  Exposure  to  cold,  pro- 
ducing neuritis,  may  cause  it,  and  it  may  be  a  part  of  a  diphtheritic  palsy. 

Symptoms. — The  result  is   paralysis  of  the  diaphragm,  which  is  com- 


DISEASES  OF  THE  CERVICAL  PLEXUS  1017 

plete  if  both  nen^es  are  involved,  as  is  the  case  in  disease  of  the  cord  or  its 
membranes;  partial  when  a  tumor  or  other  cause  affects  one  nerve.  Res- 
piration is  still  carried  on  by  the  intercostals,  and  when  the  victim  is  quiet, 
there  is  little  or  no  embarrassment,  but  examination  shows  the  abdomen  to 
be  retracted  in  inspiration  and  protruded  in  expiration.  In  other  cases,  in 
consequence  of  increased  movement  of  the  thorax,  the  upper  abdominal 
walls  are  drawn  outward  with  inspiration — a  movement  not  to  be  mistaken 
for  movement  of  the  diaphragm.  On  exertion,  however,  there  is  dyspnea, 
which  is  also  observed  if  the  paralysis  is  sudden.  The  effect  of  paralysis 
of  a  single  phrenic,  involving  one-half  of  the  diaphragm,  is  scarcely  noticeable. 

A  further  efiect  is  to  aggravate  any  lung  affection,  as  bronchitis  or 
pneumonia.  There  is  difficulty  in  coughing  effectually,  and,  therefore,  of 
emptying  the  lungs  of  mucus,  accumulation  of  which  maj^  result  in  impair- 
ment of  resonance  at  the  base  of  the  lungs  in  bronchitis  and  in  the  phj'sical, 
signs  of  edema. 

Diagnosis. — Nervous  breathing  resembles  the  breathing  of  paralysis 
of  the  diaphragm  in  that  this  muscle  is  used  very  little,  while  the  upper 
thorax  is  freely  used.  If,  however,  the  attention  of  persons  thus  breathing 
is  distracted,  or  they  are  watched  when  not  conscious  of  obsen.'ation,  the 
diaphragmatic  breathing  will  at  once  become  apparent. 

The  diaphram  does  not  move  when  it  is  inflamed  or  when  there  is 
diaphragmatic  pleurisy,  but  it  is  because  of  the  extreme  pain  which  its 
motion  causes  under  these  circumstances. 

The  diaphragmatic  palsy  from  diphtheritic  neuritis  is  only  a  part  of  the 
symptoms  due  to  such  neuritis.  In  diaphragmatic  paralysis  due  to  spinal 
disease  there  is  usually  atrophy  of  other  muscles,  together  with  other 
symptoms  of  that  disease. 

Prognosis. — This  depends  upon  that  of  the  disease  of  which  it  is  a 
part,  except  in  diphtheritic  neuritis,  in  which  it  is  the  direct  result  of  the 
disease,  and  where  the  prognosis  is  unfavorable. 

Treatment. — The  treatment  is  that  of  the  disease  of  which  it  is  the 
result.  If  there  is  neuritis,  effort  may  be  made  to  galvanize  the  nerve 
by  pressing  one  pole  outside  the  clavicular  portion  of  the  stemomastoid, 
and  the  other  pole  over  the  epigastrium  or  the  corresponding  half  of  the 
diaphragm.  Counterirritation  may  also  be  applied  in  the  triangle  of  the 
neck  outside  the  clavicular  portion  of  the  stemomastoid.  These  measures 
however,  do  not  promise  much  relief. 

BRACHIAL  PLEXUS. 

Of  the  Combined  Plexus. — This  may  be  affected  above  the  clavicle 
by  causes  producing  pressure  on  the  nerve  trunks — the  lower  four  cervical 
and  first  thoracic — after  they  leave  the  spine  and  before  they  unite  to  form 
the  plexus.  Such  causes  are  tumors  and  other  morbid  processes  in  the 
neck.  More  frequently,  causes  operate  below  the  clavicle,  of  which  the 
most  frequent  is  prolonged  luxation  of  the  humerus,  especially  under  the 
coracoid  process.  One  or  more  branches  may  be  thus  involved,  producing 
a  corresponding  degree  of  paralysis,  to  which  is  added  wasting  of  muscles, 
with  reaction  of  degeneration  and  trophic  changes  in  the  skin.     Fracture 


1018  DISE.'ISES  OF  THE  NERVOUS  SYSTEM 

of  the  humerus  is  another  cause.  Blows  or  falls  on  the  shoulder  and  in- 
juries in  the  neck  may  produce  the  same  results,  as  may  also  compression 
during  birth.  The  muscles  involved  may  be  the  deltoid,  supraspinatus, 
infraspinatus,  biceps,  and  brachialis  anticus.  A  rather  frequent  cause  is 
pressure  from  a  cervical  rib.  This  condition  may  be  recognized  by  physical 
examination  or  by  use  of  the  X-ray. 

Neuritis  of  the  brachial  plexus  also  occurs  rarely  as  a  primary  inflam- 
mation. The  result  ultimately  may  be  complete  loss  of  power  in  the  arm. 
A  still  rarer  disease  is  neuro-fibroma  of  the  plexus. 

Lesions  of  Individual  Nerves. — Of  the  Long  Thoracic  or  Posterior 
Thoracic  (Serratus  Palsy).  This  nerve  is  particularly  subject  to  pressure 
through  its  long  course  and  position,  especially  in  the  posterior  triangle  of 
the  neck.  Such  pressure  may  be  direct,  as  by  carrying  heavy  burdens  on 
the  shoulder,  or  as  the  result  of  severe  muscular  effort  in  carrying  or  wield- 
ing a  hammer,  or  long  exertion  with  the  arm  raised,  as  in  whitewashing  a 
ceiling.  The  result  may  be  a  neuritis.  Neuritis  may  also  be  caused  by  cold. 
The  same  nerve  may  be  involved  in  progressive  spinal  muscular  atrophy  or 
poliomyelitis  anterior.     From  natural  causes  it  is   more  common  in  men. 

The  result  is  a  dislocation  of  the  scapula  of  the  corresponding  side, 
which  presents  a  winged  appearance  in  consequence  of  projection  of  its 
angle  and  posterior  border,  rendered  especially  distinct  when  the  arm  is 
moved  forward,  since  the  scapula  is  no  longer  held  to  the  thorax  by  the 
serratus.  In  severe  cases  faradic  irritability  is  lost,  though  voltaic  excita- 
bility may  remain.     Severe  neuralgic  pain  may  precede  the  paralysis. 

The  course  of  serratus  palsy  is  slow,  and  the  paralysis  is  sometimes 
permanent. 

Treatment. — The  treatment  consists  in  maintaining  the  nutrition  of 
the  muscles  by  electrical  stimulation.  Counterirritation  may  be  applied 
over  the  scalenus  muscle,  because  it  is  in  it  that  the  nerve  is  most  frequently 
injured.  Among  the  conditions  to  which  the  now  popular  vibratory 
stimulation  has  been  applied  with  more  or  less  success  is  brachial  neiu-itis. 
The  arm  should  be  kept  at  rest,  and  to  this  end  should  be  carried  a  sling, 
embracing  the  elbow  in  such  a  way  as  to  raise  the  shoulder. 

Nerves  of  the  Arm. — i.  Of  the  Circumflex  Nerve. — This  rises  from 
the  posterior  cord  of  the  plexus  and  supplies  the  deltoid  and  teres  minor, 
and  the  skin  over  the  deltoid.  It  may  be  injured  by  dislocations,  blows, 
bruises,  pressure  by  a  crutch,  or  position  long  maintained,  as  during  illness. 
Neuritis  may  result  from  these  causes  and  from  cold,  or  by  extension  of 
inflammation  from  the  joint. 

There  is  loss  of  power  in  the  deltoid  and  the  arm  cannot  be  fully  raised, 
also  a  loss  of  sensation  in  the  skin  over  the  lower  part  of  the  muscle.  The 
muscle  wastes  and  the  shoulder  becomes  flattened.  The  joint  may  relax 
and  a  space  arise  between  the  head  of  the  humerus  and  the  acromion.  On 
the  other  hand,  adhesions  may  form,  partly  trophic,  since  the  articulation 
is  supplied  by  the  same  nerve.  Movement  may  be  further  imparied  by 
thickening  of  the  ligaments. 


DISEASES  OF  THE  BRACHIAL  PLEXUS  1019 

Paralysis  of  the  deltoid  is  to  be  distinguished  from  ankylosis,  in  which 
the  scapula  moves  with  the  arm,  which  it  does  not  do  in  palsy. 

2.  Suprascapular  Nerve. — This  nerve  rises  from  the  trunk  formed  by 
the  union  of  the  sixth,  fifth,  and  a  branch  of  the  fourth  cervical,  but  its 
own  fibers  are  derived  from  the  fifth  and  partly  from  the  fourth  cervical. 
It  is  occasionally  injured  alone  or  with  the  circumflex  in  dislocation  of  the 
humerus,  and  by  falls  on  the  shoulder,  or  by  carrying  heavy  weights.  The 
result  is  palsy  of  the  supraspinatus  and  infraspinatus  muscles.  The  first 
is  of  little  significance,  but  the  latter  causes  a  defect  of  rotation  outward 
of  the  humerus,  interfering  with  many  movements,  of  which  one  is  carrying 
the  hand  along  in  writing.  The  scapula  is  rotated  so  that  the  lower  angle 
is  rotated  upward  and  inward. 

3.  Musculospiral  Paralysis. — The  musculospiral  nerve  arises  from  the 
posterior  cord  of  the  brachial  plexus,  and  apparently  derives  its  motor  fibers 


Fig.  177. — Wrist-drop  in  Musculospiral  Paralysis — (Leube). 

from  the  nerve-roots  forming*  the  plexus  except  the  first  thoracic.  With 
its  branches  the  muscular,  cutaneous,  the  radial  and  posterior  interosseous, 
it  supplies  the  triceps,  all  the  muscles  of  the  back  of  the  forearm,  the  exten- 
sors of  the  wrist  and  fingers,  both  the  supinators,  as  well  as  the  skin  on  the 
radial  side  of  the  back  of  the  hand,  back  of  the  thumb,  index-finger,  and 
half  of  the  middle  finger.  As  the  musculospiral  nerve  is  called  the  radial 
by  the  Germans,  its  paralysis  is  described  in  German  literature  as  radial 
palsy. 

It  is  more  frequently  paralyzed  than  any  single  nerve,  because  of  its 
position — winding  around  the  humerus  after  it  leaves  the  plexus.  It  is 
often  bruised  by  crutches,  producing  the  so-called  "crutch  palsy,"  by 
blows  and  fractures,  and  especially  by  pressure  when  sleeping  with  the  arm 
over  the  back  of  a  chair  or  with  the  arm  under  the  head.  Even  a  sudden 
and  violent  contraction  of  the  triceps,  as  in  pulling  on  a  tight  boot,  or  forci- 
ble extension  of  the  forearm  as  in  throwing  a  ball,  may  bruise  it.  More 
rarely  it  is  the  subject  of  a  neuritis  from  cold. 


1020  DISEASES  OF  THE  NERVOUS  SYSTEM 

In  a  lesion  of  the  nerve  high  up  all  the  muscles  previously  named  are 
involved;  when  near  the  middle  of  the  hiimerus,  the  triceps  generally 
escapes.  The  supinator  longus  and  extensor  carpi  radialis  longior  usually 
are  involved,  but  escajje  if  the  lesion  is  below  the  origin  of  the  branches 
supplying  them,  and  sometimes  in  partial  injury  of  the  nerve  higher  up.  A 
characteristic  symptom  of  extensor  palsy  is  the  "wrist-drop,"  while  the 
inability  to  supinate  is  also  striking.  Sensation  is  rarely  lost,  though  there 
may  be  tingling  without  loss  of  sensibility. 

Paralysis  of  the  musculospiral  is  to  be  distinguished  from  the  wrist- 
drop of  lead  palsy,  which  is  bilateral,  while  the  supinators  usually  are  un- 
affected and  the  onset  is  gradual.  However,  in  lead  palsy  the  supinator 
longus  may  be  affected,  and  in  wrist-drop  from  pressure  this  muscle  may 


Fig.  178. — Position  ul  Wrist,  Iljud    a.iid  Fingers  in  Ulnar  Paral\sis — (Leuhc). 

escape.  Bilateral  wrist-drop  is  common  in  other  forms  of  neuritis,  espe- 
cially the  alcoholic,  but  the  gradual  mode  of  onset,  the  involvement  of  the 
legs,  and  the  sensory  symptoms  are  their  characteristics. 

The  prognosis  is  usually  favorable,  the  pressure  palsy  disappearing  in 
a  short  time,  while  recovery  is  the  rule  even  when  delaj^ed. 

Erb's  rules  as  to  prognosis  apply  as  follows:  If  both  faradic  and  gal- 
vanic irritability  are  maintained,  recovery  may  be  expected  in  from  14 
to  20  days;  if  these  are  lessened  for  the  nerve  and  increased  for  the  muscle, 
while  An  C  >  Ca  C,  with  contraction  sluggish,  recovery  may  take  place 
in  from  four  to  six  weeks,  sometimes  in  from  eight  to  ten  weeks.  When 
there  is  evidence  of  degeneration  of  the  nerve,  the  prognosis  is  more  un- 
favorable, so  that  recovery  may  be  delayed  for  from  two  to  fifteen  months. 

4.  Ulnar  Nerve. — This  comes  through  the  inner  cord  of  the  plexus 
from  the  last  cendcal  and  first  thoracic.  It  is  the  first  of  all  the  brachial 
nerves  to  be  affected  by  disease  ascending  from  the  thoracic  to  the  cervical 
part  of  the  cord.  It  supplies  the  ulnar  flexor  of  the  wrist,  the  ulnar  half  of 
the  deep  flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the  interossei, 
two  of  the  lumbricales,  the  adductor,  and  the  inner  head  of  the  short  flexor 
of  the  thumb.  Its  sensory  portion  supplies  the  ulnar  side  of  the  hand, 
back  and  front — more  of  the  back — the  little  finger  and  the  adjoining  sides 
of  the  little  and  ring  fingers.  It  communicates  with  the  posterior  branch 
of  the  internal  cutaneous  nen.-e  and  sends  a  communicating  branch  to  that 


LESIONS  OF  THE  LUMBAR  AND  SACRAL  PLEXUSES     1021 

branch  of  the  radial  nerve  which  supplies  the  adjoining  sides  of  the  middle 
and  ring  fingers.     (Gray.) 

The  course  of  the  nerve,  superficial  behind  the  elbow  and  at  the  wrist, 
makes  it  vulnerable.  It  may  be  injured  in  wounds  of  the  forearm  and  about 
the  elbow,  in  dislocations  and  fractures  about  the  shoulder  and  elbow,  and 
continued  flexion  of  the  elbow.  Neuritis  is  a  possible  cause.  The  most 
common  cause  is  probably  a  blow  upon  the  arm. 

The  hand  moves  toward  the  radial  side  because  of  paralysis  of  the  ulnar 
flexor,  and  adduction  of  the  thumb  is  impossible,  the  first  phalanges  can- 
not be  extended,  and  in  long-standing  cases  the  "claw-hand"  may  be  pro- 
duced, consisting  in  overextension  of  the  first  phalanges  and  flexion  of  the 
others.  There  may  be  wasting  of  the  muscles  supplied  by  the  nerve. 
There  is  loss  of  sensation  in  the  sensory  distribution. 

A  similar  condition  of  the  ulnar  nerve  may  be  produced  by  lesion  of 
the  lower  cervical  portion  of  the  cord. 

S.  Median  Nerve. — Its  motor  fibers  arise  from  all  the  cervical  roots 
that  enter  the  brachial  plexus.  They  supply  the  pronators,  the  radial 
flexor  of  the  wrist,  flexors  of  the  fingers — except  the  ulnar  half  of  the  deep 
flexor — the  muscles  that  abduct  and  flex  the  thumb,  and  two  radial  lum- 
bricales.  The  sensory  fibers  supply  the  radial  side  of  the  palm  and  the 
front  of  the  thumb,  the  first  two  fingers,  half  of  the  third  finger,  and  the 
dorsal  surface  of  the  same  fingers. 

Isolated  palsy  of  this  nerve  is  not  frequent,  but  it  may  be  caused  by 
wounds  or  fractures  of  the  forearm,  rarely  from  injuries  of  the  upper  arm. 
There  may  be  neuritis  from  compression. 

The  wrist  can  only  be  flexed  toward  the  ulnar  side,  and  the  thumb  is 
in  a  state  of  persistent  extension  and  cannot  be  opposed  to  the  tips  of  the 
fingers.  Pronation  is  impossible  beyond  the  midposition  to  which  the 
supinator  can  bring  the  forearm ;  an  attempt  is  made  to  supplement  this  by 
rotating  the  humerus  inward  and  separating  the  elbow  from  the  side.  The 
second  phalanges  cannot  be  flexed  on  the  first,  nor  the  distal  phalanges  of 
the  first  and  second  fingers,  while  in  the  third  and  fourth  fingers  this  action 
can  be  performed  by  the  ulnar  half  of  the  deep  flexor.  There  is  conspicuous 
wasting  of  the  thumb  muscles,  which  gives  a  characteristic  appearaiace. 

There  may  be  complete  or  partial  loss  of  sensibility.  If  there  is  anes- 
thesia, it  is  on  the  palmar  surface. 

Treatment  of  Lesions  of  Nerves  of  the  Arm. — The  first  principle  of 
treatment  is  the  removal  of  the  cause,  whatever  it  may  be,  as  determined 
from  the  etiology.  If  neuritis  is  present,  it  must  be  treated.  Rest  by 
supports  or  splints,  electrical  stimulation  and  massage  may  be  necessary. 

LUMBAR  AND  SACRAL  PLEXUSES. 

The  Lumbar  Plexus. — This  is  sometimes  damaged  by  growths  in  the 
abdomen,  especially  of  the  lymph  glands,  by  inflammatory  process,  by 
psoas  abscess,  and  by  diseases  of  the  bones  and  vertebrae  affecting  the 
nerve-roots.  The  ob'turator  nerve  may  be  injured  during  parturition;  the 
anterior  crural  nerve  by  the  same  cause,  by  wounds  of  the  groin  or  thigh, 
by  dislocation  of  the  hip,  and  sometimes  by  growths  about  the  spine. 


1022  DISEASES  OF  THE  NERVOUS  SYSTEM 

Symptoms. — In  paralysis  of  the  obturator,  adduction  of  the  thigh  and 
crossing  of  the  legs  are  impossible,  while  outward  rotation  is  also  deranged. 

In  paralysis  of  the  anterior  crural  extension  of  the  knee  is  impossible; 
there  is  wasting  of  muscles,  with  anesthesia  of  the  anterolateral  part  of 
the  thigh  and  of  the  inner  side  of  the  leg  and  big  toe.  There  may  be  pain 
in  the  area  of  distribution. 

Paralysis  of  the  superior  gluteal  nerve,  which  is  rare  in  the  isolated  form, 
causes  loss  of  the  power  of  abduction  and  circumduction  of  the  thigh  from 
paralysis  of  the  gluteus  medius  and  minimus. 

The  Sacral  Plexus. — This  suffers  from  compression  by  growths  in 
the  pelvis,  pelvic  inflammations,  and  compression  during  labor.  In  addi- 
tion to  spontaneous  neuritis,  there  may  also  be  a  neuritis  ascending  to  it 
from  the  sciatic  nerve.  The  sciatic  may  be  affected  by  wounds,  disloca- 
tion of  the  hip,  disease  of  the  bone,  and  morbid  growths.  It  is  also  oc- 
casionally the  seat  of  fibroneuroma. 

The  result  of  lesions  of  the  sciatic  varies  with  its  seat.  If  near  the 
sciatic  notch,  there  is  paralysis  of  the  flexors  of  the  leg  and  all  the  muscles 
below  the  knee,  while  injury  below  the  middle  of  the  thigh  involves  only 
the  latter  muscles,  the  flexors  of  the  leg  escaping.  There  is  anesthesia 
of  the  outer  half  of  the  leg,  of  the  sole  and  greater  portion  of  the  dorsum 
of  the  foot,  but  the  leg  may  escape,  perhaps  through  the  intermediation  of 
other  nerves.  Frequently  there  is  wasting  of  the  muscles,  with  other 
trophic  symptoms.  In  lesion  of  one  sciatic  the  leg  is  fixed  in  extension  by 
the  action  of  the  quadriceps  extensor,  and  the  patient  can  walk,  even  when 
all  the  muscles  below  the  knee  are  paralyzed,  the  foot  being  raised  by  over- 
flexion  of  the  hip. 

The  small  sciatic  is  implicated  only  when  the  pelvic  plexus  is  impinged 
upon,  and  it  rarely  suffers  alone.  The  effect  is  palsy  of  the  gluteus  maxi- 
mus  with  difficulty  in  rising  from  the  sitting  posture,  and  a  strip  of  anes- 
thesia along  the  back  of  the  middle  third  of  the  thigh  and  upper  half  of  the 
calf. 

Injury  to  the  external  popliteal  or  peroneal  nerve  results  in  paralysis  of 
the  tibialis  anticus,  long  extensor  of  the  toes,  peronei,  and  extensor  brevis 
digitorum.  There  results  inability  to  flex  the  ankles  or  extend  the  first 
phalanx  of  the  toes,  or  to  raise  the  foot  from  the  ground  in  walking — there 
is  foot-drop.  Talipes  equinus  ultimatel}'  results,  and  may  be  attended  with 
persistent  fiexion  of  the  first  or  proximate  phalanges  from  contraction  of  the 
unopposed  interossei.  In  walking  the  whole  leg  must  be  lifted,  and  there 
is  the  steppage-gait  of  neuritis.  In  old  cases  there  may  also  be  wasting  of 
the  anterior  tibial  and  peroneal  muscles.  There  is  also  anesthesia  in  the 
outer  half  of  the  front  of  the  leg  and  on  the  dorsum  of  the  foot. 

Lesion  of  the  internal  popliteal  produces  paralysis  of  the  popliteus,  calf 
muscles,  tibialis  posticus,  long  flexors  of  the  toes,  and  muscles  of  the  sole. 
The  symptoms  are  loss  of  plantar  flexion,  inability  to  extend  the  ankle- 
joint,  and,  if  the  disease  is  high  enough  to  involve  the  branch  to  the  pop- 
liteus, loss  of  power  to  rotate  the  flexed  leg  internally ;  the  foot  cannot  be 
adducted,  nor  can  the  patient  rise  on  tiptoe.  Talipes  calcaneus  results,  and 
the  toes  may  assume  a  claw-like  position  from  secondary  contraction,  due 
to  overextension  of  the  proximal  and  flexion  of  the  second  and  third  pha- 


SENSORY  MECHANISM  OF  PERIPHERAL  NERVES        1023 

langes.     There  is  also  loss  of  sensation  on  the  outer  lower  part  of  the  back 
of  the  leg  and  on  the  sole  of  the  foot. 

Treatment. — The  treatment  of  lesions  of  the  nerves  of  the  legs  is  similar 
to  that  of  lesions  of  nerves  of  the  arms.  Secondary  contractures  are  to  be 
guarded  against,  being  favored  by  position.  Fatigue  and  exposure  to  cold 
should  be  avoided,  as  they  favor  fresh  attacks  of  neuritis. 

EFFECT  OF  SECTIONS  OF  SENSORY  NERVES.     SENSORY 
MECHANISM  OF  PERIPHERAL  NERVES.^ 

The  studies  of  Head  and  Sherren  on  the  effect  of  nerve  action  go 
to  show  that  the  sensory  mechanism  of  the  peripheral  nerves  includes 
three  systems:  i.  protopathic  sensibility;  2.  epicritic  sensibility;  3.  deep 
sensibility.  When  a  nerve  is  cut  only  a  small  area  supplied  by  it  becomes 
totally  analgesic,  the  remainder  being  variously  modified  as  to  sensibility 
through  the  distribution  to  it  of  adjacent  nerves  giving  rise  to  the  S3^stems 
named. 

By  protopathic  sensibility  is  meant  altered  sensation  in  which  stimula- 
tion by  the  prick  of  a  pin  is  felt  more  severely  than  over  healthy  skin,  the 
pain  is  more  widespread  and  the  site  of  stimulation  is  not  always  accurately 
localized.  The  patient  cannot  tell  the  two  points  of  a  compass  when 
separated  by  less  than  two  centimeters.  The  power  of  recognizing  differ- 
ences of  temperature  is  so  modified  that  he  cannot  recognize  cold  above 
22°  C.  or  heat  below  40°  C.  In  considering  the  peculiarities  of  this  area 
it  is  not  the  fibers  of  the  cut  nerve  that  show  this  modified  sensibility,  but 
the  fibers  of  neighboring  nerves  that  supply  certain  forms  of  a  sensation  to 
this  impaired  area. 

The  epicritic  sensibility  presents  well-marked  and  definite  qualities, 
such  as  greater  sensitiveness  to  touch  as  shown  by  the  recognition  of  gentle 
stimulation,  as  by  cotton  wool,  more  precise  and  definite  sense  of  localization, 
the  perception  of  the  two  points  of  the  compass  as  distinct  when  separated 
by  less  than  two  centimeters,  and  the  discrimination  of  fine  grades  of  tem- 
perature. Epicritic  sensibility  is  not  only  an  addition  to  the  protopathic 
sensibility,  but  it  has  a  remarkable  inhibitory  or  modifying  effect  on  the 
protopathic  sensibility,  inasmuch  as  the  pain  felt  by  a  prick  is  less  severe 
and  a  radiation  of  pain  and  of  cold  is  much  less  extensive  than  when  proto- 
pathic sensibility  is  alone  present. 

The  deep  sensibility  which  responds  to  pressure  and  to  movements 
of  joints  is  capable  of  evoking  pain  when  pressure  is  excessive  or  when  a 
joint  is  injured.  It  is  best  demonstrated  in  an  area  where  the  skin  is  totally 
analgesic  through  division  of  a  purely  sensory  nerve.  Because  it  is  thus 
present,  where  the  skin  is  totally  insensitive  it  is  inferred  that  the  sensory 
nerves  supplying  deeper  structures,  like  muscles,  tendon,  bones,  and  joints, 
reach  their  destinations  not  by  the  purely  sensory  nerves,  but  by  the  nerves 
supplying  the  muscles.  Support  for  this  inference  is  found  in  the  facts  that 
Sherren  has  found  afferent  fibers  in  the  nerves  supplying  the  muscles  and 
that  section  of  motor  nerves  deprives  the  muscles  and  deep  structures  of  all 

1  "The  Afferent  Nervous  Systems  from  a  New  Aspect."  Henry  Head,  "Brain,"  part  xi.,  Nov.,  190S. 
"The  Consequences  of  Injury  to  the  Peripheral  Nerves  in  Man."  Ibid.  Abstracted  in  "Review  of  Neu- 
rology and  Psychiatry,"  vol.  iv.,  p.  47,  1906.  This  abstract  is  so  admirably  condensed  that  it  has  been 
necessary  to  follow  it  quite  closely. 


1024  DISEASES  OF  THE  XERVOUS  SYSTEM 

sensation.  If  an  injury  severs  the  tilnar  nerve  at  the  elbow  before  the 
muscular  branches  are  given  off,  then  deep  sensibility  of  certain  fingers  is 
destroyed.  But  if  the  ulnar  is  cut  at  the  wrist,  then  the  deep  sensibility 
of  the  fingers  persists.  If  the  injury  severs  the  tendons  as  well  as  the  ulnar 
nerve  at  the  wrist  then  the  deep  sensibility  of  these  fingers  is  lost.  Hence, 
it  is  argued  that  the  fibers  supplying  the  deep  sensibility  of  those  fingers 
reach  their  destination  by  running  along  the  tendons. 

Much  information  is  gained  by  studying  the  phenomena  attending'^he 
gradual  repair  of  the  nerve.  Some  time  elapses  before  sensation  begins 
to  be  restored,  and  the  restoration  takes  place  in  an  orderly  manner.  The 
first  sign  is  a  diminution  of  the  analgesic  area  due  to  the  gradual  spreading 
over  it  of  protopathic  sensibility,  which  proceeds  until  the  whole  analgesic 
area  is  covered.  The  time  required  for  recovery  is  from  two  to  three  months, 
and  more  than  six  months  may  elapse  before  complete  restoration  of  pro- 
topathic sensibility  is  restored.  After  this  there  is  often  an  inter^^al  of  two 
or  three  months  before  improvement  takes  place  in  epicritic  sensibility. 
When  it  begins  it  appears  as  a  blurring  of  the  margin  separating  the  proto- 
pathic from  the  epicritic  sensibility.  There  is  a  simultaneons  return  of  all 
the  forms  of  sensation  by  which  epicritic  sensibility  is  recognized — of  light 
touch,  better  localization,  appreciation  of  finer  grades  of  temperature, 
etc.  Recovery  is  gradual,  and  usually  more  than  a  year  is  required  to  com- 
plete it. 

If  the  nerve  has  been  bruised  or  incompletely  divided,  it  may  fail  to 
conduct  impulses,  and  the  resultant  loss  of  sensation  may  at  first  resemble 
that  which  follows  complete  division.  Recovery,  however,  in  such  cases 
pursues  a  difl:erent  course  from  that  following  a  complete  division  of  the 
nerve.  Thus  at  the  end  of  a  period  varying  with  the  extent  of  the  injury, 
a  sensibility  to  prick  and  light  touch  return  simultaneously,  and  as  recovery 
progresses  protopathic  and  epicritic  sensibility  return  together.  By  observ- 
ing the  form  of  recovery  one  can  tell  whether  the  nerve  is  completely  severed 
or  merely  injured. 

"A  difference  in  the  distribution  of  protopathic  and  epicritic  sensibility 
is  also  observed,  depending  partly  on  the  distance  of  the  section  from  the 
spinal  cord.  Thus  section  of  a  peripheral  branch  of  a  nerve  near  its  final 
distribution  presents  a  different  result  from  section  of  a  nerve  near  its  exit 
from  the  spinal  cord.  If  the  forearm  and  hand  be  divided  into  a  pre-axial 
(radial)  and  postaxial  (ulnar)  half,  it  is  found  that  the  ners^es  supplying 
one  of  these  halves  overlap  only  to  a  slight  extent  the  areas  supplied  by  the 
nerves  of  the  other  half,  while  the  peripheral  branches  that  supply  one  of 
these  areas  overlap  among  themselves  to  a  very  considerable  extent.  Thus 
section  of  the  internal  cutaneous  high  in  the  arm  produces  an  area  of  total 
analgesia  embracing  the  greater  portion  of  the  ulnar  half  of  the  forearm  and 
hand,  while  at  the  same  time  the  epicritic  sensation  is  lost  over  the  remaining 
portion  of  the  ulnar  half  of  the  forearm  and  hand.  This  shows  that  there 
is  very  little  overlapping  of  the  nerves  supplying  the  radial  half  of  the  fore- 
arm with  the  field  supjilied  by  the  internal  cutaneous.  Division  of  one  of 
the  two  branches  of  the  internal  cutaneous  presents  a  very  different  result — 
the  overlap  being  so  great  that  little  or  no  analgesia  results  from  section  of 
one  branch  only. 


PACHYMENINGITIS  1025 

"Injury  to  the  cords  of  the  brachial  plexus  produces  not  only  very  con- 
siderable changes  in  the  sensibility  of  the  parts  supplied  by  the  nerves 
constituting  the  cords,  but  they  sometimes  show  a  great  difference  in  the 
relationshiiJ  of  the  protopathic  and  epicritic  area.  Here  the  areas  of  proto- 
pathic  and  epicritic  sensibility  are  nearly  co-extensive. 

' '  A  further  difference  in  the  relationship  of  these  two  forms  of  sensibility 
is  shown  when  the  posterior  nerve  roots  are  cut.  In  two  cases  division  of 
several  posterior  nerve  roots  resulted  in  the  loss  of  protopathic  sensibility 
over  an  area  greater  than  that  of  epicritic  sensibility;  that  is  to  say,  there 
was  an  abolition  of  the  sensation  to  prick  over  an  area  larger  and  more 
sharply  defined  than  that  which  became  insensitive  to  light  touch.  More- 
over, this  insensibility  to  prick  was  accompanied  by  an  inability  to  appreci- 
ate temperature  below  15°  C.  and  above  60°  C,  although  40°  C.  and  23°  C. 
appeared  definitely  warm  and  cool." 

The  practical  applications  of  the  above  in  interpreting  phenomena  of 
deranged  innervations  is  evident.  Seats  of  lesions  and  progress  in  improve- 
ment may  be  inferred  by  the  study  the  phenomena  observed. 

DISEASES  OF  THE  MEMBRANES  OF  THE  BRAIN. 

Although,  anatomically  considered,  the  brain  is  enveloped  by  three 
membranes — the  tough  dura  mater,  the  delicate  arachnoid,  and  the  highly 
vascular  pia  mater — the  diseases  of  the  membranes  are  practically  confined 
to  the  dura  on  the  one  hand,  and  the  arachnoid  and  pia  conjointly  on  the 
other,  the  last  two  being  always  affected  together.  The  dura  is,  however, 
separable  into  two  layers' — a  thin  internal  layer  with  its  endothelial  lining, 
and  a  looser  external  layer  which  serves  as  a  periosteum  to  the  bones ;  these 
two  layers  may  be  affected  separately. 

The  term  pachymeningitis  is  applied  to  inflammation  of  the  dura  mater, 
and  leptomeningitis  to  that  of  the  pia  and  arachnoid ;  the  latter  is  commonly 
meant  when  the  word  meningitis  is  used  alone. 

PACHYMENINGITIS. 
Synonym. — Inflammation  of  the  Dura  Mater. 

External  Pachymeningitis. 

Etiology. — External  pachymeningitis  is  always  acute  and  is  commonly 
circumscribed.  It  usually  results  from  injuries  to  the  head,  especially 
fractures;  from  caries  of  the  petrous  portion  of  the  temporal  bone,  caused 
commonly  by  middle-ear  disease ;  or  from  syphilitic  disease  of  the  bone  with 
pus  formation.  Sometimes  no  cause  is  discoverable.  Rarely  pus  infiltrates 
between  the  two  layers  of  the  dura  mater.  More  frequently  there  is  pus 
between  the  dura  and  the  bone.  This  may  occur  in  syphilis,  which,  too, 
may  cause  thickening  of  the  bone. 

Symptoms. — These  are  indefinite  and  are  often  obscured  by  those  of  its 
causal  disease.  They  are  pain,  delirium;  sometimes,  but  not  always,  fever; 
sometimes  convulsions,  and  signs  of  pressure.  Such  pressure  may  or  may 
not  be  sufficient  to  cause  paralysis  of  the  opposite  side. 


1026  DISEASES  OF  THE  \ERVOUS  SYSTEM 

Treatment. — The  treatment  is  that  of  the  causal  disease,  with  surgical 
interference  to  remove  pressure  and  give  vent  to  pus. 

Internal  P.a.chymeningitis. 

This  is  usually  chronic.  Three  forms  are  commonly  noticed — purulent, 
pseudo-membranous,  and  hemorrhagic. 

Purulent  and  pseudo-membranous  internal  pachymeningitis  are 
not  recognized  before  death.  The  former  may  follow  an  injury  primarily, 
but  commonly  it  is  an  extension  from  inflammation  of  the  pia.  Pus  between 
the  dura  and  arachnoid  is  rare.  Pseudo-membranous  internal  pachymenin- 
gitis may  occur  as  a  secondary  process  in  infectious  diseases. 

Internal  Hemorrhagic  Pachymeningitis. — Hemorrhagic  pachy- 
meningitis, or  hematoma  of  the  dura  mater,  is  a  rare,  but  well-recognized 
condition;  it  is  much  more  common  in  infirmaries  and  hospitals  connected 
with  almshouses  and  asylums.     It  occasionally  occurs  in  children. 

Etiology. — It  is  probably  most  frequently  a  result  of  chronic  alcohol- 
ism, though  it  has  been  found  in  chronic  insanity  without  association 
with  alcoholism,  especially  in  general  paralysis  of  the  insane;  also  in  acute 
fevers,  when  it  is  associated  with  profound  anemia.  Syphilis  is  a  possible 
cause;  in  like  manner,  tuberculosis.  It  occurs  chiefly  in  males  over  50, 
but  also  in  those  between  30  and  40.  In  mild  degree  it  is  sometimes  found 
in  chronic  cardiac,  renal,  or  pulmonary  diseases,  when  it  is  commonly 
first  recognized  at  necrospy. 

Pathology  and  Morbid  Anatomy. — The  original  dictum  of  Virchow 
continues  for  the  most  part  to  be  held — viz.,  that  it  begins  as  a  hyperemia 
in  the  area  of  the  middle  meningeal  artery,  extending  thence  forward, 
backward,  and  downward.  The  arteries  become  tortuous,  dilated,  and 
surrounded  by  thickened  adventitia,  while  the  capillaries,  being  over- 
filled, produce  a  rose-colored  flush  on  the  under  surface  of  the  membrane. 
To  this  succeeds  a  delicate  web-like  tissue  containing  wide,  thin-walled 
capillaries  three  or  four  times  the  natural  width,  between  which  is  a  deli- 
cate reticulum  of  spindle  cells  extending  over  the  greater  part  of  one  or  both 
hemispheres.  This  becomes  afterward  paler  and  firmer.  Upon  this  suc- 
ceeds another  delicate  vascular  layer,  succeeded  by  another  and  even 
another.  From  three  to  seven  layers  are  thus  superposed  until  a  product 
of  from  1/8  to  1/5  inch  (3  to  5  mm.)  in  thickness  results.  The  delicately 
walled  capillaries,  however,  easily  give  way,  causing  hemorrhages  which 
vary  in  extent  from  mere  points  to  large  collections  of  blood — the  smaller 
being  interstitial  and  the  larger  between  the  youngest  vascular  layer  and 
the  next  older.  The  proportion  of  blood  and  organized  membrane  varies 
greatly,  now  one  predominating  and  now  another.  At  times  there  seems  to 
be  blood  only.     The  hemorrhage  is  believed  by  some  to  be  the  initial  event. 

Both  products  are  subjecty  to  degenerative  changes,  the  efiused  blood 
being  disintegrated  and  partially  absorbed,  while  the  blood-vessels  become 
obliterated  and  substituted  by  hnes  of  pigment  deposit  along  their  course. 
There  may  also  be  serous  infiltration,  cystic  degeneration,  and  even  diffuse 
suppuration. 


LEPTOMENINGITIS  1027 

Symptoms. — The  symptoms  are  indefinite.  There  may  be  apoplecti- 
form seizures  coincident  with  fresh  hemorrhages,  drowsiness,  or  coma. 
Muscular  weakness  was  very  marked  in  a  case  under  Tyson's  observa- 
tion. Headache  in  the  region  involved,  vomiting,  nystagmus,  convulsions , 
generally  unilateral,  and  even  hemiplegia  may  be  present,  and,  toward 
the  close,  optic  neuritis;  extensive  disease  may,  on  the  other  hand,  exist 
without  any  symptoms  whatever. 

Diagnosis. — In  the  absence  of  distinctive  symptoms  the  possibility 
of  the  presence  of  hematoma  should  be  remembrered  when  there  are  other 
signs  of  general  paralysis  or  chronic  alcoholism.  If  to  such  symptoms 
great  muscular  weakness  is  added,  further  suspicion  is  justified. 

Prognosis. — This  is  absolutely  unfavorable  so  far  as  recovery  is  con- 
cerned. 

Treatment. — This  consists  only  in  the  relief  of  sjonptoms  as  they  arise. 
Indications  of  hemorrhage  should  be  treated  by  rest  in  bed,  elevation  of  the 
head,  and  an  ice-cap. 


LEPTOMENINGITIS. 

Synonym. — Inflammation  of  the  Pia  Mater. 

Of  leptomeningitis  there  may  be  an  acute  and  a  chronic  variety.  In 
addition,  other  adjective  terms  are  used  to  indicate  its  seat  and  the  nature 
of  its  cause;  such  as  basilar  meningitis,  meningitis  of  the  convexity,  tuber- 
culous meningitis,  etc.  Epidemic  meningitis  has  received  separate 
consideration. 


Acute  Leptomeningitis. 

Definition. — An  acute  inflammation  of  the  pia  and  arachnoid  mem- 
branes, attend  by  exudation  between  two  membranes. 

Etiology. — ^All  ages  are  subject  to  meningitis,  that  of  the  convexitj' 
being  possibly  more  frequent  in  adults  because  they  are  more  subject 
to  traumatic  agencies  which  cause  it,  while  the  basilar  form  is  more  com- 
mon in  children.  It  is  rather  more  frequent  in  males,  and  there  is  a  heredi- 
tary tendency  to  one  form — tuberculous  meningitis. 

Of  the  direct  causes — 

1.  An  eruption  of  miliary  tubercles  is  the  most  frequent.  This  cause 
may  operate  at  all  ages,  but  is  most  active  in  children.  In  adults 
it  generally  starts  from  a  recognized  tuberculosis  elsewhere; in  children 
the  process  is  almost  always  part  of  a  general  tuberculosis.  Tuberculous 
meningitis  takes  place  generally  at  the  base  of  the  brain,  constituting  the 
chief  form  of  basilar  meningitis. 

2.  Adjacent  disease,  which  may  be  outside  of  the  dura  mater,  such 
as  caries,  especially  in  the  petrous  portion  of  the  temporal  bone.  Even 
disease  outside  the  skull,  like  erysipelas  or  suppurative  disease  of  the 
scalp,  may  be  a  primary  focus.  In  these  cases  it  is  usually  unilateral, 
and  may  be  accompanied  by  thrombosis  of  the  sinuses  and  abscesses;  or 
the  disease  may  result  in  abscess  within  the  brain. 


1028  DISEASES  OF  THE  NERVOUS  SYSTEM 

3. The  bacterium  or  toxin  of  the  acute  infectious  diseases — pneumonia, 
ulcerative  endocarditis,  measles,  scarlet  fever,  smallpox,  typhoid  fever, 
acute  rheumatism,  and  septicemia.  Care  must,  however,  be  taken  not 
to  confound  the  simple  intense  delirium  in  some  of  these  affections  with 
meningitis,  remembering,  too,  that  the  latter  complication  is,  under  any 
circumstances,  a  rare  one.  The  toxin  of  pneumonia  is  the  most  common 
cause,  and  perhaps  after  this  that  of  smallpox.  The  inflammation  thus 
caused  is  chiefly  of  the  convexity,  except  in  septicemia,  when  it  is  general. 

4.  Chronic  Bright's  disease  and  other  cachectic  conditions.  In  these 
the  inflammation  is  commonly  basilar. 

5.  Sunstroke. 

6.  Mental  excitement  and  brain  work — doubtful  causes. 

7.  Rarelj'  in  acute  inflammation,  syphilis,  whose  product  is  also  basal. 

8.  Finally,  unknown  causes  may  produce  meningitis  of  the  convexity 
or  of  the  base.  Possibly,  as  Gowers  suggests,  organisms  otherwise  power- 
less become  sufficient  causes  during  ill  health.  Thus  may  be  caused  some 
undoubted  though  rare  cases  of  non-tuberculous  basilar  meningitis 
of  children — leptomeningitis  infantum. 

In  tuberculous  meningitis,  which  is  chiefly  basilar,  the  eruption  of  tubercles 
precedes  the  inflammation.  There  may  even  be  tuberculosis  of  the  pia 
without  inflammation.  In  tuberculous  meningitis  the  inflammation  is 
never  actually  purulent,  though  the  lymph  has  often  the  appearance  of  pus. 
The  tubercles  are  most  abundant  about  the  optic  chiasm,  over  the  pons,  and 
in  the  fissure  of  Sylvius,  but  the  cortex  is  often  affected.  According  to 
Spiller's  experience  the  upper  part  of  the  cerebral  hemispheres  contains  more 
tubercles  than  are  found  at  the  base. 

Morbid  Anatomy. — The  early  results  of  leptomeningitis  are  the  same 
in  all  varieties.  They  consist,  first,  in  a  hyperemia  of  the  capillaries 
producing  a  diffuse  pinkish  tinge.  The  next  visible  changes  are  a  tur- 
bidity and  an  opacity  of  the  arachnoid  which  extend  to  the  pia,  where 
opacity  is  especially  distinct  along  the  blood-vessels,  consisting,  in  fact 
in  an  infiltration  of  the  h-mph  spaces  and  lymphatic  sheaths  with  leuko- 
cytes. As  the  cellular  accumulation  increases  the  exudate  beneath  the 
arachnoid  assumes  a  yellowish-white,  creamy  appearance.  The  sub- 
arachnoid fluid  increases,  constituting  hydrocephalus  externus.  In  sup- 
purative cases  it  becomes  pus,  which  forms  a  greenish-yellow  layer  at  the 
convexity  or  base,  or  both. 

Ventricular  effusion  is  present  in  the  majority  of  instances — about 
four  out  of  five — constituting  hydrocephalus  internus,  generally  associated 
with  closure  of  the  openings  of  the  fourth  ventricle.  The  effusion  is  usually 
limited  to  a  few  ounces,  but  it  may  be  large  in  quantity,  distending  the 
ventricles  and  compressing  the  cortex.  The  walls  of  the  ventricles  and  the 
choroid  plexuses  may  be  inflamed,  and  the  ventricular  effusion  may  be  the 
result  of  such  inflammation. 

In  all  varieties  of  meningitis,  and  especially  in  the  tuberculous,  the 
suijerficial  layer  of  the  cortex  is  also  involved,  being  at  least  hyperemic,  and 
sometimes  softened;  it  may  also  be  the  seat  of  punctiform  hemorrhages, 
constituting  red  softening.  This  is  especially  prone  to  occur  in  tuberculous 
meningitis,  because  of  the  extension  of  the  tuberculosis  along  the  blood-ves- 


LEP  TOMENINGI TIS  1029 

sels  which  dip  into  the  cortex.  In  pulHng  off  the  pia  these  blood-vessels  are 
dragged  with  it,  leaving  a  ragged  appearance  of  the  cortex. 

Leptomeningitis  infantum  presents  an  appearance  similar  to  that  of 
tuberculous  meningitis.  It  involves  chiefly  the  posterior  part  of  the  men- 
inges and  cerebellum,  closing  sometimes  the  foramen  of  Magendie,  whence 
the  term  occlusive  meningitis .  It  may  also  cause  an  acute,  sometimes  puru- 
lent, hydrocephalus. 

Symptoms. — These  are  varied  and  not  always  distinctive  of  the  different 
forms.  First,  it  is  important  to  remember  that  all  except  those  which  are 
peculiar  to  inflammation  of  the  base  may  be  present  in  any  of  the  serious  in- 
fectious fevers  without  meningitis,  especially  pneumonia,  typhoid  fever,  and 
smallpox ;  but  in  some  cases  of  typhoid  fever  the  typhoid  bacillus  has  been 
found  in  the  cerebral  membranes.  When  secondary  to  these  affections,  they 
are  accompanied  by  the  symptoms  of  the  disease  which  they  succeed. 

Meningitis  is  usually  ushered  in  by  premonitory  symptoms,  which,  again, 
are  not  distinctive,  being  those  usual  to  acute  disease.  Perhaps  irritability 
is  more  constant  than  in  other  acute  diseases.  In  case  of  children,  vomiting 
with  a  slight  cause,  or  without  discoverable  cause,  is  a  symptom  of  more  sus- 
picious nature.  It  is  especially  frequent  in  basilar  meningitis,  of  which  it 
is  more  or  less  charactertistic.  It  has  this  peculiarity,  that  it  is  not  usually 
accompanied  by  nausea  and  retching.  Generally  there  are  high  fever,  coated 
tongue,  and  constipation,  although  fever  is  not  invariable.  The  usual 
temperature  is  from  103°  to  104°  F.  (39.5°  to  40°  C),  but  it  may  reach  from 
105°  to  106°  F.  (40.5°  to  41.1°  C),  and  toward  the  close  of  fatal  cases,  108°  F. 
(42.2°  C).  It  is  especially  likely  to  be  mild  or  absent  in  the  meningitis  of 
Bright's  disease  or  of  debilitated  children.  The  pulse  is  increased  in  fre- 
quency at  first,  but  later  may  be  slow  and  irregular. 

Of  the  symptoms  the  direct  result  of  the  disease,  pain  in  the  head  is  the 
most  constant.  Commonly  frontal,  it  may  be  general.  Its  constancy  and 
severity  are  characteristic.  Yet  it  is  subject  to  such  exacerbations  as  may 
cause  the  patient  to  cry  out,  constituting  the  hydrocephalic  cry  of  children. 
The  headache. is  invariable,  followed  sooner  or  later  by  unconsciousness. 
Delirium  is  an  early  symptom  and  soon  follows  the  headache;  at  first 
wandering,  it  soon  becomes  active,  and  may  alternate  with  drowsiness  or 
stupor. 

General  convulsions  axe-  also  another  symptom,  occurring  in  all  forms  and 
at  all  ages,  but  more  frequently  in  the  tuberculous  meningitis  of  children. 
When  the  inflammation  is  at  the  base,  rigidity  of  the  neck  with  retraction  of 
the  head  is  very  marked,  especially  when  the  inflammation  extends  down  the 
membranes  of  the  spinal  cord.  Optic  neuritis  is  another  symptom,  usually 
late  in  occurrence — at  the  end  of  the  first  week — and  possibly  due  to  in\'olve- 
ment  of  the  sheath  of  the  optic  nerve  within  the  skull.  Strabismus  is  also 
common.  There  may  be  weakness  of  the  eye  muscles  and  slight  ptosis. 
The  pupils  are  usually  contracted  in  the  early  stage  from  intolerance  of  light ; 
later,  they  are  dilated.  Inequality  of  the  pupil  is  even  a  more  characteristic 
symptom,  though  transient  and  variable.  It  occurs  in  connection  mth  in- 
flammation of  the  convexity  as  well  as  of  the  base. 

The  facial  nerve  may  be  involved  in  basilar  cases,  producing  slight  paraly- 
sis, as  may  also  be  the  fifth  nerve,  producing  anesthesia  and  trophic  changes 


1030  DISEASES  OF  THE  NERVOUS  SYSTEM 

in  the  cornea.  On  the  other  hand,  hyperesthesic  skin  is  often  present;  also 
hyperesthesia  of  the  special  senses,  especially  hearing  and  sight. 

Sj'mptoms  in  the  limbs  may  present  themselves,  such  as  muscular  rigidity, 
unilateral  convulsions,  and  even  hemiplegia,  but  the  last  is  rare.  When  they 
occur,  they  are  late  symptoms. 

Diagnosis. — The  diagnosis  is  not  always  easy,  because  so  many  symp- 
toms may  be  simulated  by  simple  congestion  due  to  the  poison  of  the  in- 
fectious diseases.  The  basilar  symptoms  are  the  most  distinctive,  and  it  is 
a  real  help  to  know  that  a  possible  cause  is  present,  either  predisposing  or 
exciting;  such,  for  example,  as  the  tuberculous  taint,  or  tuberculous  disease, 
or  middle-ear  disease.  Retraction  of  the  head,  so  characteristic  of  this  form, 
may  result  from  myositis  affecting  the  muscles  of  the  back  of  the  neck.  Sir 
William  Jenner  pointed  out  a  difference  between  the  relation  of  headache 
and  delirium  in  general  disease  and  meningitis :  In  general  disease  the  head- 
ache ceases  when  the  delirium  begins;  in  meningitis  the  headache  continues 
and  coexists  with  the  disease.  Convulsions,  too,  when  present,  occur  at 
the  beginning  of  a  general  disease,  particularly  in  scarlet  fever;  while  they 
occur  late  in  meningitis.  Optic  neuritis  and  other  eye  symptoms  are  com- 
mon in  meningitis. 

A  rapidly  growing  intracranial  tumor  often  gives  rise  to  difficulty  in  the 
diagnosis  between  it  and  meningitis.  In  tumors  which  may  be  tuberculous 
or  gliomatous,  symptoms  in  the  extremities,  such  as  weakness,  hemiplegia, 
and  convulsions,  are  manifested  only  after  the  tumor  begins  to  interfere 
with  function,  which  it  may  not  do  at  first;  the  loss  of  power,  moreover, 
comes  on  gradually,  while  in  meningitis  all  these  symptoms  are  rapidly 
developed.  Higher  degree  of  optic  neuritis,  as  obsen-ed  by  the  ophthalmo- 
scope, are  found  in  connection  with  tumor  than  with  meningitis.  The 
duration  of  the  disease  will  settle  the  question  ultimately,  as  meningitis  is  of 
short  duration — from  two  or  three  days  to  as  man}'  weeks — while  tumors  last 
for  months  or  years. 

Meningitis,  especially  tuberculous,  is  sometimes  mistaken  for  hysteria, 
but  the  almost  invariable  presence  of  fever  in  meningitis  and  its  total  absence 
in  most  cases  of  hysteria  should  prevent  error.  In  children  the  s^^nptoms 
even  of  tuberculous  meningitis  are  sometimes  closely  simulated  in  bad 
cachectic  states,  in  which  there  is  no  meningitis  whatever.  What  is  regarded 
as  meningitis  after  sunstroke  is  a  prolonged  state  of  mental  hebetude  ^\'ith 
sv-mptoms  usually  aggravated  on  slight  exposure  to  the  sun. 

Prognosis. — The  prognosis  in  leptomeningitis  is  unfavorable,  although 
not  necessarily  hopeless.  In  meningitis  of  the  convexity  recovery  is  possible ; 
in  undoubted  tuberculous  meningitis  it  is  very  rare,  and  yet  it  may  occur. 
Especially  in  general  tuberculosis  should  we  avoid  too  unfavorable  a  prog- 
nosis, because  mistakes  here  are  quite  frequent.  In  meningitis  from  adjacent 
bone  disease  much  depends  on  the  accessibility  of  the  bone  lesion,  but  as  this 
is  generally  difficult  of  access,  the  prognosis  is  correspondingly  serious.  This 
is  especially  the  case  in  ear  disease.  In  syphilitic  meningitis  if  the  diagnosis  is 
made  early,  chances  of  recovery  or  improvement  are  better. 

Treatment. — -The  treatment  of  adjacent  disease  which  may  cause  the  men- 
ingitis is  of  the  first  importance.  Surgical  interference  should  be  promptly 
resorted  to  in  middle-ear  disease.     In  the  absence  of  such  disease  the  treat- 


LEPTOMENINGITIS  1031 

ment  is  mainly  symptomatic.  The  utmost  quiet  and  the  avoidance  of  all 
causes  of  excitement  are  paramount.  It  is  the  one  disease,  outside  of 
ophthalmia,  in  which  the  darkening  of  the  room  may  be  justified.  The  head 
should  be  raised.  Leeching  is  a  most  valuable  measure  toward  cure,  when 
possible,  and  temporary  relief  when  cure  is  impossible.  Leeches  should  be 
applied  to  the  back  of  the  ear  and  to  the  temple.  Ice  should  be  kept  applied 
to  the  head.  Counterirritation  by  blisters  to  the  back  of  the  neck  is  also  very 
useful,  and  not  so  painful  or  annoying  as  its  appearance  suggests.  It  has 
even  been  applied  to  the  whole  scalp  after  shaving  the  head,  but  there  is  no 
justification  in  this,  especially  when  the  diagnosis  of  tuberculous  disease  is 
quite  clear.     The  bowels  should  be  kept  free. 

The  diet  should  be  liquid — mUk  and  animal  broths  of  a  light  kind  are 
the  best  food.  Such  drugs  as  meet  the  symptoms  should  be  given.  Acet 
pheneiadin  to  relieve  pain  in  the  head  if  the  ice  and  abstraction  of  blood  do 
not  do  it.  The  temperature  is  kept  down  by  sponging  and  even  by  cool 
bathing.  Mercury  is  still  an  acknowledged  drug  in  meningitis  not  tuber- 
culous; and  as  chances  of  error  of  diagnosis  always  exist,  it  may  be  em- 
ployed in  any  case.  It  should  be  administered  to  the  production  of  slight 
salivation,  preferably  by  inunction  because  the  effect  is  more  rapidly 
produced.  The  mercurial  ointment  should  be  used.  Lumbar  puncture 
has  therapeutic  as  well  as  diagnostic  value. 

Chronic  Leptomeningitis. 

Etiology  and  Morbid  Anatomy. — This  comparatively  rare  disease  affects 
chiefly  the  convexity  of  the  brain,  and  is  the  result  of  alcoholism,  syphilis, 
or  tuberculosis. 

In  mUder  degrees,  seen  in  alcoholics,  the  pia  arachnoid  is  opaque,  as 
seen  over  the  sulci,  the  opacity  and  thickening  being  more  marked  along 
the  borders  of  the  blood-vessels.  In  syphilis  there  are  often  foci  or 
thickened  patches,  thickest  in  the  center  and  receding  toward  the  edges. 
These  may  reach  dimensions  to  justify  the  term  gummatous  outgrowth  or 
tumor.  The  blood-vessels  are  the  seat  of  endarteritis.  In  the  tuberculous 
forms  in  children  the  base  of  the  brain  is  affected,  as  in  acute  tuberculous 
meningitis.  Internal  hydrocephalus  may  be  a  consequence  when  there  is 
obstruction  of  the  orifices  of  the  fourth  ventricle. 

Symptoms. — These  are  those  of  the  acute  form  in  a  rrdlder  and  more 
prolonged  manner — headache,  vomiting,  mental  symptoms,  sometimes 
convulsions,-  rigidity,  retraction  of  the  head,  optic  neuritis,  more  rarely 
strabismus,  and  nystagmus.  They  may  last  from  a  month  to  a  year  or  more. 
Fever  is  more  frequently  absent  in  chronic  meningitis,  but  careful  observa- 
tion will  generally  find  some  elevation  of  temperature. 

Diagnosis.' — It  is,  in  fact,  the  chronic  variety  of  leptomeningitis  which 
is  separated  from  tumor  with  the  greatest  difficulty.  Loss  of  motor 
power  is  more  characteristic  of  tumor.  Optic  neuritis  is  also  a  more  decided 
symptom  in  tumor,  and  goes  on  increasing,  while  it  seldom  reaches  an  ad- 
vanced stage  in  chronic  meningitis.  Other  eye  symptoms — strabismus, 
irregularity  of  pupil — are  more  distinctive  of  meningitis.  Strabismus  occurs 
in  hysteria,  but  it  is  always  convergent  and  there  is  total  absence  of  fever, 
as  shown  by  the  absence  of  elevation  of  temperature. 


1032  DISEASES  OF  THE  NERVOUS  SYSTEM 

Prognosis. — This  is  not  so  unfavorable  as  in  the  acute  variety.  The 
syphilitic  form  is  quite  amenable  to  treatment,  the  alcoholic  less  so;  the 
tuberculous  is  almost  always  sooner  or  later  fatal.  Caution  in  prognosis 
is  demanded  by  occasional  error  in  diagnosis. 

Treatment. — The  cause  must  be  carefully  sought.  If  syphilitic,  iodids 
mercurials  and  salvarsan  must  be  used,  as  for  this  disease.  In  alcoholism 
and  tuberculosis  the  symptoms  must  be  treated  by  measures  already 
indicated. 

AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE  BRAIN. 

HYPEREMIA. 

Synonyms. — Cerebral  Hyperemia;  Congestion  of  the  Brain. 

Definition. — A  condition  of  the  brain  in  which  the  blood-^^essels  are 
surcharged  with  blood.  The  congestion  is  active  as  the  result  of  increased 
flow  of  blood  to  the  brain,  as  in  alcoholic  hyperemia;  passive  when  there  is 
obstruction  to  its  outward  movement,  as  in  constriction  of  the  vessels  in  the 
neck. 

Etiology. — The  causes  of  active  hyperemia  are  prolonged  mental  activity, 
excitement,  and  overwork,  pre-eminently  alcohol  and  the  causes  of  the  acute 
fevers;  the  hypertrophy  and  overaction  of  the  heart  which  attend  aortic 
regurgitation  may  be  causes.  The  causes  of  passive  congestion  are  mainly 
mechanical,  including  mitral  valvular  heart  disease,  emphysema,  straining, 
or  other  cause  obstructing  the  return  of  blood  from  the  brain — such  as  tumors 
pressing  on  the  vessels  of  the  neck,  or  tight  clothing. 

Morbid  Anatomy. — While,  from  the  standpoint  of  morbid  anatomy,  our 
ideas  may  be  very  definite  as  to  what  should  constitute  active  and  passive 
hyperemia,  it  cannot  be  said  that  a  definite  set  of  symptoms  is  associated  with 
either  in  the  case  of  the  brain.  In  the  first  place,  the  amount  of  blood  in  the 
brain  varies  greatly  wthin  the  limits  of  health,  and  while  it  might  be  said 
that  physiological  hyperemia  ends  where  abnormal  mental  phenomena 
present  themselves,  it  is  undoubtedly  true  also  that  an  overfullness  of  the 
vessels  of  the  brain  may  exist  for  some  time  without  the  symptomatic  expres- 
sion which  finally  appears.  With  the  appearance  of  such  symptoms  we 
commonly  date  the  clinical  beginning  of  the  pathological  state  known  as 
chronic  hyperemia. 

The  difficulties  are  increased  by  the  fact  that  in  acute  active  and  passive 
hyperemia,  at  least,  no  postmortem  evidences  of  it  remain,  the  congestion 
having  disappeared  with  death,  although  an  unusual  distinctness  of  the 
puncta  vasculosa  has  long  been  regarded  as  postmortem  evidence.  The 
difficulty  of  recognizing  such  condition  makes  this  sign  an  unreliable  one. 
In  chronic  hyperemia  there  result,  sometimes  at  least,  a  turbidity  and  even 
an  opacity  of  thepia  mater,  with  slight  thickening,  together  with  elongation 
and  tortuosity  of  the  vessels,  which  are  regarded  as  characteristic. 

Symptoms. — These  are  not  very  distinctive.  The  symptoms  of  active 
hyperemia,  so  far  as  recognizable,  are  a  sense  of  fullness  or  pressure,  head- 
ache, mental  excitement,  irritability,  confusion  of  ideas,  insomnia,  vertigo, 
ringing  in  the  ears,  and,  in  extreme  cases,  hallucinations,  delirium,    and 


ANEMIA  OF  THE  BRA IX  1033 

mania.  These  symptoms  are  increased  when  the  head  is  held  downward  or 
there  is  straining.  The  phenomena  of  so-called  "rush  of  blood  to  the  head" 
are  probably  the  result  of  active  hyperemia.  They  include  a  suffusion  of 
the  skin  of  the  face  and  head  and  a  feeling  of  warmth  in  these  situations, 
strong  beating  of  the  carotids,  headache,  tinnitus  aurium,  spots  before  the 
eyes,  vertigo,  and  sometimes  actual  falling. 

It  is  not  easy  to  separate  the  phenomena  of  passive  hyperemia  from  those 
of  active  congestion.  They  are,  however,  less  pronounced  and  slower  in 
their  development. 

Treatment. — The  indications  for  treatment  are,  nevertheless,  plain. 
The  head  is  to  be  kept  raised.  Purgation  is  the  first  measure  to  be  thought 
of.  The  saline  and  hydragogue  cathartics  are  especially  indicated,  because 
of  their  depleting  effect.  The  ice-cap  should  be  used.  In  extreme  cases 
even  blood-letting  may  be  necessary,  the  efficiency  of  which  is  sometimes  seen 
in  the  relief  afforded  by  bleeding  of  the  nose.  Leeches  applied  behind  the 
ears  often  afford  magical  relief  to  the  symptoms  commonly  ascribed  to  con- 
gestion of  the  brain.  Wet  cups  may  be  placed  upon  the  back  of  the  neck  for 
the  same  purpose.  The  diet  should  be  spare  and  easily  assimilable,  in  acute 
cases  liquid  only. 

Of  medicines,  the  bromid  of  potassium  theoretically  fvdfills  the  indications, 
and  in  fidl  doses  of  from  15  to  30  grains  (i  to  2  gm.)  every  three  hours  to 
adtdts  is  often  useful,  though  it  should  not  be  allowed  to  substitute  the  other 
measures  mentioned.  Acetphenetadin  is  an  admirable  remedy  for  the  head- 
ache, a  single  dose  of  10  grains  (0.66  gm.)  being  often  sufficient.  It  may 
be  repeated  if  necessary,  or  smaller  doses  may  be  given  more  frequently. 

ANEMIA  OF  THE  BRAIN. 

Definition. — The  more  usual  application  of  the  term  anemia  of  the  brain 
is  to  conditions  in  which  the  quantity  of  blood  in  the  organ  is  diminished, 
although  depraved  states  of  the  \^tal  fluid  without  loss  of  biolk  may  also 
produce  the  same  symptoms. 

Etiology. — The  causes  leading  to  this  condition  are  for  the  most  part 
those  which  withdraw  blood  from  the  brain,  but  they  include  also  such 
as  prevent  its  access.  Among  the  former  are  hemorrhages,  profuse  and 
rapid ;  bowel  fluxes,  such  as  those  of  cholera  in  adults  and  cholera  infantum 
in  children;  and  the  opening  of  vascular  areas  by  the  removal  of  pressure 
caused  by  large  tumors  or  ascitic  fluid.  Thus  is  explained  the  fainting  which 
sometimes  succeeds  the  removal  of  a  large  abdominal  dropsy.  In  the  second 
set  of  causes  are  feeble  action  of  the  heart,  ligation  of  the  carotid  artery,  or 
other  obstruction  in  vessels  carrying  blood  to  the  brain.  Such  obstructions 
are  thrombi  and  emboli.  The  brain  substance  adjacent  to  the  dilated  ven- 
tricles in  hydrocephalus  internus  is  anemic  from  compression.  The  fainting 
due  to  sudden  emotion,  such  as  fright,  is  ascribed  to  a  withdrawal  of  blood 
from  the  brain. 

Morbid  Anatomy. — This  is  more  distinctive  than  in  hyperemia.  The 
membranes  are  pale,  the  blood  in  their  vessels,  except  the  larger  ones,  is 
scanty,  and  over  the  convolutions  the  vessels  are  quite  empty.  The  gray 
and  the  white  matter  are  both  pale  on  section,  and  the  puncta  vasculosa  are 
less  distinct  and  less  numerous.     The  cerebrospinal  fluid  is  increased. 


1034  DISEASES  OF  THE  NERVOUS  SYSTEM 

Symptoms. — Some  of  these  are  definite  and  the  direct  result  of  loss  of 
blood  to  the  brain.  Such  are  the  dizziness,  confusion  of  ideas,  flashings  of 
light,  roaring  in  the  ears,  nausea,  and  ultimate  loss  of  consciousness  and  even 
death  which  succted  hemorrhages  or  emotion.  In  other  cases  the  skin  is 
cold  and  clammy,  and  a  cold  perspiration  starts  to  the  surface.  Other 
symptoms  are  less  distinctive.  They  are  ascribed  to  chronic  anemia,  but 
may  result  also  from  other  causes.  Such  are  mental  apathy,  disinclination 
to  work,  a  sleepy  feeling  during  the  day,  and  insomnia  at  night.  Nausea, 
headache,  tinnitus,  vertigo,  hallucinations,  and  delirium  are  also  conse- 
quences more  particularly  of  lowered  composition  of  the  blood,  of  anemia,  in 
fact,  the  result  of  prolonged  illness,  like  pulmonary  consumption  and  Bright's 
disease.  The  con\ailsions  characteristic  of  the  latter  disease  have  been 
ascribed  to  anemia  and  also  to  edema  of  the  brain. 

The  hydrocephaloid  symptoms,  described  by  Marshall  Hall  as  the  direct 
results  of  prolonged  diarrhea  and  of  cholera  infantmn  in  children,  are  re- 
garded as  results  of  anemia.  They  include  semistupor  with  eyes  unclosed, 
later,  dilated  pupUs,  strabismus,  convulsions,  rigidity,  and  death. 

Treatment. — The  immediate  consequences  of  the  acute  form  of  anemia 
are  diminished  or  averted  by  placing  the  patient  on  the  flat  of  the  back  with 
the  head  low ;  by  diffusible  stimulants,  of  which  ammonia  is  the  type ;  also 
cardiac  stimulants,  and  nourishing  and  easily  assimilable  foods.  The 
chronic  forms  of  brain  anemia  are  treated  by  nutritious,  easily  assimilable 
foods,  and  tonics,  especially  iron  and  arsenic.  In  the  hydrocephaloid  con- 
dition in  infants  alcohol  is  the  pre-eminent  remedy,  associated  ■with  warm 
baths  and  general  restorative  measures. 

EDEMA  OF  THE  BRAIN. 

Definition. — The  term  includes  two  conditions,  the  most  definite  and 
easily  recognizable  of  which  is  an  abnormal  accumulation  of  cerebrospinal 
fluid  within  the  pia  arachnoid.  In  the  second  condition  there  is  added  to 
the  first  an  abnormal  moistness  of  the  substance  of  the  brain. 

Etiology. — The  most  common  cause  is  mitral  stenosis,  although  any  cause 
obstructing  the  return  of  blood  from  the  brain  as  well  as  recurring  irritative 
hyperemias,  such  as  are  produced  by  alcoholism  and  the  psychoses,  are  also 
causes.     Bright's  disease  is  a  cause  of  edema  of  the  brain,  local  or  general. 

Local  edemas  of  the  brain  are  also  caused  by  obstruction  of  single  sinuses 
of  the  dura  mater,  or  compression  by  tuberculous  or  other  tumors  of  the 
veins  of  the  velum  interpositum,  known  as  the  vencE  Galeni. 

Morbid  Anatomy. — The  membranes  are  turbid,  their  ^'essels  are  dis- 
tended and  scrj^entine  in  their  course,  and  the  subarachnoid  space  is  filled 
with  clear  fluid.  The  substance  of  the  brain  is  anemic,  moist,  and  glistening. 
In  extreme  cases  there  is  compression  of  the  cortex,  ^\'ith  resulting  flattening 
of  the  convolutions  and  widening  of  the  sulci.  The  fluid  in  the  lateral 
ventricles  m.ay  also  be  increased. 

Symptoms. — These  are  ill  defined.  There  may  be  hallucinations  and 
even  mania,  very  similar,  in  fact,  to  those  of  anemia.  Traube  and  Rosen- 
stein  ascribed  the  convulsions  of  Bright's  disease  to  edema  of  the  brain,  while 
certain  unilateral  convulsions  and  paralysis  in  connection  with  this  disease 


APOPLEXY  1035 

have  been  assigned  to  the  same  cause.  Even  death  has  been  ascribed  to 
sudden  serous  effusions  of  this  kind,  constituting  acute  edema  of  the  pia 
mater,  or  apoplexia  serosa.  In  recent  years  much  has  been  written  on  cere- 
bral edema  under  the  name  of  meningitis  serosa. 

Treatment. — The  treatment  is  that  of  the  conditions  to  which  the  symp- 
toms are  secondary.  The  effects  of  cardiac  stenosis  must  be  overcome  by 
cardiac  stimulants;  Bright's  disease  must  receive  appropriate  treatment. 
Thrombosis  of  the  sinuses  admits  of  no  treatment,  though  its  effects  may 
diminish  by  gradual  contraction  and  possible  liquefaction  and  removal  of 
the  thrombus.  The  psychoses  shoud  receive  treatment  appropriate  to 
them. 

APOPLEXY. 

Definition. — The  term  apoplexy  is  applied  to  a  sudden  loss  of  motor 
power  with  or  without  loss  of  consciousness  due  to  cerebral  hemorrhage,  or 
the  sudden  plugging  of  a  blood-vessel.  Laceration  of  the  brain  without 
hemorrhage  produces  a  like  effect.  In  point  of  fact,  when  the  term  apoplexy, 
is  used,  cerebral  hemorrhage  is  commonly  intended. 

Unconsciousness  may  also  be  produced  by  simple  congestion,  and  it 
was  formerly  thought  that  a  simple  serous  transudate  could  produce  similar 
symptoms  in  a  milder  form  and  of  shorter  duration;  whence  the  term  "ser- 
ous apoplexy."     Concussion  of  the  brain,  also,  causes  similar  symptoms. 

I.  Cerebr.\l  Hemorrhage. 

Arterial  Distribution. — In  the  first  place  hemorrhage  is  meningeal  or 
central.  Meningeal  hemorrhage  may  be  outside  of  the  dura  mater  between 
it  and  the  bone,  or  between  the  dura  and  the  arachnoid,  or  within  the  pia 
arachnoid.  The  extradural  and  subdural  meningeal  hemorrhages  are  both 
traumatic,  one  variety  of  which  is  produced  during  birth,  but  those  in  the 
pia  arachnoid  are  due  to  the  causes  to  be  considered  below.  Central  hem- 
orrhages may  also  burst  into  the  membranes  as  well  as  into  the  ventricles 
of  the  brain  and  in  some  instances  the  hemorrhage  is  almost  entirely  intra- 
ventricular. Meningeal  hemorrhage  may  occur  in  the  infectious  fevers,  in 
leukemia,  and  in  anemia. 

It  is  a  rare  event  to  find  a  rupture  in  any  of  the  large  arteries  of  the  circle 
of  Willis,  although  white  patches  of  atheroma  are  often  seen  upon  them  at 
autopsy.  But  the  free  anastomosis  of  this  circle  scarcely  allows  of  increase 
of  intravascular  pressure  sufficient  to  cause  rupture.  Further,  it  is  the 
"central,"  rather  than  the  "cortical"  branches  of  this  circle  which  rupture, 
and  especially  the  central  branches  of  the  middle  cerebral,  which,  entering  the 
brain  at  the  anterior  perforated  space,  pass  to  the  corpus  striatum  and  inter- 
nal capsule. 

Etiology. — Disease  of  the  artery  involved  is  responsible  for  the  vast 
majority  of  cerebral  hemorrhages.  Indeed,  except  in  the  case  of  traumatic 
hemorrhages  either  with  or  without  fracture  of  the  skull,  it  is  very  doubtful 
whether  hemorrhage  ever  occurs  without  such  disease.  The  simplest  form 
is  the  fatty  degeneration  and  "erosion"  of  the  intima,  characteristic  of 
advanced  age.     Endarteritis,  however  produced,  is  perhaps  the  most  fre- 


1036  DISEASES  OF  THE  XERVOUS  SYSTEM 

quent  cause.  Its  ultimate  result,  as  shown  by  Charcot  and  Bouchard 
as  far  back  as  1868,  is  the  miliary  aneurysm  which  very  frequently  precedes 
the  rupture.  It  is  a  spindle-shaped,  rarely  lateral,  dilatation,  from  i  25 
to  1/5  inch  (i  to  s  mm.)  in  diameter.  The  inflammatory  process  preceding 
it  consists  in  a  proliferation  and  degeneration  of  the  intima  cells,  followed  by 
atrophy,  which  extends  also  to  the  muscular  layer  and  the  scanty  adventitia. 
These,  yielding  to  the  intravascular  pressure  at  the  weak  points,  dilate  to 
form  the  little  aneurysm,  which  is  later  ruptured  by  some  further  increment 
of  pressure.  Embolism  is  also  a  cause  of  endarteritis  which  may  result  in 
aneurysm. 

The  "fatty  erosion  "  of  the  intima  which  is  the  next  most  frequent  cause 
of  vulnerability  is  favored  by  age,  by  chronic  interstitial  nephritis,  and  the 
overstrain  of  the  vessels  due  to  hypertrophy  of  the  left  ventricle,  so  often 
associated  with  that  disease  as  well  as  with  valvular  heart  disease. 

While  by  far  the  larger  majority  of  hemorrhages  are  preceded  by  miliary 
aneurysm  or  fatty  erosion — fully  nine  out  of  ten — there  still  remain  a  number 
of  instances  in  which  careful  search  fails  to  find  an\'thing  but  diffuse  degenera- 
tion; whence  the  miliary  aneurysm  and  fatty  erosion  cannot  be  regarded  as 
indispensable  conditions.  The  infectious  fevers,  leukemia,  and  anemia  are 
also  causes  of  hemorrhage  which  is  independent  of  miliary  aneurysm. 

Age  is  also  a  predisposing  factor,  most  ruptures  occurring  after  50, 
although  apoplexy  has  occurred  under  ten;  while  the  occupations  and  dissi- 
pations of  men  furnish  additional  predisposing  elements  which  accounts  for 
its  greater  frequency  in  the  male  sex.  Other  predisposing  causes  are  those 
usually  responsible  for  endarteritis — viz.,  gout,  alcohol,  syphilis,  Bright's 
disease,  the  apoplectic  habit,  as  seen  in  the  stout,  short-necked,  full-blooded 
individual;  and,  finally,  heredity,  which  is,  strictly  speaking,  a  hereditary 
tendency  to  the  favoring  diseases. 

The  exciting  causes  are  such  as  temporarily  increase  intravascular  pres- 
sure, as  violent  exertion,  straining,  debauch  in  eating  and  drinking,  and  men- 
tal emotion. 

Morbid  Anatomy. — The  large  central  ganglia  in  the  neighborhood  of  the 
lateral  ventricles — i.  e.,  the  optic  thalami,  the  caudate  and  lenticular  nuclei , 
and  the  adjacent  white  matter  of  the  internal  capsule  and  centrum  ovale — ■ 
are  the  favorite  seats  of  miliary  aneurysm  and  consequent  hemorrhage. 
These  aneurysms  are  found  also,  but  much  more  rarely,  in  the  smaller 
branches  of  the  cortical  vessels,  in  the  pons,  cefebellum,  crura  cerebri,  or  me- 
dulla oblongata.  On  section  of  the  large  ganglia  these  may  be  seen  as  small 
dark  points,  as  large  as  a  pin's  head,  and  are  often  very  distinct  in  arteries 
drawn  out  of  the  substance  of  the  brain,  especially  the  anterior  perforated 
space.  Larger  aneurysms  are  also  found  on  the  branches  of  the  circle  of 
Willis. 

Given  a  massive  hemorrhage,  what  is  its  effect  on  the  brain  substance, 
and  what  are  the  changes  in  the  extravasated  blood?  The  former  varies 
somewhat  with  its  situation.  If  extradural,  the  dura  mater  is  torn  avv-ay 
from  the  bone  to  a  varxnng  extent.  If  subdural  or  beneath  the  pia  arachnoid, 
it  separates  these  membranes  from  the  brain  substance,  but  in  either 
event  the  convolutions  are  more  or  less  flattened  and  the  sulci  more  or  less 
obliterated. 


APOPLEXY  1037 

As  already  stated,  central  hemorrhage  most  frequently  occurs  in  the 
neighborhood  of  the  corpus  striatum,  through  which,  if  large,  the  blood 
finds  it  way  toward  the  outer  section  of  the  lenticular  nucleus,  pushing  inward 
the  optic  thalamus  and  bursting  into  the  lateral  ventricle  or  into  the  white 
matter  of  the  centrum  ovale.  The  pressure  exerted  is  often  such  as  to  flat- 
ten the  convolutions,  empty  the  parietal  veins,  and  press  the  falx  aside, 
sometim.es  even  to  produce  a  sense  of  fluctuation  over  the  membranes. 
Hemorrhages  m.ay  occur  rarely  in  the  crura  or  pons  or  fourth  ventricle,  and 
also  in  the  cerebellum,  occasionally  from  the  superior  cerebellar  artery. 
Osier  mentions  two  cases  of  death  in  women  of  twenty-five  from  cerebellar 
hem-orrhage.  Very  rarely  hemorrhages  into  the  ventricle  may  start  in  the 
choroid  plexus  or  the  ventricular  walls.  Blood  in  large  quantities  may  be 
poured  out  at  the  base  of  the  brain,  and  it  may  flow  down  upon  the  cord 
from  a  rupture  of  any  of  the  arteries  going  to  or  from  the  circle  of 
WilHs. 

If  the  patient  sur\nves,  changes  take  place  in  the  extravasated  blood, 
which  promptly  coagulates  into  a  dark  red  mass.  This  almost  immediately 
begins  to  contract,  permitting  often  the  return  of  a  certain  degree  of  func- 
tion by  removing  pressure.  As  time  elapses  the  dark  red  mass  passes  into  a 
chocolate-brown  pulp,  composed  of  liquef}ang  blood-clot  and  disintegrated 
nervous  matter.  The  microscope,  at  this  stage,  reveals  numerous  hema- 
toidin  crystals  and  granular  fat-cells  which  are  probably  fatty  by  imbibition 
of  fat-granules.  The  adjacent  nervous  tissue  is  stained  yeUow  by  the  ab- 
sorbed hematoidin.  The  clot  itself  becomes  encapsulated  by  fibrin  and 
gradually  absorbed,  being  often  substituted  by  a  semitransparent  or  com- 
pletely transparent  fluid,  forming  the  apoplectic  cyst.  If  smaller,  the  walls 
approach  and  unite,  leaving  only  a  linear  pigmented  scar.  Especially  is  this 
the  case  with  small  clots  on  the  surface  of  the  convolutions,  which  may  leave 
only  a  staining  of  the  membranes.  In  other  cases  of  abundant  cortical 
effusion,  especially  in  infants,  there  may  be  circumscribed  wasting  of  the 
convolutions  and  a  cyst  of  the  meninges  or  brain.  The  position  and  extent 
of  the  permanent  lesion  determine  the  presence  of  secondarj'  descending 
degeneration.  If  the  motor  cortex  or  motor  tract  is  involved,  there  may  be 
found,  in  persons  dying  some  years  after  a  stroke  of  apoplexy  with  hemi- 
plegia, degeneration  in  the  pyramidal  fibers  of  the  pons  and  medulla  oblon- 
gata, in  the  direct  pyramidal  fibers  of  the  cord  of  the  same  side,  and  in  the 
crossed  pyramidal  fibers  of  the  opposite  side,  and  to  some  extent  in  the 
crossed  pvramidal  fibers  of  the  same  side. 

Symptoms. — Premonitory  signs  are  rarely  present.  There  may  be 
a  feeling  of  fullness  in  the  head,  headache,  tinnitus,  vertigo,  or  numbness, 
tinghng,  pains  in  the  limbs  on  one  side,  loss  of  memory  of  words  or  chorei- 
form movements — prehemiplegic  chorea — possibly  due  to  miliary  aneurysm 
or  otherwise  diseased  vessels. 

With  the  bursting  of  a  vessel  of  sufficient  size  there  occurs  the  apoplectic 
"stroke,"  or  apoplectic  shock.  Its  most  striking  feature  is  sudden  loss  of 
consciousness.  If  complete,  the  patient  falls  heavily  to  the  ground,  and  there 
may  be  slight  convulsive  movement,  but  it  soon  ceases.  More  rarely  a  true 
convulsion  ushers  in  the  attack.  The  patient  cannot  be  aroused,  the  face 
is  suffused,  cyanotic — sometimes,  however,  pale;  the  breathingis  slow,  noisy, 


1038  DISEASES  OF  THE  XERVOUS  SYSTEM 

stertorous  often  attended  with  a  pufling  sound  during  expiration;  corre- 
sponding with  a  blowing  out  of  the  relaxed  cheek  on  the  paralyzed  side ;  it 
may  also  be  of  the  Cheyne-Stokes  type.  In  contrast  with  the  foregoing,  the 
development  of  unconsciousness  is  sometimes  much  more  gradual,  requiring 
several  hours  or  a  day,  corresponding  to  which  it  is  presumed  that  the  hem- 
orrhage is  slow,  constituting  the  "ingravescent  form." 

The  second  major  symptom  of  apoplexy  is  motor  paralysis,  of  which 
hemiplegia  is  the  most  conspicuous  form.  In  most  cases  the  motor  pyram- 
idal tract,  as  it  descends  in  the  internal  capsule,  is  either  directly  destroyed 
or  indirectly  affected.  Hence  most  patients  who  survive  the  primary 
shock  present  a  hemiplegia — paralysis  of  half  the  body  opposite  that  of  the 
hemorrhage,  and  most  frequent  on  the  right  side.  It  is  most  noticeable  in 
the  arms  and  legs.  These  are  thoroughly  relaxed,  falling  limp  when  allowed 
to  drop,  as  the  limb  of  one  thoroughly  etherized.  More  rarely  there  is  earlj^ 
rigidity,  especially  on  the  paralyzed  side.  Reflex  action  is  early  either  totallj'- 
suspended  or  only  brought  out  in  response  to  a  deep  pin  thrust  or  severe 
pinching. 

The  signs  of  hemiplegia  are  not  always  easily  elicited  at  first,  because  a 
certain  degree  of  consciousness  is  necessary  to  stimulate  attempt  at  motion, 
but  it  may  be  that  the  angle  of  the  mouth  hangs  down  lower  on  one  side — 
the  paralyzed  side — while  the  puffing  of  the  cheek  alluded  to  may  be  present 
on  the  same  side,  or  the  limbs  of  one  side  may  be  appreciably  more  flaccid 
than  those  of  the  other,  or  a  small  amount  of  reflex  response  may  be  elicited 
on  the  sound  side.  The  pulse  is  usually  slow,  full,  strong,  and  tense.  The 
temperature  may  be  subnormal  at  first,  rising  to  normal  and  even  above, 
and  in  basal  hemorrhage  may  be  higher.  In  a  rapidly  fatal  case  it  remains 
subnormal  to  the  end.  The  pupils  are  irregular — i.e.,  sometimes  contracted, 
at  others  dilated,  unequal.  They  respond  to  light  either  slowlj'  or  not  at  all. 
If  the  hemorrhage  is  where  it  can  irritate  the  nucleus  of  the  third  nerve, 
the  pupil  is  contracted.  This  ma\^  occur  with  hemorrhage  into  the  pons  or 
ventricles. 

In  cortical  lesions  quite  often  one  of  the  early  s\Tnptoms  in  hemiplegia  is 
conjugate  deviation  from  the  paralyzed  side  and  toward  the  side  of  lesion, 
from  which  we  have  the  expression  that  "the  patient  looks  at  the  lesion;" 
that  is,  in  right  hemiplegia  the  head  and  eyes  look  toward  the  left  side. 
This  symptom  usually  passes  away,  but  sometimes  continues  for  weeks, 
and,  as  Gowers  suggests,  is  perhaps  occasionally  represented  by  nystagmus 
or  movement  in  the  direction  concerned.  Should,  however,  convulsion,  or 
spasm,  or  early  rigidity  develop,  the  head  and  eyes  are  rotated  toward 
the  paralyzed  side — i.  e.,  away  from  the  side  of  lesion.  This  is  true  only  of 
cortical  lesions. 

In  lesions  of  the  pons,  on  the  other  hand,  where  the  conjugate  deviation 
may  also  occur,  the  phenomena  are  reversed — the  patient  looks  away  from 
the  lesion,  in  the  absence  of  spasm — but  if  the  convulsion  or  spasm  or 
rigidity  occur,  the  eyes  and  head  look  toward  the  lesion.  These  facts  are  a 
little  confusing  at  first  and  may  be  expressed  in  the  following. 

In  lesion  of  the  cortex — 

Without  spasm,  conjugate  deviation  is  toward  the  side  of  lesion. 
With  spasm  or  con\ailsion  or  early  rigidity, /rom  the  side  of  lesion. 


APOPLEXY  1039 

In  lesion  of  the  pons — 

Without  spasm,  from  lesion. 
With  spasm,  etc.,  toward  lesion. 

This  may  be  due  to  the  fact  that  these  movements  in  health  are  in- 
nervated from  both  sides,  and  when  a  lesion  occurs  on  one  side  of  the  cere- 
brum, the  innervation  is  given  over  to  the  other  side  until  the  injured  one 
resumes  its  function.  In  pontile  lesions  the  destruction  occurs  possibly 
below  the  decussation  of  the  fibers  innervating  the  parts  affected  in  the 
conjugate  deviation  and  the  symptoms  are  reversed.  Conjugate  deviation 
in  lesions  of  the  pons  is,  however,  a  rare  phenomenon. 

Where  unconsciousnes  exists  the  feces  and  urine  are  passed  involuntarily, 
and  the  latter  is  sometimes  slighth^  albuminous. 

As  to  further  progress  in  a  few  cases  there  is  no  reaction  from  the  previ- 
ously described  condition.  The  s^rmptoms  all  deepen,  the  breathing 
becomes  rapid  and  rattling,  the  skin  cool,  the  pulse  weak  and  rapid,  and  the 
patient  dies.  In  most  cases,  however,  there  is  a  certain  abatement  of  the 
symptoms,  even  if  the  patient  does  not  recover  more  fully.  Consciousness 
returns  partially  or  completely,  the  patient  can  be  aroused  by  a  loud  voice, 
and  one  can  recognize  which  side  is  paralj^zed.  There  may,  at  this  time,  be 
a  febrile  movement,  due  to  cerebral  inflammation  or  disruption  of  heat- 
regulating  centers,  during  which  the  patient  may  die;  or  there  may  be 
another  hemorrhage  which  carries  him  off. 

On  the  other  hand,  improvement  may  continue  to  a  further  degree. 
The  consciousness  and  intelligence  may  return  completely,  and  the  signs 
of  paralysis  may  gradually  grow  less,  more  rapidly  in  the  legs  than  in  the  arms. 
They,  however,  almost  never  disappear  completeh^  the  patient  continuing 
lame  and  requiring  the  use  of  a  cane  for  the  rest  of  his  life.  In  severe  cases  a 
remnant  of  paralysis  of  the  face  can  almost  always  be  recognized,  while 
articulate  speech  may  also  continue  defective. 

Such  marked  improvement  is,  for  the  most  part,  reserved  for  the  milder 
attacks,  in  which  there  is  great  variety  as  to  degree.  In  such  the  loss  of 
consciousness  is  of  short  duration,  or  it  may  not  occur  at  all.  Such  attacks 
are  not  infrequently  ushered  in  by  nausea,  vomiting,  vertigo,  or  sudden 
headache.  The  paralytic  symptoms  may  still  be  marked,  and  permit  a 
study  rather  more  satisfactory  than  the  fulminating  cases.  In  such  stud}- 
it  will  be  found  that  all  muscles  are  by  no  means  equally  paralyzed.  Thus 
it  will  be  seen  that  the  lower  division  of  the  facial  nerve,  which  supplies  the 
muscles  of  the  cheek,  nose,  and  mouth,  is  plainly  paralyzed;  while  the  upper 
division,  distributed  to  the  muscles  of  the  eyes  and  forehead,  is  almost, 
if  not  entirely,  intact.  The  forehead  may  be  wrinkled  with  equal  ease  on 
the  two  sides,  but  an  attempt  to  draw  up  the  nose  or  purse  the  mouth  fails, 
while  one  labionasal  fold  may  be  obliterated  and  one  angle  of  the  mouth 
lower  than  the  other.  The  natural  wrinkles  of  the  forehead  are  commonly 
less  distinct  on  the  paralyzed  side  than  on  the  other.  This  event — the 
comparative  freedom  from  paralysis  in  the  upper  part  of  the  face — may  be 
explained  by  the  fact  that  while  both  sides  of  the  face  receive  fibers  from 
each  cerebral  hemisphere,  this  is  especially  true  of  the  muscles  of  the  upper 
part  of  the  face,  which  are  always  exercised  bilaterally. 

The  tongue  may  not  be  paralyzed,  but  when  it  is,  if  protruded,  it  usually 


1010  DISEASES  OE  THE  NERVOUS  SYSTEM 

Ijut  not  always  goes  toward  the  paralyzed  side,  being  pushed  out  by  the 
geniohyoglossal  muscle  of  the  other  side,  the  innervation  being  by  the  hypo- 
glossal nerve.  Oecasionally  paralysis  of  the  tongue  contributes  to  difficulty. 
in  articulation.  The  motor  branch  oft  he  fifth  ners^e  is  sometimes  involved 
on  the  hemiplegic  side,  and  there  is  paralysis  of  the  pterygoid,  temporal,  and 
masseter  muscles. 

Of  the  trunk  muscles,  the  trapezius  is  most  involved,  and  that  but  slightly, 
permitting  the  shoulder  to  drop  a  little,  and  the  paralyzed  side  of  the  chest 
may  expand  more  than  the  normal  side  in  ordinary  breathing,  while  in 
voluntary  deep  breathing  this  is  not  the  case.  The  reason  of  this  possibly 
may  be  found  in  the  exaggeration  of  the  reflexes  on  the  paralyzed  side; 
ordinary  breathing  being  a  reflex  action. 

Sensation  is  but  slightly  impaired  in  most  cases  of  hemiplegia  due  to 
cerebral  hemorrhage,  and  such  impairment  usually  grows  rapidly  less  as 
time  elapses,  unless  the  optic  thalamus  is  seriously  damaged.  It  is  hemi- 
anesthesia when  anesthesia  exists,  and  it  is  on  the  side  opposite  that  of  the 
lesion.  There  may  also  be  trifling  paresthesia  at  first.  Any  marked  dis- 
turbance of  sensation  means  that  the  posterior  extremity  of  the  internal 
capsule  is  involved,  or,  according  to  some  authors,  it  indicates  that  the 
optic  thalamus  is  invaded.  Distinct  impairment  of  the  deep  sensibility — 
the  so-called  muscular  sense  or  sense  of  position — may  indicate  a  lesion  of 
the  parietal  lobe.  There  is  sometimes  temporary  and  even  permanent 
hemianopia,  which  implies  some  lesion  of  the  fibers  of  the  optic  radiation 
posterior  to  the  internal  capsule  or  in  the  posterior  portion  of  the  optic 
thalamus — the  pulvinar. 

Astereognosis  or  the  inability  to  recognize  objects  by  touch  is  sometimes 
a  symptom. 

The  tendon  reflexes  are  increased  in  nearly  all  cases  on  the  paralyzed 
side,  though  at  the  very  beginning  of  a  severe  shock  they  may  be  abolished, 
and  if  this  abolition  of  the  reflexes  persists,  it  is  regarded  as  a  serious  sign. 
In  cases  of  any  duration  even  the  periosteal  reflexes  are  increased,  and  to  a 
less  degree  the  reflexes  of  the  sound  side  are  increased,  because  each  side  of 
the  body  is  innervated  from  both  sides  of  the  brain,  although  the  number  of 
fibers  passing  to  the  same  side  of  the  body  is  considerably  less  than  those 
passing  to  the  opposite  side.  There  is  even,  at  times,  ankle  clonus,  and, 
more  rarely,  wrist  clonus.  These  events  are  explained  by  supposing  a 
suspension  of  the  inhibitory  reflex  cortical  centers,  due  to  the  cerebral  lesion. 
The  skin  reflexes,  on  the  other  hand,  are  diminished  on  the  paralyzed  side, 
remaining  normal  on  the  sound  side. 

The  rapid  improvement  mentioned  as  occurring  in  some  cases  is  usually 
confined  to  a  few  weeks  or  days,  after  which  improvement  goes  on  more 
slowly,  the  lower  extremities  recovering  more  completeh'  than  the  upper. 
The  gait  resulting  from  partial  recovery  is  peculiar.  Short  steps  are  taken 
by  the  affected  leg,  and  the  toe  is  dragged  more  or  less,  while  locomotion  is 
sometimes  accomplished  by  sweeping  the  leg  around  in  a  semicircle  by  the 
iliacus  and  psoas  and  the  vastus  externus,  while  it  is  held  stiff,  as  in  a  splint, 
by  the  quadriceps  extensor  muscle.  In  the  upper  limb  the  hand  muscles 
are  the  last  to  recover. 

Later  in  the  historv  of  the  case  contractures  may  come  on  in  the  para- 


APOPLEXY  1041 

lyzed  muscles,  shown  especially  in  flexion  of  the  fingers,  contracture  of  the 
forearm  in  a  position  of  pronation,  and  partial  flexion,  with  the  upper  arm 
adducted.  The  lower  extremity  is  usually  in  the  position  of  extension. 
This  contracture  is  explained  by  some,  and  notably  by  StriimpeU,  as  a 
"passive  contracture,"  the  position  assumed  being  the  natural  one  in  a  state 
of  rest.  On  the  other  hand,  Charcot  and  his  pupils  hold  that  the  contractures 
are  due  to  secondary  degeneration  of  the  pyramidal  tract.  It  is  very  doubt- 
ful whether  secondary  degeneration  produces  sj^mptoms. 

There  are  also  sometimes  associated  movements  of  the  paralyzed  muscles, 
to  which  Hitzig  has  called  attention.  In  these,  movements  of  the  sound 
side  excite  associated  movements  in  the  corresponding  muscles  of  the  other 
side,  and  attempts  to  move  the  affected  side  result  in  motion  of  correspond- 
ing muscles  of  the  sound  side.  Sometimes,  also,  involuntary'  movements  of 
the  lower  extremity  occur  when  the  patient  attempts  to  move  the  corre- 
sponding arm.  A  posthemiplegic  chorea,  first  described  by  Weir  Mitchell, 
should  also  be  mentioned.  It  is  seen  not  so  much  in  the  hemiplegia  resulting 
from  cerebral  hemorrhage  as  from  focal  disease  of  the  posterior  end  of  the 
internal  capsule  and  optic  thalamus.  A  form  of  hypertonia  has  recently 
been  described  in  which  the  muscles  are  in  a  state  of  exaggerated  tonicity 
without  much  paralysis.  In  this  condition  the  position  of  the  spastic  limbs 
varies  from  time  to  time.  It  is  seen  in  some  cases  in  which  a  cerebral  lesion 
has  occurred  early  in  life. 

Trophic  symptoms  may  appear  late  in  the  disease,  seen  at  first  in  elevation 
of  temperature,  increase  of  color  on  the  paralyzed  side  of  the  face,  swelling 
of  the  eyelids,  and  contraction  of  the  pupil;  also  swelling  of  the  hands.  It 
is  to  be  remembered,  however,  that  slight  swelling  may  resiolt  from  sluggish 
circulation  of  blood  and  lymph,  contributed  to  by  diminished  muscular 
contraction  and  absence  of  use.  In  a  more  advanced  stage  the  extremities 
become  cooler  and  are  often  constantly  moist.  Among  these  vasomotor 
events  Charcot  has  placed  what  he  calls  acute  malignant  decubitus — a  dis- 
position to  rapid  gangrene  of  the  tissues  over  the  sacrum.  It  may  appear  in 
a  few  days  after  the  shock,  beginning  with  a  circumscribed  redness  and 
formation  of  vesicles,  succeeded  by  deep-reaching  necrosis.  While  this  is 
probably,  as  Charcot  regards  it,  a  vasomotor  phenomenon,  it  is  also  invited 
by  the  usual  causes  of  gangrene  in  dorsal  decubitus,  such  as  irritation  by 
urine,  feces,  and  even  inequalities  in  the  bed-clothing.  Charcot  also  con- 
siders an  occasional  arthritis,  acute  or  chronic,  a  neuropathic  event. 

General  nutrition  is  well  maintained,  the  patient  even  gaining  in  flesh  at 
times.     More  rarely  there  is  rapid  wasting. 

The  mental  condition  of  patients  who  recover  partially  from  the  effects 
of  hemorrhage  is,  for  the  most  part,  good,  but  it  not  infrequently  happens 
that  after  a  time  mental  weakness  manifests  itself  in  loss  of  memory  and 
defective  intellection,  while  imbecility  sometimes  ultimately  supervenes. 

Diagnosis. — The  greatest  difficulty  lies  in  the  differential  diagnosis 
between  cerebral  hemorrhage,  embolism,  thrombosis  and  cerebral  sclerosis. 
We  will,  however,  defer  its  consideration  until  cerebral  embolism  and  throm- 
bosis are  treated. 

In  fulminating  cases  the  coma  is  sometimes  so  profound  that  it  is  difficult 
or  impossible  to  ascertain  the  presence  of  hemiplegia.     The  symptoms 


1042  DISEASES  OF  THE  NERVOUS  SYSTEM 

which  aid  in  determining  this  have  been  mentioned  on  page  1038.  To  these 
may  be  added  the  increase  of  reflexes  on  the  affected  side,  present  in  an  early 
stage  of  the  paralysis,  conjugate  deviation  of  the  head  and  eyes,  and  rigidity 
of  limbs  on  one  side.  It  is  this  condition  that  is  sometimes  confounded  with 
epilepsy,  opium  poisoning,  acute  alcoholism,  or  uremia.  In  epilepsy  there 
is  the  history  of  previous  convulsions,  and  it  is  only  when  this  has  been  over- 
looked that  mistakes  occur.  In  opium  poisoning  the  coma  is  slow  in  its 
onset,  the  pupils  are  uniformly  contracted,  and  the  odor  of  laudanum  is 
often  on  the  breath.  But  here,  too,  the  victim  is  often  only  discovered  after 
coma  has  thoroughly  developed.  In  alcoholism  there  is  the  odor  of  whisky, 
but  many  an  innocent  person  has  been  treated  as  a  drunkard  on  whose 
brain  lay  a  clot  pressing  him  to  death.  The  young  ambulance  or  police 
surgeon  is  wise  who  defers  his  opinion.  Sometimes  alcoholism  and  apoplexy 
are  combined,  in  which  event  a  conservative  course  will  be  no  less  astute. 
The  coma  of  uremia  in  Bright 's  disease  very  strongly  simulates  that  of 
apoplexy,  especially  in  the  rare  cases  of  the  latter  in  which  there  are  con\Tal- 
sions.  The  presence  of  dropsy,  or,  in  its  absence,  of  the  peculiar  anemia  of 
Bright's  disease,  and  the  finding  of  albuminuria  and  casts  should  suggest 
this  disease,  but  albumin  may  be  found  in  hemiplegia  not  of  renal  origin. 
It  is  to  be  remembered,  too,  that  uremic  convulsion  may  terminate  in  hemor- 
rhage, while  Bright's  disease  is  also  associated  with  a  state  of  the  arteries 
which  disposes  them  to  rupture.  The  use  of  the  phthalein  test  will  make 
for  or  against  a  kidney  lesion.  Coma  in  a  puerperal  woman,  associated 
with  high  blood  pressure  dropsy  and  albuminuria,  means  taxaemia  of 
pregnancy. 

Prognosis. — To  have  had  a  stroke  of  paralysis  is  justly  regarded  as 
having  received  a  blow  which  marks  the  beginning  of  inevitable  decline  in 
health  and  usefulness,  though  cases  are  constantly  occurring  in  which  a 
"slight  stroke"  is  followed  by  complete  recovery.  Some  of  these  are  prob- 
ably errors  of  diagnosis,  many  being  temporary  loss  of  power  caused  by 
cerebral  sclerosis,  yet  all  are  not.  Minute  areas  of  softening  and  cortical 
hemorrhages  are  the  lesions  most  frequently  followed  by  recove^>^  After 
these  come  a  large  number  of  cases  of  first  attack,  from  which  the  patient 
recovers  quite  a  considerable  degree  of  health.  Second  attacks  are  prone  to 
occur,  which  usually  are  more  severe,  and  few  survive  a  third  serious  attack. 

The  unfavorable  cases  are  those  in  which  the  coma  is  profound  and 
lasting.  Such  are  hemorrhages  into  the  ventricles  and  corona  radiata, 
which  are  rapidly  fatal.  Meningeal  hemorrhages  are  serious,  but  less  so 
when  traumatic  than  when  due  to  diseases  of  the  vessels.  Cases  attended 
by  earl}^  and  persistent  fever  and  delirium  are  unfavorable,  as  are  also  cases 
complicating  renal  disease  and  alcoholism.  Hemorrhages  into  the  corpus 
striatum  and  internal  capsule  produce  persistent  hemiplegia,  followed  by 
contracture.  When  cases  survive  the  primary'  stroke  and  improvement  sets 
in,  this  is  much  more  rapid  in  the  first  few  weeks  than  later.  In  explanation 
of  this  it  has  been  held  that  the  s>'Tnptoms  thus  rapidly  removed  are  in- 
direct focal  symptoms,  due  to  pressure  of  the  clot  on  adjacent  nervous 
tissue,  while  those  more  slow  to  yield  are  the  result  of  destructive  lesion. 

Treatment. — The  patient  should  be  promptly  placed  in  a  horizontal 
position  iinth  the  head  raised.     This  is  of  the  greatest  importance,  as  it  con- 


APOPLEXY  1043 

stantly  happens  that  a  patient  in  whom  consciousness  is  returning  immedi- 
ately becomes  comatose  when  the  head  is  lowered.  He  should  then  be  bled 
if  the  blood  pressure  is  high  or  rising.  The  bleeding  should  be  accompanied 
by  a  laxative,  which  should  be  given  alone  if  there  be  any  reason  why  phle- 
botomy should  not  be  practiced.  In  view  of  the  unconscious  state  of  the 
patient  the  best  laxatives  are  croton  oil  and  elaterium.  Two  drops  of  the 
former  should  be  mixed  in  a  little  glycerin  or  oil  and  carried  to  the  back  part 
of  the  throat,  or  1/4  grain  (0.0165  gm-)  of  elaterium,  dissolved  in  a  small 
quantity  of  water,  may  be  given  in  the  same  way.  The  rectum  should  be  at 
once  cleaned  out  by  an  enema  of  warm  water.  An  ice-bag  should  be  placed 
on  the  top  of  the  head,  hot  water  and  mustard  to  the  feet,  while  counterirri- 
tation  may  also  be  applied  to  the  back  of  the  neck.  The  patient  should 
be  kept  in  bed  as  long  as  there  is  any  evidence  of  bleeding. 

Compression  of  the  carotid  artery,  formerly  recommended  and  practiced 
on  empirical  grounds,  has  received  the  indorsement  of  Horsley  and  Spencer, 
these  experimenters  having  found  that  bleeding  from  the  lenticulostriate 
artery  ceases  when  the  carotid  is  compressed.  It  is  especially  in  the  in- 
gravescent form  that  it  has  been  recommended. 

If,  after  bleeding  and  purgation,  the  pulse  continues  bounding,  the  ti7ic- 
ture  of  aconite,  veratrum  viride  or  nitro-glycerine  may  be  given  in  doses  of  a 
minim  every  half -hour  until  the  pulse  is  influenced.  lodid  of  potassium  can 
hardly  be  expected  to  promote  absorption  of  the  clot,  but  may  be  given  if 
syphilis  is  suspected.  It  may,  however,  facilitate  circulation  by  lowering 
peripheral  pressure. 

The  foregoing  treatment  is  for  the  period  immediately  succeeding 
hemorrhage.  The  remainder  of  treatment  consists  in  measures  to  protect 
the  patient  against  the  effect  of  decubitus  if  this  is  prolonged,  and  in  main- 
taining the  nutrition  of  muscles  and  protecting  against  contractures. 
The  former  is  accomplished  by  attending  to  the  secretions,  preventing 
the  irritation  of  the  body  by  putrid  urine  and  feces  or  foreign  substances  like 
bread-crumbs,  by  bathing  and  drying  the  body  thoroughly,  by  frequent 
changes  of  posture.  The  latter  will  also  guard  against  pneumonia,  which  is 
rather  prone  to  occur  on  the  paralyzed  side.  This  last  disease  may  also  be 
caused  by  the  inspiration  of  particles  of  food,  liable  to  happen  if  there  is  paraly- 
sis of  the  muscles  of  deglutition.  The  second  indication  is  met  by  massage, 
faradization,  and  gymnastics,  but  they  should  be  deferred  for  two  or  three 
weeks.  Warm  salt  baths  three  or  four  times  a  week  are  useful  to  the  same 
end.  Tonics  in  the  form  of  iron  in  small  doses,  quinin,  and  strychnin  may  be 
given,  but  alcohol  in  more  than  very  moderate  amounts  is  contraindicated. 

Operative  treatment  has  been  suggested  to  relieve  the  pressure  of  a  clot 
in  cerebral  hemorrhage.  When  the  clot  is  meningeal,  especially  after  frac- 
ture, operation  is  imperative.  Gushing  has  shown  that  a  rising  blood 
pressure  is  due  to  an  attempt  to  counteract  the  intracranial  pressure.  He 
advises  decompression  to  relieve  pressure  and  removal  of  the  colt  if  practic- 
able. Careful  attention  should  be  paid  to  the  facts  mentioned  under  topical 
diagnosis  with  a  view  to  determining  the  seat  of  hemorrhage  and  the  place 
to  trephine. 


1044  DISEASES  OF  THE  NERVOUS  SYSTEM 

II.  Embolism  and  Thrombosis  of  the  Cerebral  Vessels. 
A.  Of  Cerebral  Arteries. 

Synonyms. — Cerebral  Softening;  Acute  Softening. 

Definition. — By  embolism  is  meant  the  plugging  of  an  artery  by  a  foreign 
body  carried  by  the  blood-current  from  some  point  in  the  vascular  system  to 
a  situation  beyond  which  it  cannot  pass.  By  thrombosis  is  meant  plugging 
of  an  artery  or  vein  by  a  clot  formed  in  situ. 

Etiology. — Nature  and  Source  of  Embolism. — The  embolus  is  most 
frequently  a  vegetation  from  a  diseased  valve  in  the  left  ventricle.  Less 
commonly  it  is  a  fragment  of  a  clot  in  the  same  ventricle  or  in  the  auricular 
appendage  or  in  an  aneurysm,  or  it  may  be  a  calcareous  particle  from  an 
atheromatous  vessel  or  a  piece  of  thrombus  from  the  same.  Even  the  terri- 
tory of  the  pulmonary  veins  may  contribute  an  embolus.  Embolism  is  very 
much  more  frequent  in  chronic  valvular  disease  than  in  primary  acute 
endocarditis.  It  is  prone  to  occur  in  recurring  valvulitis,  and  especially  in 
malignant  mycotic  endocarditis.  Pregnancy  with  or  without  heart  disease, 
the  infectious  fevers,  and  blood  dyscrasiae  may  be  predisposing  causes. 

The  embolus  commonly  enters  the  brain  by  the  carotid,  especially 
the  left — which  furnishes  the  most  direct  course — thence  through  the  internal 
carotid  to  the  left  middle  cerebral  in  the  fissure  of  Sylvius ;  more  rareh^  by  the 
vertebral  and  the  posterior  cerebral  artery. 

Thrombosis. — In  thrombosis  there  is  also  plugging  of  a  vessel,  but 
by  a  clot  formed  in  situ,  which  is  either  primary  at  the  point  plugged  or 
secondary  about  a  previous  embolus.  Some  favoring  cause  commonly 
exists.  This  is  most  frequently  roughening  due  to  endarteritis,  with  or 
without  atheroma.  Weak  heart  and  blood  dyscrasias  are  also  predisposing 
causes.  Ligation  of  the  carotid  artery  is  sometimes  followed  by  thrombosis 
of  cerebral  vessels. 

The  vessels  most  frequently  affected  in  thrombosis  are  the  middle 
cerebral  and  the  basilar  in  its  course  or  at  its  bifurcation;  but  the  vertebral, 
the  posterior  cerebral,  and  the  branches  of  the  circle  of  Willis  maybe  plugged. 

Relative  Frequency  of  Thrombosis  and  Embolism. — Embolism  has  been 
thought  to  be  more  frequent  in  women,  but  of  79  cases  collected  by  Newton 
Pitt  at  Guy's  Hospital,  44  were  in  men  and  35  in  women.  Thrombosis  is 
considered  more  common  in  men.  Embolism  is  rare  in  children,  being  more 
frequent  at  from  20  to  50;  thrombosis  in  older  persons  at  from  50  to  70. 

Morbid  Changes  Due  to  Thrombosis  and  Embolism. — Degeneration 
and  softening  of  the  brain  are  the  direct  result  of  obstruction  of  its  arteries, 
and  occur  sooner  or  later  when  the  shutting  off  of  the  blood-supply  is 
sufficiently  complete.  The  process  generally  begins  within  24  hours  and 
the  minimum  time  required  to  complete  it  is  from  one  to  two  days.  The 
local  anatomical  product  of  embolism  is  much  less  distinctive  in  the  brain 
than  in  the  lungs  or  spleen.  Thus,  there  is  almost  never  a  distinct  hemor- 
rhagic infarct,  though  there  is  often  a  condition  resembling  it,  the  area  cut 
off  being  infiltrated  with  blood.  At  other  times  the  region  is  paler  than  in 
health  and  slightly  softer.  In  either  event  the  area  becomes  gradually 
infiltrated  with  serum  and  a  more  or  less  complete  liquefaction  results. 


CEREBRAL  THROMBOSIS  AND  EMBOLISM  1045 

presenting  a  reddish,  yellow,  or  white  color,  whence  the  terms  red  softening, 
yellow  softening,  or  white  softening.  These  variations  are  not  the  result  of 
any  essential  difference  in  the  nature  of  the  process,  as  was  formerly  thought, 
but  are  rather  accidental.  In  red  softening  the  softened  focus  happens  to 
contain  an  unusual  amount  of  extravasated  blood,  due  to  punctiform  hemor- 
rhage or  capillary  bleeding.  This  blood  melts  away  and  stains  the  softened 
mass.  In  yellow  softening  the  proportion  of  fatty  degenerated  cells  is  larger, 
and  it  is  found,  therefore,  chiefly  in  the  cortex,  where  cells  prevail.  In  white 
softening  there  are  few  or  no  cellular  elements,  hence  the  white  softening  is 
found  in  the  white  nervous  matter.  It  is  most  characteristically  seen  about 
tumors  and  abscesses.  As  the  gray  matter  of  the  cortex  is  also  the  most 
vascular  part  of  the  brain,  it  is  here  also  that  we  find  red  softening.  Certain 
superficial  yellow  spots  known  as  plaques  jaunes  are  found  at  times  on  the 
surface  of  the  cortex  in  old  persons.  They  are  sharply  circumscribed, 
measure  from  2  to  4  centimeters  (0.8  to  1.6  inches),  are  made  up  of  a 
yellow,  turbid  material  sometimes  crossed  by  trabeculae,  and  are  the  result  of 
fatty  degeneration  of  peripheral  cortical  arteries. 

Minutely  examined,  the  softened  areas  consist  of  fatty  granules  and  oil 
drops,  myelin  drops,  fragments  of  swollen  nerve  fibers,  fatty  graniilar  cells 
representing  fatty  neuroglia  and  nerve  cells,  or  leukoc}i;es  and  neuroglia 
cells,  and  perhaps  endothelial  cells  which  have  imbibed  the  oil  drops,  arising 
probably  from  disintegrated  nervous  matter.  In  the  3'ellow  softening 
these  constitute  the  sum  of  altered  materials.  In  red  softening  there  are 
added  in  the  early  stages  blood-disks,  later  pigment  grantiles  or  hematoidin 
crystals,  or  there  is  general  staining  by  dissolved  hemoglobin.  In  the  white 
softening  the  fragments  of  nerve  fibers  together  with  myelin  drops  make  up 
the  chief  bulk,  as  already  stated.  If  collateral  compensatory  circulation  is 
set  up  within  two  days,  the  destruction  may  not  go  so  far,  and  the  nen'ous 
elements  may  resume  their  function ;  or  if  this  does  not  occur  and  the  patient 
lives,  the  dead  and  disintegrated  tissue  may  be  gradually  absorbed  and 
eventually  be  replaced  by  a  cyst,  while  a  minute  focus  of  softening  maj'  be 
replaced  by  indurated  cicatricial  tissue.  If  the  embolus  is  derived  from  an 
infective  focus,  as  ulcerative  endocarditis,  an  abscess  may  result. 

Symptoms. — Neither  thrombosis  nor  embolism  of  the  cerebral  arteries 
is  always  followed  by  recognizable  symptoms.  All  the  large  arteries  of  the 
base  and  the  smaller  arteries  of  the  surface  anastomose  so  freely  that  the 
effects  of  obstruction  are  promptly  equalized.  Nay,  more;  it  is  not  un- 
usual to  find  at  the  necropsies  of  elderly  persons  yellow  spots  of  fatty  de- 
generation; the  plaques  jaunes  referred  to,  scattered  over  the  convolutions 
where  nothing  was  suspected  before  death.  Moreover,  softening  maj^  take 
place  in  the  "silent  regions"  without  exciting  suspicion. 

Very  different  is  it  with  obstruction  of  the  middle  cerebral  artery — the 
artery  of  the  fissure  of  Sylvius.  The  clinical  aspect  differs,  however,  accord- 
ing as  this  vessel  is  plugged  at  its  origin  or  a  little  further  on  in  its  course. 
Allusion  has  already  been  made  to  the  two  separate  systems  with  which 
the  brain  is  supplied — the  "cortical  arteries"  (Duret),  passing  to  the  cor- 
tex, and  the  "central"  arteries,  passing  to  the  central  ganglia.  The  cen- 
tral arteries  are  the  first  given  off  by  the  cerebral  branches  of  the  circle 
of  Willis,  and  are  terminal  arteries,  unprovided  with  anastomoses.     The 


1046  DISEASES  OF  THE  NERVOUS  SYSTEM 

cortical  arteries  spring  from  a  network  of  branches  of  the  cerebral  arteries 
in  the  pia  mater,  in  which  tolerably'  free  communication  exists  between  the 
tertiary  branches  of  the  same  trunk,  and  even  between  the  branches  of  differ- 
ent trunks.  These  two  systems  are,  however,  altogether  independent  of 
each  other,  and  no  anastomosis  takes  place  between  them,  the  zone  at  which 
they  meet  within  the  cerebral  substance  being  situated  about  an  inch  and  a 
half  below  the  cerebral  convolutions.  In  the  case  of  the  middle  cerebral 
artery,  when  it  is  obliterated  beyond  the  point  at  which  its  "central," 
branches  come  off,  the  superficial  parts  of  the  brain  are  alone  affected,  and 
since  its  branches  in  the  pia  mater  anastomose  with  those  of  the  anterior  and 
posterior  cerebrals,  there  may  be  no  softening  at  all,  and  but  a  temporary 
loss  of  function.  At  other  times  softening  does  occur,  the  exact  situation 
and  extent  of  which  vary  with  the  arteries  plugged.  The  blood-supply  of 
the  central,  frontal,  and  parietal  convolutions  being  more  or  less  cut  off, 
there  is  motor  paralysis  of  the  opposite  side  of  the  body,  and  as  the  lesion  is 
most  frequent  on  the  left  side,  there  are  right-sided  hemiplegia  and  aphasia; 
the  same  phenomena,  in  fact,  as  follow  hemorrhage,  and  which  may  be  per- 
manent or  transient ;  or  the  lesion  may  be  still  more  limited.  The  embolus 
may  lodge  in  the  artery  passing  to  the  third  frontal  convolution,  or  in  that 
of  the  ascending  frontal  or  ascending  parietal.  It  may  lodge  in  the  branch 
passing  to  the  supramarginal  or  angular  gyrus,  or  to  the  lowest  branch, 
which  is  distributed  to  the  upper  convolution  of  the  temporosphenoidal  lobe. 
If,  on,  the  other  hand,  the  seat  of  the  lesion  is  at  the  point  where  the  Sylvian 
artery  arises  from  the  internal  carotid,  the  central  ganglia  are  involved,  and 
there  is  almost  certain  to  be  softening  of  the  corpus  striatum  and  optic 
thalamus,  because  the  arteries  have  no  anastomoses,  while  the  cortex  escapes 
entirely  because  its  vessels  are  distinct. 

Diagnosis. — It  has  already  been  said  that  the  chief  difficulty  lies  in  the 
differential  diagnosis  between  cerebral  hemorrhage,  on  the  one  hand, 
and  embolism  and  thrombosis  on  the  other.  Sometimes,  indeed,  at  first  it  is 
impossible.  As  ■  to  embolism,  both  it  and  hemorrhage  are  sudden.  In 
embolism  the  patient  is  commonly  younger,  but  not  always  so,  and  we  look 
for  valvular  heart  disease.  According  to  Charles  L.  Dana,  even  in  patients 
between  the  ages  of  30  and  50,  when  there  is  no  heart  disease,  the  chances  are 
six  to  one  in  favor  of  hemorrhage.  An  apoplectic  seizure  after  parturition  is 
likely  to  be  embolic.  In  embolism,  too,  there  is  less  disturbance  of  tempera- 
ture, the  paralysis  is  more  likely  to  precede  the  coma  and  convulsions  if  the 
latter  are  present;  the  turgid  face,  hard  pulse,  loud  breathing,  and  greater 
general  disturbance  of  a  serious  stroke  of  apoplexy  from  hemorrhage  arc 
wanting. 

In  thrombosis  the  difficulty  in  diagnosis  may  be  even  greater.  The 
symptoms  of  thrombosis  are  slower  in  their  development,  but  in  the  "in- 
gravescent" form  of  apoplexy,  in  which  the  hemorrhage  is  gradual,  requiring 
sometimes  a  day  or  two,  the  development  of  symptoms  is  correspondingly 
slow.  In  thrombosis  there  are  more  frequently  prodromata  in  the  shape  of 
slight  seizures,  quickly  recovered  from.  Such  events  occurring  in  the  aged, 
when  there  is  evident  atheroma  of  the  blood-vessels  and  weak  heart,  point 
to  thrombosis,  in  which,  too,  there  is  absence  of  stertorous  breathing,  of 
variations  in  temperature,  and  of  pupillary  disturbance. 


CEREBRAL  THROMBOSIS  AND  EMBOLISM  1047 

It  is  also  important  to  be  able  to  decide  whether  the  obstruction  is  embolic 
or  thrombotic.  In  the  former  the  onset  is  sudden,  without  premonitorj'' 
symptoms;  in  the  latter  it  is  gradual,  and  there  are  often  premonitory  symp- 
toms. In  embolism  there  may  be  convulsive  twitchings,  but  hemiplegia 
quickly  follows,  without  or  without  temporary  loss  of  consciousness.  In 
thrombosis  the  patient  has  previously  complained  of  headache,  vertigo,  or 
tingling  in  the  fingers ;  then  paralysis  may  begin  in  one  hand  or  foot  and  extend 
slowly,  the  hemiplegia  often  remaining  partial.  Speech  may  have  been 
embarrassed  for  some  days  previous,  and  the  memory  defective.  In  throm- 
bosis due  to  syphilis,  especially,  the  hemiplegia  may  come  on  gradually 
without  loss  of  consciousness.  The  same  is  true  of  the  so-called  senile 
softening,  which  is  generally  due  to  thrombosis  after  atheroma  of  the 
cerebral  arteries.  In  a  few  cases  the  onset  is  more  sudden,  and  may  happen 
during  sleep.  The  temperature  usually  has  a  slight  initial  fall,  followed  by 
rise,  as  in  hemorrhage.  In  embolism  aphasia  is  quite  a  characteristic  sjTnp- 
tom,  as  it  seems  to  occur  more  frequently  on  the  left  side  than  on  the 
right. 

In  both  embolism  and  thrombosis  the  hemiplegia  tends  to  improve 
rapidly  unless  the  vessel  obstructed  be  a  large  one  or  there  be  rupture  of  a 
collateral  branch.  It  is  true  that  acute  softening  may  terminate  fatally 
within  24  hours,  but  usually  the  patient  siurvives  the  onset,  and  at  the  worst 
dies  after  several  weeks,  the  phenomena  of  the  chronic  stage  being  almost 
identical  with  those  of  that  stage  after  hemorrhage.  Spastic  symptoms 
may  also  occur,  and  there  is  a  tendency  to  the  characteristic  mobile 
spasm. 

Prognosis. — A  patient  rarely  dies  of  a  first  attack  of  cerebral  embolism, 
unless  a  very  large  vessel  is  obstructed,  such  as  the  internal  carotid  or  basilar, 
whose  occlusion  is  usually  fatal ;  next  in  seriousness  after  these  is  plugging  of 
the  middle  cerebral  and  vertebral,  while  obstruction  of  the  two  vertebrals  is 
always  fatal.  Every  succeeding  attack  increases  the  danger.  Embolism 
is  less  serious  than  thrombosis.  Sudden  severity  in  thrombosis  is  serious, 
and  deranged  breathing  is  an  unfavorable  symptom.  Convulsions  may  be  a 
result  of  syphilitic  thrombosis.  When  the  embolism  is  due  to  valvular  heart 
disease,  the  condition  is  likely  to  recur;  when  due  to  other  causes,  not. 
Thrombosis  is  prone  to  recur,  especially  when  caused  b}^  atheroma. 

Treatment. — Neither  thromobsis  nor  embolism  demands  blood-letting. 
Indeed,  it  is  strongly  contraindicated.  Rest  in  bed,  with  head  raised,  is  im- 
portant. If  syphilis  is  the  cause  of  thrombosis,  it  should  receive  the  usual 
treatment — the  iodid  of  potassium  in  ascending  doses  until  doses  of  a  dram  or 
more  are  reached,  or  mercury  or  salvarsan.  There  is  no  treatment  for 
atheroma.  Attention  should  be  paid  to  the  heart,  kidneys,  and  bowels. 
The  heart  is  commonly  feeble,  and  digitalis  and  strophanthus  are  needed  to 
keep  its  action  uniform  and  strong,  by  which  one  condition  resulting  from 
thrombosis  is  removed.  The  urine  is  scanty  and  highly  colored,  but  the 
treatment  for  the  heart  is  also  the  treatment  for  the  scanty  secretion,  which 
calls  also  for  diluents.  The  bowels  should  be  kept  freely  open.  The  circu- 
lation is  aided  by  nitroglycerin,  which  may  be  given  in  doses  of  i/ioo  grain 
(0.0066  gm.)  every  two  hours.  The  iodid  of  potassium  is  useful  also  for  this 
purpose.     Its  effects  are  more  permanent  than  those  of  nitroglycerin.     From 


1048  DISEASES  OF  THE  NERVOUS  SYSTEM 

5  to  15  grains  of  the  iodid  (0.33  to  0.99  gm.)  should  be  given  three  times 
a  day. 

Moderate  stimulation  is  beneficial.  The  aromatic  spirit  of  ammonia  and 
alcohol  are  the  most  useful  for  this  purpose.  Mental  excitement  is  to  be 
especially  avoided  after  a  return  to  consciousness,  and  physical  rest  should 
be  continued.  Stimulants  are  then  best  discontinued,  or  continued  in  great 
moderation.     Care  should  be  taken  to  protect  against  the  effects  of  decubitus 

Unfortunately  there  is  no  treatment  which  will  restore  softened  brain 
matter,  although  a  certain  amount  of  function  may  be  vicariously  assumed. 
The  same  measures  calculated  to  maintain  nutrition  and  muscular  integrity 
as  are  recommended  in  the  treatment  of  hemorrhage  should  be  taken. 

Thrombosis  of  the  Cerebral  Sinuses  and  Veins. 

Description. — Thrombosis  occurs  in  the  sinuses  rather  than  veins  and 
is  primary  or  secondary.  Primary  thrombosis  is  the  result  of  a  state  of  the 
blood  and  circulation;  secondary,  a  consequence  of  disease  adjacent  to  the 
sinuses.     The  former  is  much  the  rarer,  occurring  half  as  often. 

Primary  thrombosis  is  met  in  the  longitudinal  sinus,  more  rarely  in  the 
lateral,  sometimes  in  the  cavernous.  It  is  found  associated  with  general 
malnutrition  and  prostration,  more  frequently  in  children  during  the  first 
six  months  of  life  as  the  result  of  exhausting  maladies,  especially  diarrhea. 
It  is  met  also  in  older  children.  Brayton  Ball  and  others  have  showTi  its 
association  in  young  girls  with  chlorosis  and  anemia.  It  occurs  in  the  aged 
also  as  the  result  of  exhausting  disease,  like  pulmonary  tuberculosis  and 
cancer. 

Coagulation  is  favored  by  the  trabecule  which  cross  the  cavity  of  the 
sinus,  and  by  irregularities  in  the  shape  and  lining  of  the  latter.  It  may  or 
may  not  be  associated  with  phlebitis. 

Very  little  is  known  of  primary  thrombosis  of  the  cerebral  veins,  except 
that  it  may  occur  in  veins  of  the  convexity  as  the  result  of  meningitis,  and 
from  other  causes  that  produce  thrombosis  of  sinuses. 

Secondary  thrombosis  occurs  at  any  age,  and  is  the  result  of  disease 
adjacent  to  a  sinus,  commonly  caries  of  bone,  and  is  especially  frequent 
as  the  result  of  disease  of  the  internal  ear.  It  spreads  more  frequently 
from  the  posterior  wall  of  the  middle  ear,  but  also  from  the  mastoid  sinuses. 
Fracture,  suppurative  disease  outside  of  the  skull,  especially  erysipelas,  and 
tumor  compressing  the  sinus  may  produce  it. 

Symptoms. — There  may  be  no  SAinptoms  in  primary  thrombosis,  or 
there  may  be  nausea  and  vomiting,  headache,  and  hebetude  increasing  to  coma. 
Dilatation  of  the  pupils,  choked  disks,  and  paresis  have  been  reported. 

Secondary  thrombosis  is  a  septic  process.  It  is  commonly  announced  by 
a  chill,  followed  hy  fever  and  occipital  pain,  succeeding  on  earache  with  sup- 
purative otitis.  The  sinuses  occluded  are  those  near  the  ear,  but  the  blood 
escapes  by  other  channels,  and  the  brain  substance  is  not  seriously  invaded. 
The  symptoms  of  meningitis  are  soon  added.  They  are  headache,  somno- 
lence, and  stupor,  or  there  may  be  active  delirium  and  convulsions,  rigidity, 
or  optic  neuritis,  all  the  results  of  meningitis.  Death  is  most  frequenth' 
caused  by  suppurative  pulmonary  pyemia,  as  was  the  case  in  70  per  cent,  of 


INTRACRANIAL  ANEURYSM  1049 

Newton  Pitt's  cases,'  and  the  appearance  of  the  latter  disease  under  the 
circumstances  is  almost  conclusive  evidence  of  previous  sinus  thrombosis. 

Prognosis. — This  is  always  grave.  The  average  duration  of  the  sec- 
ondary disease  is  about  three  weeks,  and  its  termination  is  almost  always 
fatal.  Pitt  reports  a  case  of  recovery  in  a  boy  of  ten  who  had  otorrhea  for 
years,  after  removal  by  operation  of  a  foul  clot  from  the  lateral  sinus. 

Treatment. — For  primary  thrombosis  there  is  no  treatment  except 
that  for  its  cause.  For  secondary,  operative  treatment  is  indicated  by 
trephining  or  other  measures  to  give  exit  to  pus.  Quinin  and  restorative 
measures  are  indicated.  Gowers  lays  particular  stress  on  the  use  of  the 
tincture  of  the  chlorid  of  iron. 

INTRACRANIAL  ANEURYSM. 

.  Definition. — Intracranial  aneurysms  are  of  two  kinds,  miliary  and  those 
of  larger  size.  The  former  have  been  considered  when  treating  of  hemor- 
rhage.    The  latter  vary  in  size  from  that  of  a  pea  to  a  walnut. 

Distribution. — Larger  aneurysms  affect  the  larger  arteries  at  the  base  of 
the  brain  in  the  following  order : 

1.  Middle  cerebral. 

2.  Basilar. 

3.  Internal  carotid. 

4.  Anterior  cerebral. 

The  anterior  or  posterior  communicating  and  vertebral  arteries  are 
also  occasional  seats;  the  posterior  cerebral  and  inferior  cerebellar  rarely. 
William  Osier  found  12  of  these  aneurysms  in  800  autopsies,  and  Newton 
Pitt  ig  in  1900. 

Etiology. — Intracranial  aneurysms  are  found  rather  more  frequently 
in  the  male  sex,  and  most  frequently  between  the  ages  of  10  to  60.  Osier 
and  Pitt  each  found  one  at  the  age  of  six.  Heredity  exercises  some  influence. 
Endarteritis  and  embolism,  both  of  which  weaken  the  vessels,  are  the  chief 
causes.  The  former  may  be  syphilitic  or  simple.  The  presence  of  endocar- 
ditis should  especially  invite  examination  for  aneurysm  at  autopsies. 

Symptoms. — Death  from  apoplexy,  owing  to  rupture  of  the  aneurysm, 
may  be  the  first  intimation.  Not  only  are  there  often  no  S3anptoms,  but 
when  present  they  are  vague.  They  may  be  those  of  tumor  at  the  base  of 
the  brain,  including  optic  neuritis  and  paralysis  of  the  third  and  other 
cranial  nerves.  There  are  rarely  convulsions.  There  may  be  headache, 
vertigo,  nausea,  hebetude,  and  even  coma,  hemiplegia,  and  hemianopia.  A 
murmur  may  be  heard  on  auscultating  the  skull,  while  occasionally  the 
patient  himself  is  conscious  of  a  murmur  or  recognizes  the  pulsations  in  his 
head. 

Diagnosis. — This  is  usually  impossible,  but  the  foregoing  symptoms, 
associated  with  endarteritis,  may  excite  suspicion.  Syphilitic  disease 
being  as  likely  to  produce  tumor,  the  history  of  its  presence  gives  no  assist- 
ance in  diagnosis. 

Treatment. — None  exists  which  can  be  specifically  directed  to  the 
disease. 


1050  DISEASES  OF  THE  NERVOUS  SYSTEM 

THE  CEREBRAL  PALSIES  OF  CHILDREN. 

Definition. — Referring  to  the  division  already  made  of  the  motor  path 
into  an  upper  cortico-spinal  segment,  extending  from  the  cells  of  the  cortex 
to  the  gray  matter  of  the  cord,  and  a  lower  spino-muscular,  extending  from 
the  ganglia  of  the  anterior  horns  to  the  motorial  end-plates,  the  diseases 
now  to  be  considered  have  their  anatomical  seat  in  the  former,  and  are 
characterized  by  paralysis,  with  spasm  or  disordered  movements,  exagger- 
ated reflexes,  normal  electrical  reactions,  without  rapid  or  extreme  wasting. 
They  result  from  a  destructive  lesion  of  the  motor  centers,  or  of  the  py- 
ramidal tract  in  the  hemisphere,  internal  capsule,  cms,  or  pons.  The 
condition  is  hemiplcgic,  diplegic,  or  paraplegic. 

Spastic  Infantile  Hemiplegia. 

Synonyms. — Hemiplegia  spastica  cerebralis  (Heine);  Hemiplegia  spastica 
infantilis  (Bernhardt);  Acute  Encephalitis  der  Kinder  (Strumpell); 
Die  atrophische  Cerebrallahmung  (Henoch) ;  Agenbse  cerebrale  (Cazau- 
vieilh) ;  Sclerose  cerebrale  atrophic  partielle  (other  French  writers) .  Hemi- 
plegia in  infants  and  children  with  spastic  symptoms. 

Distribution. — The  disease  is  somewhat  more  common  in  girls  than 
in  boys,  63  out  of  120  cases  studied  by  Osier  at  the  Nervous  Infirmary  in 
Philadelphia  being  of  this  sex.  Of  these  cases  15  were  congenital,  45  began 
in  the  first  year,  22  in  the  second,  14  in  the  third,  one  in  the  fourth,  three  in 
the  fifth,  sixth,  and  seventh,  one  in  the  eighth,  ninth,  tenth.  In  ten  the 
age  of  onset  was  not  given.  The  hemiplegia  was  right-sided  in  68  and  left- 
sided  in  52  cases. 

Etiology. — Among  the  causes  may  be  mentioned  abnormal  conditions 
of  the  mother  during  pregnancy,  including  accidents,  possibly  disease, 
especially  syphilis,  in  a  few  cases  fright  or  distress,  the  effect  of  the  last  two 
being  doubtful.  Especially  frequent  causes  are  difficult  or  abnormal  labor, 
injury  with  forceps  producing,  depressions  and  fractures  of  the  cranial  bones 
during  delivery.  After  birth  are  penetrating  wounds  of  the  head,  ligation  of 
the  common  carotid,  and  infectious  diseases,  including  whooping-cough, 
diphtheria,  scarlet-fever,  measles,  meningitis,  typhoid  fever,  vaccinia,  and 
mumps.  Previous  convulsions  maj^  cause  the  lesion  on  which  the  paralysis 
depends,  and  in  a  few  cases  embolism  may  be  responsible. 

Morbid  Anatomy. — The  morbid  states  of  the  brain  found  at  autopsy 
are  mainly  sclerosis  and  porencephalia,  the  latter  a  defect  consisting  in  arrest 
of  development  of  the  brain  shown  by  absence  of  convolutions  or  even  lobes, 
causing  irregular  subpial  cavities.  Embolism  and  thrombosis  of  vessels, 
especially  of  the  Sylvian  artery,  and  hemorrhage  into  the  ventricle  and 
substance  of  the  brain,  have  been  found  in  a  few  cases.  The  sclerosis 
involves  groups  of  convolutions,  an  entire  lobe,  or  even  an  entire  hemisphere. 
The  skull  may  be  flattened  on  the  affected  side,  broad  and  prominent  above 
the  mastoid  processes,  sometimes  thickened.  The  dura  may  be  thickened 
and  adherent;  the  arachnoid  turbid  and  thickened  and  the  amount  of 
cerebrospinal  fluid  increased.  The  pia  mater  may  be  thickened  and  adherent, 
and  portions  of  the  cortex  maj-  be  torn  away  when  the  pia  is  removed,  leav- 


CEREBRAL  PALSIES  1051 

ing  a  roughened  surface,  while  there  may  be  nodular  projections  of  sclerosed 
tissue.  The  reduction  of  weight  of  the  sclerosed  hemisphere  may  be  very 
considerable;  in  one  case,  referred  to  by  Osier  in  his  monograph,  the  at- 
rophied hemisphere  weighed  s  1/2  ounces  (169  gm.),  the  normal  being  20 
ounces  (653  gm.) .  The  lateral  ventricle  may  be  greatly  dilated,  and  the  brain 
tissue  over  it  very  thin,  while  cysts  have  been  found  in  the  sclerosed  areas — 
the  remnants  of  old  hemorrhages.  The  Rolandic  area  is  that  most  fre- 
quently involved. 

In  90  cases  studied  by  Osier  the  lesions  in  50  were  atrophy  and  sclerosis, 
in  24  porencephalia,  and  in  16  embolism,  thrombosis,  or  hemorrhage. 

Symptoms. — The  symptoms  are  complex  and  varied,  but  may  be  divided 
into  three  classes :  those  of  the  onset,  those  pertaining  to  the  paralysis,  and 
the  residual  symptoms. 

The  most  important  symptoms  of  the  onset  are  convulsions  and  coma, 
although  the  hemiplegia  may  come  on  suddenl}',  without  spasm  or  loss  of 
consciousness,  in  children  apparentl}^  healthy.  In  the  majority  of  cases, 
however,  the  disease  begins  with  the  convulsions,  partial  or  general  Loss 
of  consciousness  almost  always  accompanies  the  convulsions,  and  may  last 
from  a  few  hours  to  many  days.  Rarely  coma  occurs  without  con\nilsions. 
Among  other  symptoms  may  be  mentioned  fever,  transient  or  persistent ; 
according  to  Striimpell  and  Guadard,  it  is  an  invariable  accompaniment  of 
the  convulsions.  Delirium  is  a  common  symptom,  as  is  also  soreness  of  the 
general  surface.     Vomiting  and  screaming  spells  are  also  noticed. 

The  hemiplegia,  which  is  noticed  as  soon  as  the  child  recovers  conscious- 
ness, is  usually  complete.  Less  commonly  there  is  first  paresis,  which 
gradually  extends  to  complete  loss  of  power;  and  in  some  instances  a  total 
paralysis  is  established  after  repeated  convulsions.  The  face  is  not  always 
involved,  and,  as  a  rule,  in  facial  paralysis  of  cerebral  origin  the  superior 
muscles  are  intact,  and  the  child  can  close  the  eyes  and  elevate  the  brows. 
■The  facial  palsy  usually  disappears  rapidly  and  completely. 

As  to  residual  symptoms,  the  residual  paralysis  is  most  marked  in  the 
arm,  which  is  subject  to  slow  wasting,  and  is  commonly  useless  for  the  ordi- 
nary purposes  of  life.  The  atrophy  is  moderate,  but  there  may  be  arrested 
development,  leaving  a  wasted  and  withered  member.  In  extreme  cases 
the  arm  is  held  close  to  the  side,  the  forearm  strongly  flexed  at  right  angles 
and  in  a  semiprone  position,  the  hand  flexed  and  the  fingers  contracted, 
the  palm  usually  embracing  the  thumb.  Motion  may  be  almost  lost  in  the 
arm  and  completely  in  the  fingers,  though  in  most  cases  there  is  considerable 
power  of  movement,  the  patient  being  able  to  lift  the  arm  above  the  head, 
while  flexion  and  extension  can  be  made  at  the  elbow  and  wrist.  The  finger 
and  more  delicate  movements  of  the  hand  are  rarely  recovered.  The  leg, 
as  a  rule,  recovers  more  rapidly  and  completely  than  the  arm,  and  the  palsy 
may  disappear  entirely  in  it,  while  it  rarely  does  in  the  upper  extremity. 
In  the  leg  the  wasting  is  also  less  pronounced,  while  arrested  development 
is  also  less  frequent.  A  persistent  halt  is  apt  to  remain — indeed,  almost 
always  does — as  evidence  of  impaired  power;  this  may  consist  in  simply 
favoring  the  affected  side,  noticeable  only  on  rapid  walking.  A  decided 
dragging  of  the  Hmb  is,  however,  nore  usual,  and  there  may  be  tremor  of  the 
leg  while  moving. 


1052  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  frcquenc\-  with  which  rigidity  is  jjrcsent  has  given  rise  to  one  of  the 
names  of  the  disease,  spastic  infantile  hemiplegia.  It  is  not,  however,  an 
invariable  symptom',  and  the  paralyzed  limbs  may  be  relaxed  a  long  time 
after  paralysis  sets  in.  When  rigidity  is  present,  it  is  lessened  during  sleep, 
and  is  increased  by  emotion  and  forcible  attempts  to  overcome  the  spasm. 
Contracture  may  ultimately  result,  after  which  relaxation  is  no  longer  pos- 
sible. A  form  of  rigidity  with  partial  paralysis  is  known  as  postapoplectic 
hemi-hypertonia,  and  has  been  previously  referred  to. 

The  reflexes  are  almost  always  increased  in  the  affected  limbs,  ankle 
clonus  being  often  obtainable  in  addition  to  exaggerated  knee-jerk.  The 
reflexes  may  even  be  increased  on  the  sound  side.  Rectus  clonus  and  clonus 
of  the  flexors  of  the  fingers  are  rarely  present,  while  in  a  very  few  cases  the 
reflexes  are  absent. 

Sensation  is  rarely  affected,  but  vasomotor  derangements  arc  sometimes 
present.     Electrical  reactions  are  normal,  as  a  rule. 

Posthemiplegic  chorea — hemiataxia — is  not  infrequent.  More  uncom- 
mon are  mobile  spasm  and  athetosis  and  posthemiplegic  tremor.  These 
interesting  symptoms  were  first  described  by  S.  Weir  Mitchell  and  Ham- 
mond in  a  study  of  cases  of  cerebral  palsy. 

Aphasia  is  present  in  a  majority  of  cases  and  is  almost  invariably 
transitory,  is  associated  most  commonly  with  right  hemiplegia,  ver\'  rarely 
with  left. 

Defects  of  intelligence  are  very  common,  the  degree  of  feeble-mindedness 
ranging  from  low-grade  imbecility  to  total  idiocy.  Psychoses  may  occur 
late  in  life,  even  when  there  have  been  no  defects  in  childhood. 

Epilepsy  is  very  frequent,  and  is  sometimes  confined  to  the  paralyzed 
side,  but  also  tends  to  become  general.  The  attacks  usually  begin  within 
two  or  three  years,  sometimes  within  a  few  weeks,  after  the  onset  of  the 
hemiplegia,  but  may  be  delayed  from  eight  to  ten  years,  or  even  longer. 
The  seizures  may  present  three  well-defined  degrees — -the  first,  in  which  the 
child  is  simply  dazed  for  a  moment  or  two,  or  longer,  without  any  motor 
involvement;  second,  Jacksonian  epilepsy,  without  loss  of  consciousness,  in 
which  the  spasms  are  confined  to  the  affected  side,  and  third,  general  con- 
vtdsions,  beginning  in  the  paralyzed  limbs,  and  usually  accompamed  by  loss 
of  consciousness.  The  Jacksonian  epilepsy  is  most  common,  but  all  forms 
may  occur  in  any  one  case.  Jacksonian  epilepsy  is  usually  without  loss  of 
consciousness,  unless  the  convulsions  are  very  severe  or  involve  a  large 
portion  of  the  body. 

Diagnosis. — Infantile  spinal  paralysis  (anterior  poliomyelitis),  most 
frequently  must  be  excluded,  usually  without  diffictilty.  The  history  of  the 
case,  including  the  presence  of  some  of  the  causes  named,  the  frequent  onset 
with  convulsions,  the  hemiplegia,  the  absence  of  rapid  wasting  of  the 
affected  muscles,  the  retained  electrical  reactions,  are  characteristic  of  infan- 
tile cerebral  hemiplegia  in  its  early  stages;  while  rigidit}^  of  muscles, 
increased  reflexes,  the  peculiar  gait,  and  residual  palsy,  with  mental  impair- 
ment and  epileptic  seizures,  distinguish  the  later  stage. 

Tumor  of  the  brain  sometimes  produces  similar  symptoms.  Tubercu- 
losis and  glioma  are  the  forms  most  common  in  children.  Pressure  paralysis 
hj  obstetrical  forceps  aft'ects  the  face  and  upper  extremities,  but  other 


CEREBRAL  PALSIES  1053 

symptoms  are  wanting,  and  it  is  scarcely  likely  to  be  confounded  with 
infantile  hemiplegia. 

Prognosis  and  Treatment. — The  prognosis  is  favorable  so  far  as  life  and 
the  recovery  of  considerable  locomotive  power  are  concerned;  unfavorable 
as  to  recovery  from  mental  defect  and  epilepsy.  An  institution  for  feeble- 
minded children,  in  which  the  subjects  have  the  benefit  of  training  and  watch- 
ing, is  the  safest  permanent  home  for  them. 

Bilateral  Infantile  Spastic  Hemiplegia. 

Synonyms. — Spastic  Rigidity  of  the  New-born  (Little);  Tonic  Contraction 
of  Extremities;  Essential  Contractions ;  Permanentes  Kinder-Tetanus  (Stro- 
meyer) ;  Spastic  Diplegia:  Spastic  Paralysis  of  Children  (Adams) ;  Spastic 
Diplegia  (Gee) ;  Spasme  Musculaire  Idiopathique  (Delpech) ;  Birth  Palsies 
(Gowers) ;  Little's  Disease. 

Definition. — Double  hemiplegia  in  infants  and  children  with  spastic 
symptoms. 

Etiology. — Most  cases  of  bilateral  hemiplegia  in  children  date  from  birth, 
and  are  the  result  of  injury  during  birth.  Many  are  caused  by  premature 
birth.  The  infectious  fevers  are  responsible  for  a  certain  number,  and  a 
few  are  direct  results  of  convulsions.  In  a  word,  the  causes  are  those  of 
infantile  hemiplegia.  J.  H.  W.  Rhein'  reports  a  case  of  spastic  diplegia 
following  pertussis. 

Morbid  Anatomy. — As  may  be  inferred  from  the  name,  the  lesions  are 
bilateral  and  involve  motor  areas  of  the  cortex  almost  solely.  They  consist 
in  sclerosis  or  porencephalous  defect,  of  which  the  most  frequent  primary 
cause  is  compression  by  a  blood-clot  from  meningeal  hemorrhage  from  the 
veins  or  longitudinal  sinus.  A  meningo-encephalitis  may,  however,  be 
responsible  for  the  sclerosis.  In  cases  of  premature  birth  there  is  arrest  in 
the  development  of  the  motor  system  in  the  brain  and  cord. 

Descending  degeneration  of  the  pyramidal  tracts  or  imperfect  develop- 
ment of  these  tracts  has  been  found  in  a  few  cases. 

Symptoms. — These  are  to  be  distinguished  from  those  of  the  next  form, 
cerebral  spastic  paraplegia,  which  the  disease  closely  resembles  when  the 
arms  are  so  slightly  affected  that  the  palsy  is  scarcely  appreciable.  The 
cerebral  spastic  paraplegia  of  childhood  is  due  to  lesions  similar  to  those  of 
the  bilateral  spastic  hemiplegia.  In  the  diplegic  state  all  the  extremities 
must  be  more  or  less  spastic,  although  the  legs  almost  always  are  more  so 
than  the  arms.  These  cases  are  further  characterized,  as  are  those  of  spastic 
paraplegia,  by  their  occurrence  at  or  very  soon  after  birth. 

There  may  be  convulsions  or  a  prolonged  succession  of  convulsions  imme- 
diately after  birth.  After  this  or  without  it  there  may  be  noticed  a  limpness 
or  flaccidity  of  muscles,  an  expression  of  paresis,  often  overlooked,  because 
present  at  a  time  when  the  muscular  development  of  the  child  is  so  slight 
that  little  is  expected  of  it.  Soon,  however,  the  inability  to  hold  up  its  head 
may  be  observed,  and  when  the  time  comes  for  it  to  walk,  it  is  noticed  that 

1  Rhein,  J.  H.  W.     "Spastic  Diplegia  Following  Pertussis,"  "Journal  of  Amer.  Med.  Assoc.,"  March  4, 
1905. 


1054  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  limbs  are  clumsily  used,  and  when  examined,  they  are  found  to  be  stiff. 
As  the  child  grows  older  it  slowly  acquires  some  power  so  as  to  be  able  to 
sit,  but  the  legs  are  crossed  and  the  head  is  not  well  supported  by  the  neck 
muscles.  If  it  is  held  up,  the  legs  are  extended  and  strongly  adducted,  and 
crossed  with  the  feet  in  the  pes  equinus  or  equino-varus  position.  Occasion- 
ally the  legs  are  partially  flexed,  while  stiffness  varies  greatly,  involving,  in 
extreme  cases,  the  whole  body,  sometimes  one  side  more  than  the  other.  It 
is  sometimes  constant,  at  other  times  not.  It  may  be  greater  on  one  side 
than  another.     The  arms  are  usually  stiff  ^^  flexion. 

To  the  spastic  symptoms  described  are  added,  in  certain  cases,  spasm 
and  certain  movements  known  as  athetoid.  In  the  former,  in  an  attempt  at 
voluntary  movement,  as  taking  hold  of  an  object,  the  fingers  are  thrown  out 
in  a  stifi^,  spasmodic,  or  irregular  manner,  or  there  may  be  constant  irregular 
movements  of  arms  and  shoulders,  movements  which  are  usually  character- 
ized as  choreic.  In  fact,  such  cases  have  been  named  chorea  spastica, 
being  differentiated  from  the  congenital  choreas  by  the  spastic  feature. 
Spasm  rarely  affects  the  muscles  of  the  face,  though  it  does  occasionally, 
causing  a  continual  grimacing,  which  does  not  always  disappear  during 
sleep. 

The  athetosis  is  double  or  bilateral,  resulting  in  the  most  grotesque  and 
distorted  movements.  They  consist  in  a  constant  flexion  and  extension  of 
muscles,  more  partictilarly  of  those  of  the  fingers  of  one  hand  and  forearm. 
Flexion  of  the  fingers  of  one  hand  may  take  place,  while  those  of  the  other 
may  be  extending,  and  the  same  may  be  true  of  different  fingers  of  the  same 
hand.  The  shoulder  and  trunk  muscles  may  be  also  affected,  producing  a 
rhythmical  and  orderly  twisting  and  bending  of  the  body;  or  those  of  the 
neck,  producing  a  turning  of  the  head  from  side  to  side.  These  movements 
are  all  increased  under  excitement  or  vnth.  the  effort  to  do  an\'thing. 

Mental  defect,  consisting  in  imbecility  and  various  grades  of  idiocy,  is 
more  or  less  characteristic  of  these  cases,  but  is  commonly  less  than  in  infan- 
tile hemiplegia. 

The  form  resulting  from  premature  birth  should  be  distinguished  from 
that  caused  by  injuries  at  birth,  or  by  lesions  acquired  later,  as  in  the  former 
convulsions  and  athetoid  movements  do  not  usually  occur,  mentality  may 
not  be  affected,  or  only  slightly  so,  and  improvement  may  be  slowly  pro- 
gressive even  after  many  years. 

Infantile  Spastic  Paraplegia. 

Synonyms. — Paraplegia  cerebralis  spastica  (Heine) ;  Tetanoid  Pseudopara- 
plegia  (Seguin);  Spastic  Spinal  Paralysis  (Erb);  Tabes  dorsalis  spas- 
modique  (Charcot). 

Definition. — Spastic  paralysis  of  the  legs  in  infants  and  children. 

Etiology. — The  causes  are  those  of  spastic  diplegia  and  infantile  hemi- 
plegia, and  also  premature  birth,  the  child  being  born  at  a  period  when  the 
central  motor  tracts  are  very  imperfectly  developed;  premature  birth  causes 
an  arrest  in  the  development  of  these  tracts. 

Morbid  Anatomy. — This  is  less  known  than  the  morbid  anatomy  of  the 
other  forms  of  cerebral  palsy.     It  may  be  due  to  cerebral  lesion  involving 


CEREBRAL  PALSIES  1055 

especiall}'  the  centers  for  the  lower  limbs,  to  imperfect  development  of  the 
motor  tracts,  or  to  other  causes.     A  few  cases  with  necropsy  are  recorded. 

Symptoms. — These  are  almost  identical  with  those  already  described  as 
belonging  to  the  spastic  paraplegia  of  adults,  with  which  the  earlier  writers 
classed  it.  Spastic  paralysis  of  the  lower  extremities,  dating  from  birth  or 
appearing  within  the  first  few  years  of  life,  with  talipes  equinus  or  equino- 
^^arus,  adductor  spasm,  rigid  stiff  gait,  the  patient  walking  on  his  toes  or 
by  crossed-legged  progression — all  without  wasting — these  are,  in  a  word, 
the  symptoms.  The  order  of  sequence  of  events  is  very  similar  to  that 
described  under  spastic  diplegia.  In  attempting  to  walk  the  heels  are 
everted  and  knees  approximated,  because  of  spasm  of  the  adductors,  which 
may  be  so  strong  as  to  make  it  impossible  to  separate  the  thighs.  The 
spastically  extended  legs  may,  however,  be  gradually  forced  into  flexion  after 
the  marmer  of  the  "lead-pipe"  contraction.  If,  however,  the  attempt  be 
made  to  extend  the  leg,  the  spasm  returns.  If  the  extension  be  gradually 
insisted  upon,  it  often  happens  that  when  the  extension  is  nearly  complete, 
the  spasm  suddenly  completes  it,  as  the  spring  acts  on  the  blade  of  a  pocket- 
knife,  whence  the  name  "clasp-knife"  rigidity. 

Mental  imbecility  is  not  so  serious  as  in  spastic  diplegia  or  even  as  in 
infantile  hemiplegia,  and  may  be  entirely  absent,  especially  in  those  cases 
restdting  from  premature  birth. 

Diagnosis. — The  distinction  between  spastic  diplegia  and  paraplegia  is 
not  a  very  important  one.  The  two  conditions  are  probably  the  results  of 
different  degrees  of  similar  lesions  ha\'ing  different  locations.  There  is  an 
affection  of  children  known  as  pseudoparalytic  rigidity,  idiopathic  contraction 
with  rigidity,  or  tonic  contraction  of  the  extremities,  with  which  it  is  some- 
times confounded,  but  the  following  table  of  differences  from  Osier's  mono- 
graph will  aid  in  separating  the  two  conditions. 

Pseudoparalytic  Rigidity.  Spastic  Paralysis;  Diplegia  and 

Paraplegia. 

Follows   a  prolonged   illness.     Is   often   as-  Usually  exists  from  birth.     Historj^  of  difficult 

sociated     with     rickets,     laryngismus  labor  [or  of  premature  labor],  of  asphyxia 

stridulus,    and    the    so-called    hydro-  neonatorum  or  of  convulsions. 

cephaloid  state. 

Begins   in  hands   and    feet    as    carpopedal  Arms  rarely  involved  without  legs  and  not  in 

spasm;  often  confined   to   hands   and  so  marked  a  degree. 

arms. 

Spasms  painful  and  attemps   at   extension  Usually  painless. 

cause  pain. 

Intermittent  and  of  transient  duration.  Variable  in  intensity,  but  continuous. 

The  spasm  in  the  pseudo  cases  is  altogether  more  severe  and  difficult  to 
overcome.  The  disease  is  associated  with  rickets  and  other  constitutional 
diseases. 

Tetany  is  characterized  by  a  different  history  and  causation.  Bilateral 
rigidity  may  also  be  produced  by  tumors  of  the  pons  and  cerebellum. 

Treatment. — The  treatment  varies  with  the  stage  existing  at  the  time 
the  physician  is  called.  If  in  the  stage  of  initial  convulsion,  there  the  best 
remedy  is  chloral,  which  should  be  given  in  doses  by  mouth  or  rectum  suf- 
ficient to  control  the  fits.  In  the  mild  degrees,  or  with  a  view  to  keep- 
ing up  an  effect  first  obtained  by  chloral,  the  bromids  may  be  used.  If 
chloral  fails,  chloroform  may  be  inhaled. 


1056  DISEASES  OF  THE  NERVOUS  SYSTEM 

In  established  paralysis  medicines  do  not  avail  miich  and  recoveries  are 
rare.  Hygiene  and  good  food,  g>Tnnastics,  manipulation,  massage,  passive 
motion,  and  surgical  appliances  may  be  used.  Baths  and  electricity  should 
not  be  forgotten. 

The  epileptic  convulsions  should  be  treated  as  when  occurring  under  other 
conditions,  though  the  cortical  lesions  occasioning  the  disease  preclude  any 
expectation  of  permanent  relief.  Operative  procedure  has  been  suggested 
in  certain  selected  cases  and  carried  out,  but  with  results  which  have  been 
disappointing. 

The  mental  deficiencies  are  best  treated  in  an  institution  for  feeble- 
minded children,  where  all  such  cases  should  be  taken,  whatever  the  circum- 
stances of  the  parents. 


Herpes  Zoster. 

Synonyms. — Acute  hemorrhagic  inflammation  of  the  dorsal  root  ganglia;  zona; 
cingulum;  ignis  sacer;  zoster;  shingles. 

Definition. — Herpes  zoster,  as  shown  by  the  studies  of  Head  and  Camp- 
bell, is  an  acute  inflammation  of  the  posterior  ganglia  of  the  spinal  nerve-roots 
associated  with  extravasations  of  blood  and  destruction  of  the  ganglion  cells 
and  their  axis  cylinder  processes. 

Etiology. — There  is  usually  a  specific  cause.  In  some  cases  there  is  a 
prodromal  period  of  illness  and  neuralgic  pain,  on  the  third  or  fourth  day  of 
which  the  eruption  makes  its  appearance.  Atmospheric  influences,  such  as 
severe  cold  and  dampness,  may  act  as  causes.  So  may  checking  of  profuse 
perspiration  and  mechanical  violence  producing  injury  to  ner\'es,  all  favored 
by  lowered  resisting  power  from  mental  and  physical  fatigue.  Arsenic 
is  occasionally  a  cause. 

Symptoms. — The  chief  sj^mptom  is  a  painful  vesicular  eruption,  along 
the  course  of  the  afferent  spinal  nerves,  covering  their  respective  skin  fields, 
and  is  therefore  correspondingly  irregiilar.  It  is,  as  a  rule,  confined  to  one 
side  of  the  body,  though  in  rare  instances,  especially  about  the  head,  it  in- 
vades both  sides.  According  to  the  locality,  it  is  called  zoster  capitis, 
z.  faciei,  z.  orbicularis,  z.  nuchce,  z.  brachialis,  z.  pectoralis,  z.  abdominalis, 
and  z.  femoralis,  and  in  these  different  varieties  corresponding  ganglia  are 
involved ;  the  Gasserian  ganglion  in  zoster  of  the  face,  the  otic  ganglion  in  z. 
orbicidaris  which  may  be  complicated  with  transient  paralysis  and  some- 
times severe  auditory  and  visual  symptoms.  On  the  head  it  may  invade 
the  scalp  as  well  as  the  forehead,  appearing  in  the  course  of  the  supraorbital 
ner\''e  and  upward  over  the  scalp.  The  circular  involvement  of  the  chest, 
zoster  pectoralis,  whence  the  name  herpes  zoster,  is  rarely  complete,  indeed 
seldom  embraces  half  the  circumference. 

Evcry'where  there  is  the  same  severe  burning  pain  in  the  region  of  the 
eruption  which  is  on  an  angry  red  surface.  While  rupture  of  the  vesicles 
is  infrequent,  their  contents  may  sometimes  become  purulent  and  result  in 
chronic  ulceration.  There  may  be  an  extension  of  the  process  from  the 
posterior  ganglia  to  the  adjacent  meninges,  causing  pains  down  the  spine, 
girdle  pains,  and  exaggerated  knee-jerks  with  leukocytosis. 


MUTIPLE  SCLEROSIS  1057 

It  is  met  in  both  sexes,  in  children  as  well  as  adults.  In  th?  case  of  per- 
sons past  middle  life,  the  disease  is  often  very  exhausting,  being  sometimes 
the  beginning  of  a  decline  in  health  which  is  permanent.  Among  the 
sequelae  is  a  most  inveterate  form  of  neuralgia. 

Prognosis. — The  prognosis  is  most  favorable  in  children,  and  in  ordinary 
circumstances  ten  days  to  three  weeks  suffice  to  cover  its  duration,  although 
it  may  be  prolonged  much  beyond  this  period.  Subjects  rarelv  have  more 
than  one  attack,  although  Duhring  refers  to  a  case  of  Kaposi  in  which  nine 
relapses  occurred  all  on  the  right  side  of  the  body  but  not  in  exactly  the 
same  region.  The  disease  commonly  runs  an  acute  course,  terminating 
spontaneously  in  recovery  except  in  those  rare  cases  followed  by  neuralgia. 

Treatment. — This  appears  to  be  without  effect  in  cutting  short  the  dis- 
ease and  is  commonly  limited  to  soothing  local  applications.  The  pain  is 
often  so  severe  as  to  require  the  hypodermic  injection  of  morphine.  Mor- 
phine ma,y  be  employed  locally  in  the  shape  of  a  dusting  powder.  Solutions 
of  carbolic  acid  lo  to  15  grains  to  an  ounce  of  water  (0.3-0.5  grm.  to  30  c.c.) 
may  be  used  locally,  and  it  is  generally  comforting  to  have  the  parts-  pro- 
tected from  the  atmosphere  by  a  light  covering.  Dusting  with  stearate  of 
zinc  is  a  soothing  treatment. 


MULTIPLE  SCLEROSIS  OF  THE  BRAIN  AND  SPINAL  CORD. 

Synonyms. — Insular  Sclerosis;  Disseminated  Nodular  Sclerosis;  Sclerose  en 

plaques. 

Definition. — A  chronic  affection  of  the  brain  and  spinal  cord,  consisting 
in  the  presence  of  numerous  sclerotic  patches  scattered  through  the  nen,"e 
centers,  characterized  especially  by  intention  tremor,  scanning  speech,  and 
nystagmus. 

Etiology. — Its  precise  cause  is  imiknown.  The  infectious  diseases, 
especially  scarlet  fever,  are  alleged  causes;  so  are  cold,  exposure,  mental 
emotion,  and  syphilis,  but  without  definite  foundation.  Hereditarj^  pre- 
disposition has  been  noticed.  The  disease  is  more  common  between  the 
ages  of  18  and  3S,  though  Strumpell  reports  a  case  which  came  to  autopsy  at 
60.  Both  sexes  are  equally  subject.  Prichard  states  that  more  than  50 
cases  have  been  reported  in  children,  but  it  is  doubtful  whether  the  diagnosis 
was  invariably  correct.  It  has  been  thought  that  the  disease  depends  on 
anomalies  of  the  vessels,  but  this  view  is  not  held  by  all. 

Morbid  Anatomy. — The  sclerosed  patches  are  widely  scattered  through 
the  brain  and  cord,  rarely  in  the  cord  alone.  They  may  generally  be 
recognized  by  their  gray  color  and  unnatural  firmness.  On  section,  thej- 
appear  as  grayish-red  areas.  Histologically  they  consist  of  thickened  neu- 
roglia traversed  by  a  few  healthy  nerv^e-fibers.  In  the  vessels  there  is  an 
increase  of  the  nuclei  and,  later,  a  thickening  of  the  walls.  Fatt\'  granular 
cells  are  present  in  fresh  cases.  Many  of  the  axis-cylinders  are  preser^-ed  in 
the  sclerotic  patches  for  quite  a  long  time  after  destruction  of  the  medullar}'- 
sheaths.  The  favorite  seats  of  the  plaques  in  the  brain  are  the  centrum 
ovale,  the  walls  of  the  lateral  ventricles,  the  corpus  callosum,  and  the  cere- 
bellum; while  they  are  quite  numerous  in  the  pons,  less  so  in  the  medulla 


1058  DISEASES  OF  THE  NERVOUS  SYSTEM 

oblongata,  but  numerous  in  the  cord,  especially  the  white  substance.  The 
brain  cortex  is  not  often  invaded. 

Symptoms. — By  no  means  can  every  case  of  multiple  sclerosis  be  recog- 
nized, so  often  are  the  symptoms  united  with  those  of  other  lesions  whose 
effects  predominate,  while  the  slowness  of  the  onset  necessitates  delay  in  the 
recognition  of  even  typical  cases.  Typical  cases  do,  however,  occur,  and 
they  present  a  set  of  sj^-mptoms  whence  their  recognition  is  more  or  less  easy. 

One  of  the  most  important  of  these  symptoms  is  tremor,  known  as 
"intention  tremor,"  because  it  is  associated  with  any  voluntary  effort  to 
perform  an  act,  as  picking  up  an  object,  raising  a  glass  of  water  to  the  lips, 
or  opposing  the  ends  of  the  fingers  of  the  two  hands.  This  does  not  prevent 
the  ultimate  attainment  of  purpose.  When  the  patient  is  quiet,  the  tremor 
ceases,  and  in  this  respect  it  can  be  differentiated  from  the  trembling  of 
paralysis  agitans.  It  is  not  confined  to  the  arms,  but  occurs  also  in  the 
head  and  trunk,  so  that  the  head  trembles  when  it  is  raised  from  the  pillow. 
It  is  increased  by  excitement. 

Another  characteristic  sj^mptom  is  what  is  known  as  scanning  speech, 
a  slow,  measured,  yet  indistinct  and  obscure  utterance,  depending  upon  dis- 
turbances in  the  innervation  of  the  tongue  and  larynx,  probably  caused  by 
sclerotic  patches  in  the  pons  and  medulla  oblongata.  There  maj^  be  tremor 
in  the  tongue  and  lips  when  speaking.  The  third  symptom  is  nystagmus — 
oscillatory  or  lateral  movements  of  the  eyeballs  when  the  eyes  are  directed 
to  an  object.  In  addition  there  may  be  spastic  symptoms  manifested  chiefly 
in  the  presence  of  increased  reflexes — including  periosteal  as  well  as  tendon 
reflexes — in  both  upper  and  lower  extremities,  but  the  skin  reflexes  remain 
normal.  There  is  ankle  clonus,  and  the  gait  is  often  spastic.  Paresis,  at 
first  absent,  ultimately  appears,  amounting  at  times  to  complete  paralysis. 
Indeed,  spastic  rigidity  and  paresis  may  be  among  the  earliest  signs  of  the 
disease.  The  sphincters  remain  intact,  at  least  until  toward  the  close. 
There  are  no  disturbances  of  sensibility  in  the  majority  of  cases.  Optic 
atrophy  is  present  in  40  per  cent,  of  cases  and  in  15  per  cent,  in  tabes  dorsalis, 
and  is  associated  with  such  derangements  of  vision  as  amblj'opia,  achromat- 
opia,  and  even  blindness.  Optic  neuritis  may  occur  with  subsequent  atrophy, 
especially  in  the  temporal  halves  of  the  optic  nerve.  There  may  be  also 
derangements  of  innervation  with  diplopia. 

Mental  weakness  and  imbecility  are  sometimes  present,  more  rarely 
melancholia  or  exaltation.  Apoplectiform  attacks  also  occur,  foUowning  pro- 
dromal symptoms,  such  as  vertigo  and  headache,  and  succeeded  by  hemi- 
plegia, which,  however,  subsequently  disappears. 

Diagnosis. — This  is  not  difficult  in  typical  cases.  The  intention  tremor, 
the  scanning  speech,  and  nystagmus  are  characteristic,  and  when  associated 
with  spastic  weakness,  the  diagnosis  of  multiple  sclerosis  is  probably  correct. 
The  apoplectiform  seizures  and  mental  weakness  are  also  valuable  signs. 
When  the  symptoms  are  mixed  with  those  of  other  ner\^ous  lesions,  diagnosis 
is  not  so  easy.  In  paralysis  agitans  tremor  occurs  during  rest  as  well  as  in 
motion;  in  multiple  sclerosis  only  when  motion  is  attempted.  Strumpell 
says :  "The  circumstance,  indeed,  that  the  anomalous  cases  will  not  properly 
fit  the  molds  of  any  other  form  of  disease  should  make  us  think  of  the  possi- 
bility of  multiple  sclerosis." 


PARETIC  DEMENTIA  1059 

The  disease  known  as  pseudo  sclerose  en  plaques,  described  by  Westphal, 
seems  to  have  most  of  the  symptoms  of  multiple  sclerosis  except  nystagmus. 
The  tremor  movements  are  said  to  be  more  violent.  Strumpell  has  found 
slight  degeneration  of  the  pyramidal  tracts  in  a  few  cases  of  this  kind.  It 
is  probably  a  diffuse  sclerosis  which  is  not  always  easy  to  detect  with  the 
microscope,  but  may  be  sufficient  to  cause  a  peculiar  hardness  of  the  brain 
and  cord  before  they  have  been  put  in  any  hardening- fluid. 

Prognosis. — This  is  unfavorable  after  a  long  and  tedious  course,  termi- 
nating in  the  bedridden  state. 

Treatment. — This  is  unavailing.  The  end  possibly  may  be  delaj^ed  by 
galvanism  and  tepid  bathing. 

PARETIC  DEMENTIA. 

Synonyms. — Chronic   Diffuse   Meningo-encephalitis;    Dementia   Paralytica; 
General  Paresis;  Progressive  General  Paralysis  of  the  Insane. 

Definition. — A  chronic  progressive  meningo-encephalitis,  or  meningo- 
rachitis,  with  resulting  mental  and  motor  derangements,  terminating  in 
dementia  and  paralysis. 

Etiology. — At  least  75  per  cent,  of  all  cases  are  caused  by  syphilitic 
infection,  and  observations  reported  by  Krafft-Ebing  seem  to  indicate  that 
the  proportion  is  much  greater.  Starting  out  with  this  assumption,  we  have 
at  once  an  explanation  of  its  greater  frequency  in  the  male  sex,  though 
many  women  have  it ;  while  it  is  rather  a  sad  commentary  on  the  fidelity  of 
man  that  it  is  much  more  frequent  among  married  men.  It  is  possible, 
however,  that  syphilis  was  contracted  before  marriage,  as  the  development 
of  paretic  dementia  may  be  delayed  for  a  number  of  years  after  a  sj^philitic 
infection.  The  fact  that  it  occurs  most  frequently  between  the  thirtieth 
and  fiftieth  years,  that  it  is  a  disease  of  the  better  classes — especially  army 
officers  and  artists — and  that  it  is  pre-eminently  a  disease  of  the  cities, 
should  be  added.  Although  other  factors  apparently  enter  into  the  causa- 
tion of  general  paresis,  those  who  have  most  closely  studied  the  subject  are 
disposed  to  assign  to  them  a  predisposing  role.  Such  influences  are  heredity 
and  exhausting  mental  work,  such  as  comes  of  public  political  life  and 
ambitious  financial  ventures.  Intemperance,  chronic  lead-poisoning,  and 
traumatism  are  included  among  causes. 

Morbid  Anatomy. — An  atrophy  of  the  brain,  and  especially  of  the  frontal 
lobes,  may  be  set  down  as  the  most  important  morbid  change.  The  convo- 
lutions are  wasted  and  pale  in  color,  the  fissures  are  wider,  and  the  weight 
of  this  portion  is  reduced  to  one-fourth  or  one-third  the  normal,  while  the 
consistence  is  firmer  and  more  resisting  to  section.  Other  macroscopic 
changes  are  a  thickening  of  the  dura  mater,  pachymeningitis  interna,  edema 
of  the  pia  with  thickening,  opacity,  and  adhesion  to  the  cortex.  Minute 
examination  of  the  cortex  recognizes  thickening  of  the  vessel-walls  and  cellular 
infiltration  of  the  adventitia  of  the  arterioles  and  lymphatic  sheaths — in 
other  words,  the  effects  of  mild  inflammation.  To  these  are  added  demon- 
strable destruction  of  nerve  elements,  especially  of  the  fine  medullary  nerve 
fibrils  known  as  "tangential  fibers"  in  the  frontal  convolutions,  island  of 
Reil,  and  elsewhere;  also  atrophy  of  the  ganglion  cells.  Associated  with 
this  are  neuroglia  proliferation  and  numerous  Deiters'  spider  cells.     Here 


1060  DISEASES  OF  THE  NERVOUS  SYSTEM 

enters  a  contested  question  as  to  whether  the  nerve  changes  are  primary', 
or  secondary  to  an  interstitial  encephaUtis.  Tuczek,  Wernicke,  and 
Strtimpell  hold  to  the  former  view;  while  Rindfieisch  and  Mendel  adopt  the 
latter,  making  the  destruction  of  nervous  tissue  secondary  to  the  overgrowth 
of  neuroglia. 

The  white  matter  is  also  involved,  the  central  ganglia  as  well.  Coin- 
cident changes  in  the  spinal  cord — first  described  by  Westphal — consisting 
in  fascicular  systemic  degeneration  of  the  lateral  columns  and  posterior 
columns,  either  alone  or  jointly,  are  quite  constantly  present.  To  these  is 
ascribed  a  large  part  of  the  ataxic  and  spasto-paralytic  symptoms.  From 
this  brief  statement  of  the  character  and  situation  of  the  morbid  changes 
it  will  be  seen  that  they  are  widespread,  while  they  are  also  degenerative. 

Symptoms. — So  widely  scattered  a  distribution  of  morbid  changes 
naturally  brings  about  corresponding  differences  in  the  variety  and  severity 
of  the  symptoms.  As  further  characteristic,  no  absolute  constancy  is  ob- 
served in  the  order  of  their  development.  As  a  rule,  however,  the  first 
stage  is  characterized  by  abnormal  mental  processes,  and  these  are  at  first 
what  may  be  comprehended  under  the  single  expression  peculiarity  or  "  queer- 
ness"  oj  conduct.  The  patient  will  perform  acts  wholly  unnatural  to  him, 
and  will  surprise  his  friends  and  family  by  breaches  of  decorum  and  morality. 
An  apathy  and  loss  of  memory,  causing  the  omission  of  obligations,  are  also 
constant.  At  first  these  may  pass  unnoticed  as  temporary,  but  their  per- 
manence is  gradually  established.  In  lieu  of  this  may  be  present  an  irri- 
tability and  intense  restlessness,  so  that  the  patient  cannot  remain  in  one 
spot,  but  walks  constantly  to  and  fro.  Not  often  in  this  stage  is  there 
much  volubility,  but  rather  a  morose  silence  is  observed.  In  this  stage,  too, 
the  patient  may  make  rash  and  ruinous  financial  ventures,  and  lose  his  own 
money  and  that  of  his  friends,  or  he  may  become  wevy  generous,  giving  away 
freely  all  he  possesses,  and  more,  too.  The  power  of  arithmetical  calcula- 
tion is  defective  or  gone.  He  may  be  self-satisfied  and  intensely  egotistical. 
On  the  other  hand,  he  may  be  conscious  of  these  ills  and  be  anxious  about 
them,  as  well  as  experience  a  discomfort  or  malaise,  for  which  he  may  con- 
sult the  physician. 

Nor  are  motor  disturbances  wholly  wanting  in  the  first  stage.  They  are 
chiefly  derangements  of  speech  and  handwriting,  and  are  of  no  smaU  diagnostic 
value.  The  speech  is  slow  and  hesitating,  yet  the  patient  stumbles  over 
syllables,  especially  when  the  word  is  complex  or  rather  diflScult  to  enunciate. 
As  to  the  handwriting,  it  is  tremulous,  characterized  by  the  omission  of 
letters  and  substitution  of  wrong  ones,  as  well  as  erroneous  spelling — aU 
motor  defects. 

Other  symptoms  of  the  first  stage  are  inequality  oJ  the  pupils,  ocular 
paralysis,  in  tabetic  cases  often  reflex  immobility  of  the  pupils.  There 
may  be  absence  of  the  patellar  reflexes,  and  in  spastic  cases  increase  of 
reflexes.     There  may  be  neuralgic  pain  and  attacks  of  migraine. 

The  second  stage  is  characterized  by  more  exalted  mental  symptoms  and 
excitement,  with  a  higher  degree  of  motor  disturbance.  The  former  consist 
in  exaggeration  of  all  previously  maintained  mental  symptoms,  amounting 
to  noisy,  boisterous,  and  maniacal  excitement,  and  even  uncontrollable 
violence.     In    this   stage    belong,    too,    those   extraordinary    delusions   of 


PARETIC  DEMENTIA  1061 

grandeur — expansive  delirium — in  which  the  patient  imagines  himself  or 
herself  to  be  a  person  of  great  consequence  and  unlimited  wealth.  This  is 
not,  however,  invariable,  and  there  may  be  an  exaggerated  degree  of  the 
opposite  condition  of  melancholy  sometimes  present  in  the  first  stage,  or 
the  two  conditions  of  delirium  and  depression  may  alternate  or  may  be 
absent.  Sleeplessness  may  be  added  to  restlessness  and  mental  excitement, 
causing  rapid  decline  of  strength. 

Motor  disturbances  are  greatly  increased  in  this  stage,  but  a  uniform 
order  of  invasion  is  by  no  means  always  observed,  while  remissions  and 
temporary  improvement  are  often  noticed.  Speech  becomes  almost  im- 
possible and  incomprehensible.  There  is  paraphasia — persistent  repetition 
of  words — and  reading  and  writing  are  impossible.  The  voice  can  no  longer 
be  modulated,  and  is  weak  and  rough  from  imperfect  innervation  of  the 
vocal  cords. 

The  gait  becomes  defective,  and  the  patient  often  trips  in  walking. 
There  may  be  ataxia  and  other  tabetic  symptoms ;  apoplectic  seizures  with 
paralysis;  or  epilepsy  with  grand  or  petit  mal  and  aura,  sometimes  one- 
sided and  followed  by  monoplegia  or  hemiplegia.  There  maj'  be  loss  of 
sensibility  with  bladder  and  rectum  paralysis.  The  tendon  reflexes  may  be 
lost  and  the  pupil  be  immobile,  or  the  opposite  condition  of  spasm  with 
increased  tendon  reflexes  prevails.  The  -paxdlytic  attacks  may  occur  in 
the  earlier  stages,  though  in  mUd  degree,  manifested  by  vertigo  or  obscura- 
tion and  loss  of  consciousness,  lasting  for  a  short  time  and  then  passing 
away.  There  may  be  local  twitching  in  the  face  and  extremities  and  even 
typical  Jacksonian  epilepsy.  Finally,  bulbar  symptoms  may  appear  with 
invasion  of  the  medulla  oblongata.  Ultimately,  the  patient  becomes  help- 
less, bedridden,  and  completely  demented,  dying  from  exhaustion  or  inter- 
current disease.  In  a  few  cases  none  of  the  mental  symptoms  described 
are  present,  but  a  gradual  decline  of  mental  power  takes  place  until  com- 
plete dementia  supervenes. 

An  acute  variety  is  also  sometimes  met,  properly  termed  "galloping," 
in  which  the  disease  runs  its  whole  course  in  a  few  months,  and  is  especially 
characterized  by  emaciation  and  rapid  loss  of  strength  due  to  restlessness, 
sleeplessness,  and  insufficient  food.  The  pulse  and  temperature  are  essen- 
tially normal,  or  at  least  there  are  not  characteristic  variations. 

Diagnosis. — To  recognize  paretic  dementia  ab  initio  is  perhaps  impos- 
sible, but  to  watchful  observation  the  disease  commonly  reveals  itself  after 
the  symptoms  have  existed  for  a  short  time.  The  early  symptoms  resemble 
those  of  neurasthenia,  but  differ  from  those  of  the  latter  disease  in  their 
steady  progression.  Other  affections  possibly  mistaken  for  it  are  cerebral 
syphilis,  tumors  of  the  brain,  and  multiple  sclerosis.  In  cerebral  syphilis 
the  onset  is  usually  more  sudden,  and  paralytic  symptoms  appear  earlier. 
Headache  is  more  frequent  and  severe,  and  there  may  be  convulsi\e  seizures; 
affections  of  the  tongue  and  speech  are  wanting,  while  the  train  of  mental 
symptoms  is  less  complete  and  characteristic,  and  expansive  delirium,  as 
a  rule,  does  not  occur.  The  epilepsy  is  more  commonly  Jacksonian.  It  is 
to  be  remembered  that  the  syphilitic  virus  produces  both,  and  it  is  not  un- 
natural that  the  two  should  sometimes  merge.  Tumors  of  the  brain  fre- 
quently, but  not  always,  produce  symptoms  more  localized,  and  often  also 


1062  DISEASES  OF  THE  NERVOUS  SYSTEM 

optic  symptoms,  including  choked  disk.  The  symptoms  of  insular  sclerosis, 
which  include  dementia,  are  often  identical  with  those  of  paral>'tic  dementia, 
and  the  two  diseases  cannot  then  be  differentiated.  Intention  tremor  is 
more  characteristic  of  sclerosis.  The  cerebral  symptoms  of  some  forms 
of  plumbism,  it  is  said,  also  sometimes  closely  resemble  those  of  parahi;ic 
dementia. 

Prognosis. — The  prognosis  is  almost  always  unfavorable,  although  the 
course  of  the  disease  varies  somewhat.  The  most  rapid  cases  of  the  gallop- 
ing form  may  terminate  in  a  few  months,  but  two  or  three  years  is  the  more 
usual  duration;  sometimes  much  longer,  it  may  be  lo  years  or  more.  Death 
ensues  from  exhaustion,  hastened  by  the  complications  and  secondary  con- 
ditions which  naturally  supervene  on  an  illness  so  prolonged  and  in  which 
nutrition  is  so  interfered  with ;  or  it  may  be  due  to  intercurrent  disease. 

Treatment. — In  view  of  the  general  acknowledgment  of  the  syphilitic 
origin  of  chronic  diffuse  meningo-encephalitis,  antisyphilitic  treatment  has 
been  employed  but  with  little  success,  as  it  cannot  restore  degenerated 
tissue  and  probably  cannot  arrest  active  degenerations.  The  treatment  is 
confined  mainly  to  iodids,  mercurials  and  salvarsan.  Mercurials  are  best 
used  by  inunction  or  hypodermatic  injections,  and  the  iodids  in  ascending 
doses. 

As  to  the  rest,  treatment  must  be  symptomatic.  The  bromids  and 
chloral,  with  quiet,  hygienic  surroundings,  and  sometimes  enforced  retire- 
ment, are  measures  demanded  for  the  relief  of  the  nervous  excitement. 

For  the  opposite  condition  of  depression  and  melancholia  change  of  scene 
by  travel  and  residence  in  different  localities  should  be  enjoined.  Further 
than  this  the  use  of  a  proper  hygiene,  with  bathing,  frictions,  wholesome 
outdoor  life,  and  an  abundance  of  nourishing  and  easily  assimilable  food  con- 
stitute about  the  sum  of  the  means  we  can  bring  to  bear  against  the  disease. 

PARALYSIS  AGITANS. 

Synonyms. — Chorea  scelotyrbe  sive  festinans  (Sauvages);  Chorea  procursiva 
(Bernt) ;  Shaking  Palsy;  Parkinson's  Disease. 

Definition. — A  chronic  nervous  disease  characterized  by  muscular  weak- 
ness, tremor,  or  shaking  in  the  extremities,  muscular  rigidity,  and  forward- 
bent  gait. 

Etiology. — Shaking  palsy  is  commonly  a  disease  of  the  second  half  of 
life,  but  occasionally  occurs  between  30  and  40,  and  has  been  observed  as 
early  as  the  twentieth  year.  It  is  a  little  less  frequent  among  women  than 
men — 11  to  14.  Among  the  causes  held  responsible  for  it  are  fright,  mental 
excitement,  business  worry,  injury — whether  to  nerves  or  other  parts  of  the 
body— alcoholism,  sexual  excesses,  and  the  infectious  diseases,  including 
malaria,  while  heredity  is  said  to  have  a  slight  influence.  The  etiology  of 
the  disease  is  largely  a  matter  of  conjecture  and  inference. 

Morbid  Anatomy. — This  is  unknown  so  far  as  essential  lesions  are 
concerned.  Various  lesions  have  been  described,  while  the  brain,  spinal 
cord,  and  peripheral  nerves  of  the  most  typical  cases  have  been  examined 
with  results  not  entirely  satisfactory. 

As  the  phenomena  are  similar  in  kind,  if  not  in  degree,  to  those  of  senility, 


PARALYSIS  AGITANS  1063 

it  is  held  by  Dubief ,  Borgherini,  Koller,  Sass,  Jacobson,  Ketscher,  and  Sanders 
that  they  have  for  their  anatomical  basis  the  lesions  of  senility  somewhat 
intensified,  and  that  the  disease  differs  from  true  senility  only  in  its  earlier 
onset.  Other  investigators  conclude  that  this  is  not  the  case,  and  that  paraly- 
sis agitans  is  a  disease  sui  generis,  although  there  are  many  changes  in  the 
spinal  cord  and  brain,  which  are  common  to  the  two  affections,  consisting 
essentially  in  increase  in  interstitial  tissue  and  proliferation  of  neuroglia 
cells  in  the  spinal  cord,  medulla  oblongata,  pons,  and  the  motor  cortex  in  a 
less  degree.  Some  investigators  attribute  paralysis  agitans  to  abnormal 
conditions  of  the  ductless  glands,  but,  the  pathology  of  this  disease  is  un- 
known, and  is  at  present  a  subject  for  speculation. 

Symptoms. — The  disease  is  not  a  very  rare  one  in  this  country,  and  the 
county  almshouses  almost  always  contain  one  or  more  cases — easily  rec- 
ognized by  the  characteristic  shaking  or  tremulousness  of  the  hand.  Though 
commonly  gradual  in  onset,  the  symptoms  may  come  on  quite  suddenly,  and 
at  first  only  after  exertion.  Indeed,  there  may  even  be  a  prodrome  in  the 
shape  of  neuralgic  pains,  paresthesia,  dizziness,  and  the  like.  The  more  sud- 
den cases  follow  fright  or  trauma.  The  tremor  is  most  marked  in  the  fingers 
and  hands,  where  it  commonly  begins,  and  whence  it  extends  to  the  arms  and 
lower  extremities.  The  upper  arm  muscles  are  rarely  involved.  It  most 
frequently  passes  from  the  right  arm  to  the  right  leg,  thence  into  the  left 
arm,  and  thence  into  the  left  leg;  or  the  course  may  be  crossed — that  is,  from 
the  right  arm  to  the  left  leg.  It  may  remain  in  one  limb  to  the  exclusion  of 
the  others.  In  the  fingers  the  movements  between  the  thumb  and  index- 
finger  is  frequently  that  of  rolling  pills,  but  the  movement  may  not  always  be 
characteristic.  At  the  wrist  it  is  one  of  pronation  and  supination.  In  the 
feet  it  is  most  marked  at  the  ankle-joint.  It  affects  the  writing,  making  it 
trembling,  as  in  the  aged,  and  ultimately  it  becomes  impossible  to  write. 
The  muscles  of  the  head  and  face  are  last  involved,  sometimes  not  at  all,  and 
when  present,  the  motion  is  vertical  and  quite  rhythmical,  usually  about  five 
times  in  a  second.  At  first  the  tremor  ceases  during  sleep,  but  continues 
during  the  waking  state  even  when  the  muscles  are  at  rest,  but  ultimately 
it  continues  even  during  sleep — in  fact,  sleep  is  sometimes  prevented  thereby. 
It  frequently  is  partially  arrested  by  voluntary  motion  and  is  increased  by 
emotion.     Should  rigidity  become  excessive,  the  motion  may  cease. 

The  rate  of  tremor  varies  greatly,  being  at  first  slower,  and  increases  in 
rapidity  as  the  disease'  advances.  Roughly,  it  may  be  put  down  at  from 
three  to  five  times  a  second.  There  may  be  intermissions  of  the  tremor 
of  days  and  even  weeks. 

Muscular  weakness  is  a  less  striking  symptom,  but  may  be  estimated  by 
the  dynamometer,  and  increases  with  the  duration  of  the  disease  and  the  in- 
tensity of  the  tremor.  It  is  most  striking  at  least  in  the  extensor  muscles, 
the  flexors  being  disposed  to  rigidity  and  spasm,  which  early  produce  a  slow- 
ness and  stiffness  of  motion  which  is  characteristic.  It  is  this  flexor  spasm 
which  brings  the  thumb  and  forefinger  into  the  writing  or  pill-rolling  position. 
At  other  times,  hyperaction  of  the  interossei  muscles  over  that  of  the  common 
extensors  of  the  fingers  results  in  the  position  so  characteristic  of  arthritis 
deformans — ^that  is,  with  the  first  phalanx  bent,  the  second  extended,  and 
the  terminal  phalanx  also  bent.  Ultimately  extension  is  impossible. 
Occasionally  the  opposite  state  of  fixed  extension  exists. 


1064  DISEASES  OF  THE  XERVOUS  SYSTEM 

The  attitude  and  gait  ultimately  assumed  by  the  subject  of  shaking  palsy 
are  also  the  result  of  rigidit}',  which  sooner  or  later  affects  most  of  the  muscles. 
The  head  is  bent  forward,  the  back  is  bowed,  the  arms  are  held  away  from 
the  body  and  flexed  at  the  elbows,  and  the  knees  are  approximated  so  that 
they  are  often  rubbed  in  walking;  while  the  general  appearance  is  that  of  a 
man  in  danger  of  falling  forward.  The  position  of  the  body  due  to  flexion 
also  gives  rise  to  a  "propulsive "  gait,  caused  by  carrying  forward  the  center 
of  gravity,  so  that,  when  started,  the  patient  is  likely  to  "get  a-going"  and 
cannot  stop  until  he  comes  up  against  some  object.  On  the  other  hand,  a 
push  backward,  bringing  the  center  of  gravity  behind  the  point  of  support,  is 
apt  to  make  the  patient  fall,  because  be  cannot  move  back  fast  enough 
to  save  himself  by  "retropulsion."  Charcot  regards  both  these  phenomena 
as  "forced  movements,"  but  Strumpell  prefers  to  explain  them  by  simple 
physical  laws,  as  previously  described.  Sometimes  the  characteristic  posi- 
tion of  the  patient  exists  without  the  shaking,  and  for  this  the  name  ' '  paraly- 
sis agitans  sine  agitatione"  has  been  employed. 

The  similarity  in  the  rigid  bent  condition  of  the  vertebral  column  and  the 
deformities  of  the  hands  in  this  disease  and  rheumatoid  arthritis,  together 
with  other  points  of  resemblance  has  suggested  to  W.  G.  Spiller  a  similar 
origin  of  the  two  diseases. 

The  facial  expression  is  also  very  strikingly  altered.  The  face  is  indeed 
without  expression,  stiff  and  mask-like,  giving  rise  to  the  name  "Parkinson's 
mask."  There  is  often  a  dribbling  of  saliva  from  the  partially  closed  mouth. 
On  the  other  hand,  sometimes  the  mouth  is  kept  closed,  and  is  found  full  of 
saliva — a  condition  ascribed  to  delayed  deglutition  rather  than  to  increased 
secretion.  The  speech  is  slow,  hesitating,  and  monotonous,  and  the  voice 
may  be  piping  and  shrill.  On  the  other  hand,  if  the  lips  and  tongue  share  in 
the  tremor,  the  speech  is  stuttering,  as  though  the  patient  were  in  a  hurry  to 
speak — quite  different  from  the  scanning  speech  of  insular  sclerosis. 

The  remaining  nervous  and  organic  functions  are  essentially  normal. 
Sensation  is  usually  unaltered,  and  the  bowels  and  bladder  are  usually  un- 
affected, as  is  also  the  temperature,  although  it  is  said  that  the  surface 
temperature  is  sometimes  elevated.  Charcot  has  noticed  an  alteration 
of  the  temperature  sense.  There  is  sometimes  a  tendency  to  unnatural 
perspiration. 

Diagnosis. — This  is  usually  very  easy,  and  can  generally  be  made  at  a 
glance.  Multiple  sclerosis  resembles  it  in  some  respects.  Both  have  tremor, 
but  in  multiple  sclerosis  this  is  shown  more  particularly  when  the  patient 
attempts  to  do  something,  as  to  bring  a  glass  of  water  to  his  lips  or  approxi- 
mate his  fingers.  The  speech  is  rhythmical,  "scanning,  "  instead  of  stutter- 
ing, as  in  shaking  palsy;  there  is  nystagmus,  and  the  disease  begins  almost 
invariably  in  the  lower  extremities,  while  the  attitude  is  not  that  of  paralysis 
agitans.  Chorea  is  characterized  by  movements,  but  these  are  irregular 
and  more  intermittent. 

Prognosis. — A  well-established  case  of  paralysis  agitans  is  not  curable 
by  medicines.  On  the  other  hand,  the  disease  lasts  indefinitely,  the  patient 
getting  slowly  worse,  with  perhaps  the  intermissions  alluded  to,  until  he  dies 
of  some  intercurrent  disease  or  from  the  effects  of  some  accident  growing 
out  of  his  condition. 


TUMORS  OF  THE  BRAIN  1065 

Treatment. — ^Under  the  circumstances  this  must,  for  the  most  part,  be 
by  tonics  and  general  hygienic  measures.  As  the  disease  advances  the 
patient  should  be  guarded  against  accident;  and  especially  when  in  bed  his 
position  should  be  changed  for  him  if  he  cannot  change  it  himself,  as  is  often 
the  case. 

Cases  have  improved  under  the  use  of  the  iodid  of  potassium  and  arsenic, 
and  hyoscin  has  been  especially  recommended  by  Erb — hypodermically, 
in  doses  of  from  1/150  to  i/ioo  of  a  grain  (0.00044  to  0.00066  gm.)  of  the 
hydrobromate,  but  it  may  be  given  by  the  mouth.  Good  results  have  also 
been  reported  from  the  use  of  atropin,  of  which  from  i/ioo  to  1/60  grain 
(0.00066  to  0.00 1 1  gm.)  may  be  used  subcutaneously  or  by  the  mouth. 

Measures  calculated  to  improve  the  general  health  are  indicated,  such 
as  sea-bathing,  massage,  electricity,  fresh  air,  and  outdoor  life. 

Other  Forms  of  Tremor. 

Synonym. — Ballismus. 

In  addition  to  the  tremor  in  paralysis  agitans,  a  similar  tremor  occurs 
under  other  circumstances,  sometimes  without  assignable  cause,  when  it  is 
known  as  simple  tremor,  or  it  may  be  induced  by  fright  or  overexertion. 
A  hereditary  tremor  has  been  described  by  C.  L.  Dana.  Senile  tremor  is 
the  well-known  form  of  tremor  which  comes  on  with  advancing  years,  at 
times  earlier  than  others,  but  usually  not  until  after  70  years.  The  existence 
of  a  tremor  due  to  senility  was  denied  by  Charcot,  but  is  accepted  by  most 
neurologists. 

Toxic  tremor  is  due  to  a  number  of  toxic  agents,  among  which  tobacco 
and  alcohol  are  the  most  frequent.  Lead  and  excessive  drinking  of  tea  or 
coffe  are  other  causes.  Finally,  hysterical  tremor  occurs  as  a  part  of  hyster- 
ical phenomena  in  women.  Asthenic  tremor  is  due  to  simple  weakness,  and 
is  especially  seen  in  exertion  during  convalescence  from  acute  disease. 

TUMORS  OF  THE  BRAIN. 

Synonyms. — Neoplasmata  cerebri;  Intracranial  Tumors. 

Definition. — Cerebral  tumors,  clinically  considered,  include  not  only 
tumors  of  the  meninges  and  substance  of  the  brain,  but  also  all  intracranial 
and  even  such  extracranial  tumors  as  ultimately  invade  the  brain.  Among 
the  latter  are  tumors  of  the  orbit  or  nasal  cavitj^  of  the  antrum,  and  of  the 
sphenopalatine  fossa. 

Varieties. — The  principal  varieties  of  cerebral  tumor,  approximateh^ 
in  the  order  of  frequency,  are ; 

I.  Glioma.  2.  Tyroma,  or  tuberculous  tumor.  3.  Sarcoma  4.  Car- 
cinoma. 5.  Cystic,  including  parasitic  cysts  and  cysts  arising  in  sarcomata 
and  gliomata.  6.  Gumma.  7.  Histioid  tumors.  Among  these  occur  in 
irregular  order,  cholesteatoma,  lipoma,  myxoma,  angioma,  fibroma,  psam- 
moma.  Even  dermoid  cysts,  as  well  as  parasitic  cysts — including  the 
echinococcus  or  hyatid  cyst  and  the  cysticercus  cellulosae,  are  met.  Of 
these  tumors,  psammoma  and  glioma  are  peculiar  to  the  brain.     According 


1066  DISEASES  OF  THE  NERVOUS  SYSTEM 

to  M.  Allen  Starr's  tables,  gliomata  and  gliosarcomata  practically  equal  in 
number  the  sarcomata,  but  the  term  gliosarcoma  is  regarded  by  many 
unfavorably. 

Etiology. — Tubercle  is  more  common  in  childhood;  parasites,  glioma, 
sarcoma,  and  gumma  in  early  and  middle  life,  and  cancer  in  middle  and  late 
life,  but  is  rare  even  then.  Brain  tumors  of  any  kind  are  rare  after  60. 
Heredity  appears  to  have  slight,  if  any,  influence.  A  few  brain  tumors  are 
metastatic,  especially  carcinoma,  and  to  a  less  degree  sarcoma.  Eichhorst 
relates  several  remarkable  cases  in  which  trauma  seemed  to  be  the  ex- 
citing cause. 

Distribution. — Certain  tumors  seek  by  preference  special  localities. 
Thus,  tuberculous  tumors  are  most  numerous  in  the  cerebellum  and  about  the 
base  of  the  brain.  Glioma  starts  from  the  neuroglia  in  any  part  of  the  brain, 
but  more  frequently  the  cerebrum  or  pons,  and  may  also  attain  a  large  size 
— larger  than  any  other  brain  tumor ;  it  is  further  characterized  at  times  by 
its  great  vascularity,  leading  sometimes  to  rupture  and  apoplectic  symptoms. 
Glioma  may  also  occur  in  the  eye.  Sarcoma  develops  most  frequently  in  the 
membranes  of  the  brain  and  sheaths  of  the  vessels;  it  may  be  primary  or 
secondary;  it  is  often  encapsulated  and  often  appears  as  endothelioma. 
Myxoma  and  fibroma  occur  in  the  same  localities.  Carcinoma  is  usually 
secondary,  but  may  be  primary ;  it  arises  more  frequently  in  the  membranes 
or  pituitary  body,  but  may  be  found  in  the  substance  of  the  hemispheres; 
it  is  especially  secondary  to  primary  cancer  of  the  breast,  lungs,  or  pleura. 
Syphiloma  elects  the  cerebral  hemispheres  or  the  pons  and  vicinity;  it  is 
generall)^  superficial,  grows  from  the  meninges,  or  is  attached  to  arteries, 
attaining  sometimes  a  large  size.  It  may  be  multiple.  Parasitic  tumors  are 
found  in  the  membranes,  the  substance  of  the  brain,  and  the  ventricles. 
The  hydatid  cysts  developed  by  the  echinococcus  are  usually  on  the  surface 
of  the  brain;  the  cysticercus,  usually  multiple,  on  the  surface  or  in  the  ven- 
tricles. Psammoma,  or  sand  tumor,  is  found  commonly  in  the  neighborhood 
of  the  pineal  gland. 

Symptoms. — The  symptoms  of  cerebral  tumor  are  in  no  way  specialized 
by  the  kind  of  tumor  present,  and  depend  entirely  upon  the  effect  exerted 
on  the  surrounding  brain  substance,  chiefly  by  pressure.  They  do,  however, 
vary  somewhat  with  the  part  of  the  brain  involved.  It  occasionall}' 
happens  that  a  brain  tumor  may  produce  no  sjTnptoms  whatever,  being 
thoroughly  latent,  and  disclosed  only  by  the  autopsy.  On  the  other  hand, 
apparently  insignificant  tumors  cause  very  decided  sjonptoms.  Such 
differences  may  depend  in  part  on  the  location  of  the  tumor,  and  in  part  on 
the  rapidity  of  its  development. 

As  in  all  local  diseases  of  the  brain,  two  sets  of  symptoms  usually  present 
themselves:  (i)  Diffuse  and  (2)  focal  symptoms. 

I.  Diffuse  or  General  Symptoms. — These  are  symptoms  which  may  be 
associated  with  various  forms  of  nervous  disease.  The  most  constant  of 
these  is  perhaps  headache,  which  varies  in  intensity  and  constancy.  Prob- 
ably the  severest  headaches  human  beings  suffer  are  caused  by  brain  tumors, 
exhibiting  every  variety  of  pain — sharp,  cutting,  shooting,  boring,  or  dull 
and  pressing.  At  times  it  is  moderate,  producing  a  sense  of  discomfort  only. 
It  may  be  intermittent  or  constant.     It  mav  be  over  the  entire  head,  or 


TUMORS  OF  THE  BRAIN  10G7 

half  of  it,  or  be  still  more  localized  in  the  forehead  or  back  of  the  head,  extend- 
ing also  from  the  former  over  the  face  and  the  latter  down  the  neck.  It  may 
be  increased  by  mental  excitement  of  any  kind,  by  noise,  or  by  alcoholic 
drink  or  strong  light.  There  may  be  tenderness  on  pressure,  or  pain  in  per- 
cussing the  head.  The  seat  of  pain  is,  however,  for  the  most  part,  no  indi- 
cation of  the  seat  of  the  tumor,  though  the  presence  of  pain  limited  to  the 
occiput  and  back  of  the  neck  suggests  a  tumor  in  the  posterior  fossa  of  the 
skull,  the  occiput,  or  the  cerebellum.  Localized  pain  on  tapping  the  skull 
is  a  more  reliable  index. 

Astereognosis  is  an  occasional  symptom. 

Vomiting  is  another  characteristic  symptom  of  brain  tumor.  It  may 
occur  independent  of  headache,  but  is  often  associated  with  it.  It  is  further 
characterized  by  being  independent  of  food  ingestion,  may  be  without  nau- 
sea, and  is  likely  to  be  worse  in  tumors  of  the  cerebellum  and  pons. 

Dizziness  is  also  a  very  frequent  symptom,  and  often  an  early  one.  It 
is  at  times  intermittent,  at  others  constant,  and  it  may  be  so  severe  as  to 
make  it  impossible  for  the  patient  to  walk.  It  is  most  serious  in  tumors  of 
the  posterior  fossa  and  of  the  cerebellum.  Along  with  vertigo  may  be 
slowing  of  the  pulse. 

Mental  symptoms  may  be  present.     They  may  be  intermittent,   and 
variously  manifested  in  peculiarities  of  temper,  such  as  suUenness,  indiffer- 
ence, absent-mindedness,  and  loss  of  memory;  or  the  opposite  condition  of  . 
maniacal  excitement  or  delirium;  or  there  may  be  drowsiness  and  even 
coma.     Such  mental  states  may,  indeed,  be  the  only  manifestations  of  timior. 

Speech. — The  patient  may  talk  slowly,  and  the  facial  expression  is  some- 
times altered. 

Apoplectic  seizures  and  epileptiform  attacks,  especially  of  the  Jacksonian 
variety,  are  distinctive  symptoms.  The  former  may  be  due  to  hemorrhages 
in  the  tumor  or  around  it,  and  may  be  followed  by  transitory  paralysis  and 
paresis.  Epileptic  convulsions,  especially  if  unilateral,  point,  though  not 
unmistakably,  to  tumors  in  the  cerebral  hemispheres  impinging  on  the 
cortex.     Choreiform  movements  are  sometimes  present. 

Choked  disk,  papilloedema  or  papillitis  and  optic  neuritis  are  the  most 
constant  and  most  valuable  diagnostic  symptoms  of  brain  tumor.  Choked 
disk  consists,  in  brief,  in  a  swelling  of  the  optic  nerve,  with  overdistension 
and  congestion  of  the  retinal  veins,  and  narrowing  of  the  retinal  arteries. 
It  is  usually  bilateral,  rarely  unilateral.  There  is  still  much  difference  of 
opinion  as  to  the  mechanism  of  choked  disk,  but  it  is  thought  by  many  to 
be  the  result  of  intracranial  pressure  forcing  the  cerebrospinal  fluid  from  the 
subarachnoid  space  into  the  lymph  sheath  of  the  optic  nerve,  causing  com- 
pression of  the  nerve  and  the  vessels  within  it.  The  vision  is  not  necessarily 
deranged  in  choked  disk,  and  its  defects  are  not  uniform,  varying  from 
slight  amblyopia  to  total  blindness.  The  swelling  may  diminish  and  im- 
provement in  vision  ensue,  but  retinitis  or  neuro-retinitis  may  set  in  with 
consequent  nerve  atrophy,  producing  permanent  impairment  of  vision. 
The  choked  disk  is  sometimes  the  only  sjTnptom  of  brain  tumor,  and  its 
subject  first  consults  the  oculist  for  relief.  On  the  other  hand,  it  is  not 
caused  by  brain  tumor  alone,  but  it  may  result  from  meningitis  or  abscess, 
in  fact  anything  which  produces  intracranial  pressure.     Papilloeden^a  occurs 


1068  DISEASES  OF  THE  NERVOUS  SYSTEM 

in  from  80  to  90  per  cent,  of  all  cases  of  intracranial  tumor.  It  may  be 
absent,  even  though  a  brain  tumor  of  considerable  .size  exists.  By  optic 
neuritis  a  milder  degree  of  papilloedema  is  generally  understood. 

The  senses  of  smell  and  hearing  may  be  impaired  by  tumors  impinging 
on  the  olfactory  or  auditory  nerves,  and  there  may  be  modifications  of 
cutaneous  .sensibility;  also  neuralgic  pains.  If  the  tumor  is  on  the  floor  of 
the  fourth  ventricle,  there  may  be  polyuria  and  glycosuria.  Finally,  sooner 
or  later  the  appetite  may  fail  and  the  nutrition  suffer,  although  the  opposite 
condition  of  large  appetite  and  good  nutrition  may  obtain.  In  the  terminal 
stage  there  may  be  irregularity  of  breathing  (Cheyne-Stokes)  and  slowing  of 
the  pulse,  while  the  final  issue  is  often  preceded  by  afebrile  movement.  The 
pulse  rate  falls  with  increasing  intracranial  pressure  often  as  low  as  48  and 
less.     It  is  not  permanent  and  may  alternate  with  frequent  pulse. 

2.  Focal  Symptoms. — These  are  symptoms  peculiar  to  the  seat  of  irrita- 
tion or  destruction,  and  become,  therefore,  of  value  in  diagnosis.  They  are 
the  results  either  of  irritation  or  destruction  of  nervous  tissue,  irritation 
causing  contraction  or  spasm,  while  destruction  causes  paresis  or  paralysis. 

Tumors  of  the  prefrontal  area,  especially  on  the  right  side,  often  give 
no  localizing  symptoms  whatever,  motor  or  sensory,  while  general  symptoms 
may  also  be  absent  and  the  tumor  truly  latent.  Then,  again,  general  symp- 
toms may  be  well  marked,  including  mental  torpor  and  imbecility,  childish- 
ness, irritability,  and  emotional  phenomena.  These  symptoms  occur  which- 
ever side  of  the  brain  is  affected,  but  possibly  are  more  pronounced  in 
tumors  of  the  left  frontal  lobe.  If  the  tumor  extends  downward  into  the 
inferior  frontal  convolution,  it  may  cause  aphasia;  or  if  backward,  it 
may  occasion  irritative  spasm  or  destructive  paralysis.  In\-olvcment  of  the 
optic  tract  may  cause  hemianopsia  and  optic  neuritis;  of  the  olfactory 
system,  anosmia;  if  the  tumor  invades  the  orbit,  oculomotor  paralysis 
and  protrusion  of  the  eye.  Percussion  tenderness  may  aid  in  localizing 
the  tumor. 

Tumors  in  or  near  the  central  or  motor  region  (possibly  true  only  of 
the  precentral  convolution)  may  cause  irritative  lesions,  resulting  in  spasm. 
If  the  tumor  is  in  or  near  the  upper  third  of  this  area,  the  spasm  may  begin  in 
the  toes,  in  the  ankles,  or  in  muscles  of  the  leg;  if  in  or  near  the  middle  third, 
spasm  beginning  in  the  fingers,  in  the  thumb,  in  the  muscles  of  the  wrist 
or  shoulder;  if  in  or  near  the  lower  third,  in  the  muscles  of  the  face,  the 
angle  of  the  mouth,  or  tongue.  In  a  word,  the  phenomena  of  Jacksonian 
epilepsy  are  present.  All  of  these  may  be  preceded  or  associated  with  sen- 
sory disturbance,  such  as  numbness  and  tingling,  and  may  be  limited  to  one 
muscle  group  before  extending  to  another,  constituting  the  "signal  symp- 
tom" of  Seguin.  There  may  be  an  aura,  and  the  muscular  sense  is  also 
sometimes  affected. 

Destructive  lesions  cause  paralysis,  and  this  may  have  the  same  dis- 
tribution as  the  convulsions  which  sometimes  precede.  If  on  the  left  side 
in  right-handed  persons,  aphasia  and  agraphia  may  result. 

3.  Tumors  of  the  parietal  area  may  produce  no  symptoms  of  sensory 
or  motor  phenomena,  but  there  may  be  impairment  of  stereognostic  percep- 
tion, and  often  of  ordinary  sensation  and  of  the  sense  of  position  with  ataxia. 
With  the  involvement  of  the  angular  g\"rus  and  lower  parietal  lobule  may 


TUMORS  OF  THE  BRAIN  1069 

come  word-blindness  and  mind-blindness.  If  the  tumor  is  upon  or  near 
the  central  area,  spasms  and  paralysis  of  the  various  muscular  groups  de- 
scribed under  2  may  develop.  Paralysis  of  the  third  nerve  has  occurred 
in  connection  with  tumors  in  the  neighborhood  of  the  angular  gyrus;  no 
satisfactory  explanation  for  this  has  been  offered — possibly  it  is  due  to 
pressure  at  a  distance. 

4.  Tumors  of  the  occipital  lobe,  if  in  the  cuneus  or  neighboring  parts, 
may  produce  homonymous  lateral  hemianopia;  and  if  double,  total  bhnd- 
ness;  if  elsewhere  on  the  left  side,  there  may  be  mind-blindness;  and  if  the 
tumor  extends  also  into  the  angular  gyrus,  word-blindness,  along  with  hemi- 
anopsia; if  obtruding  further  forward  into  the  parietal  lobe,  hemianesthesia, 
hemiataxia,  and  perhaps  some  hemiplegia  from  involvement  of  the  internal 
capsule  may  occur. 

5.  Tumors  of  the  temporosphenoidal  area  on  the  right  side  rarely  produce 
symptoms;  on  the  left  side,  in  the  posterior  part  of  the  first  and  upper 
posterior  part  of  the  second  gyrus,  they  cause  word-deafness.  Disturb- 
ances of  the  senses  of  smell  and  taste  may  result  from  involvement  of  the 
hippocampal  convolution. 

6.  Tumors  of  the  pons  and  medidla  oblongata  produce  two  sets  of  phe- 
nomena by : 

(a)  Irritation  or  destruction  of  fibers  in  the  pons  and  medulla  oblongata. 

ib)  Pressure  on  the  nerves  emerging  in  this  region. 

Either  may  occur  alone  or  both  jointly.  Lesions  here  are  especiallv 
likely  to  produce  alternate  paralysis :  that  is,  involvement  of  certain  of  the 
cranial  nerves  on  one  side  and  the  limbs  on  the  opposite  side. 

If  the  tumor  is  in  the  cerebral  peduncle,  there  may  be  a  palsy  of  the 
third  nerve  on  the  same  side  and  a  hemiplegia  on  the  opposite  side;  if  lower 
down  and  in  the  pons,  a  palsy  of  the  fifth  on  the  same  side  and  hemiplegia 
on  the  other;  if  still  lower  down,  it  may  involve  the  sixth  nerve,  producing 
internal  strabismus,  the  seventh  producing  facial  paralysis,  and  the  eighth 
causing  deafness.  If  the  tumor  is  very  large,  it  may  produce  a  hemian- 
esthesia as  well,  and  there  may  be  forced  movements  of  the  body,  either 
toward  or  from  the  side  of  lesion.  Conjugate  deviation  of  the  eyes  away 
from  the.  side  affected  may  also  occur.  This  is  in  direct  contrast  to  the 
conjugate  deviation  sometimes  noticed  in  cerebral  lesions,  in  which  the  head 
and  eyes  are  turned  toward  the  side  of  the  lesion. 

Tumors  of  the  medulla  oblongata  may  produce  hemiplegia  and  hemi- 
anesthesia, and,  if  the  tumor  is  large,  symptoms  of  bulbar  paralysis.  From 
irritation  of  nerves  on  the  same  side,  the  ninth,  tenth,  eleventh,  and  twelfth, 
difficulty  in  swallowing,  irregular  action  of  the  heart,  irregular  breathing, 
and  vomiting  may  arise.  Sometimes  also  there  is  retraction  of  the  head,  or 
sensory  symptoms  including  numbness  and  tingling  and  finally  convulsions. 
If  the  cerebellum  is  impinged  upon,  there  may  be  unsteadiness  of  gait,  but 
this  is  frequently  caused  by  implication  of  the  cerebellar  peduncles  without 
involvement  of  the  cerebellum. 

7.  Tumors  of  the  cerebellum  produce  very  characteristic  symptoms, 
though  here,  too,  there  may  be  latency  if  the  growth  is  limited  to  the  hemi- 
spheres. If  the  middle  lobe  is  invaded,  vertigo,  vomiting,  headache, 
papilloedema,  with  blindness  and  cerebellar  ataxia,  are  present.     Papilla- 


1070  DISEASES  OF  THE  XERVOUS  SYSTEM 

edema  is  more  common  in  cerebellar  than  in  cerebral  tumors  and  is  usually  an 
early  sign.  The  pressure  causing  papilloedema  is  not  directly  on  the  occipital 
lobe  or  optic  tract,  but  is  generally  on  the  cranial  contents,  and  possibly 
interference  with  the  circulation  of  fluid  in  the  ventricles  causes  pressure 
on  the  optic  chiasm  by  an  excess  of  fluid  in  the  third  ventricle.  More 
rarely  nystagmus  and  neuralgic  pains  in  the  neck  and  occiput  occur.  The 
irregvdar  and  staggering  gait  of  cerebellar  ataxia  is  very  striking,  the  patient 
reeling  like  a  drunken  man,  or  he  may  be  thrown  sideways  or  forward, 
rarely  backward,  by  forced  motion. 

If  the  medulla  oblongata  is  compressed  b}'  the  tumor,  \'omiting  from 
this  cause  may  ensue,  also  bulbar  symptoms  and  glycosuria. 

8.  Tumors  of  the  corpus  callosum  are  rare.  The  symptoms  are  similar 
to  those  of  tumors  in  the  third  and  lateral  ventricles  of  the  brain,  extending 
peripherally.  They  cause  general  symptoms  of  brain  tumor,  with  gradually 
developing  hemiplegia,  and  later  paraplegia.  With  this  there  are  mental 
dullness  and  drowsiness  and  indisposition  to  speak.  The  cranial  nerves  are 
not  involved. 

9.  Tumors  of  the  basal  ganglia  and  the  internal  capsule  pioduce  symp- 
toms similar  to  those  that  occur  in  the  corpus  callosum.  They  are  partly 
pressure  symptoms.  There  is  progressive  hemiplegia,  with  which  there  is 
likely  to  be  hemianesthesia.  Sometimes  there  are  choreic  and  athetoid 
movements  if  the  tumor  involves  the  optic  thalamus  and  adjacent  parts  of 
the  internal  capsule.  Tumors  of  the  caudate  nucleus  alone,  or  of  the  lenticu- 
lar nucleus  alone,  are  generally  latent  or  not  recognizable;  so  are  those  of 
the  anterior  three-fourths  of  the  optic  thalamus,  except  that  choreic  and 
athetoid  movements  referred  to  may  be  noticed,  due  to  irritation  of  fibers 
of  the  internal  capsule,  or,  as  supposed  by  some,  to  irritation  of  the  anterior 
cerebellar  peduncle.  Tumors  of  the  basal  ganglia  are  often  infiltrative 
(glioma)  and  therefore  cause  few  sjTnptoms  at  first.  Tumors  in  these 
areas  are  very  likely  to  give  pressure  symptoms.  A  large  tumor  of  the  thala- 
mus may  involve  the  fibers  of  the  optic  radiation  and  cause  hemianopia 
or  sometimes  hemianesthesia.  This  may  be  differentiated  from  hemianopia 
due  to  lesions  of  the  occipital  lobe  by  the  presence  of  the  hemianopic  pupil- 
lary reaction,  in  accordance  with  which  a  ray  of  light  thrown  on  the  insensi- 
tive part  of  the  retina  will  not  produce  a  reflex  contraction  of  the  pupil. 
Papilloedema  is  likely  to  be  an  early  sjTnptom  of  tumors  in  this  ^^cinity. 

10.  Tumors  of  the  corpora  quadrigemina  usually  involve  the  crura  as 
well.  They  are  characterized  by  inco-ordination,  forced  movements,  and 
oculomotor  palsies,  to  which  may  be  added  hemianopia,  or  blindness  due 
to  destruction  of  the  primary  optic  centers;  the  pupillary  reflex  is  lost  and 
there  is  nystagmus. 

11.  Tumors  of  the  crus  from  involvement  of.  the  third  ner\-e  are  espe- 
cially characterized  by  oculomotor  paralysis  on  one  (the  same)  side  and 
hemiplegia  on  the  other.     Tumors  of  the  crus  are,  however,  rare. 

12.  Tumors  of  the  base,  if  of  the  anterior  fossa,  produce  symptoms  much 
like  those  of  tumors  of  the  prefrontal  area,  adding,  however,  anosmia  from 
destruction  of  the  olfactory  lobe;  while  there  may  be  also  involvement  of  the 
optic  and  oculomotor  nerves  and  of  the  orbital  contents.  Tumors  of  the 
middle  fossa  and  of  the  interpeduncular  space  produce  pressure  on  the  optic 


TUMORS  OF  THE  BRAIN  1071 

chiasm  with  consequent  neuritis  and  bitemporal  hemianopsia,  by  which 
lesions  of  this  area  are  distinguished  from  those  in  the  anterior  fossa. 

Diagnosis. — This  consists  first  in  the  recognition  of  the  presence  of 
tumor  from  the  general  symptoms,  and  then  the  determination  of  its  loca- 
tion in  either  hemisphere  from  the  focal  symptoms.  The  same  symptoms 
may  be  produced  by  any  agency  causing  pressure  on  these  structures. 
Papilloedema,  which  is  so  constant  a  symptom  of  tumor,  may  be  caused  by 
Bright's  disease,  cerebral  syphilis,  lead  encephalopathy,  and  anemia.  The 
albuminuria,  hypertrophy  of  the  right  ventricle,  polyuria,  and  tube-casts 
usually  help  to  recognize  the  first.  Other  symptoms  of  lead-poisoning  indi- 
cate that  disease,  and  the  usual  symptoms  of  anemia  point  to  it.  Meningeal 
thickening,  hemorrhage,  aneurysm,  and  abscess  may  also  produce  pressure 
symptoms. 

The  nature  of  the  tumor  may  be  determined  in  part  by  what  has  been, 
said  of  the  preference  for  certain  localities  and  the  age  of  the  patient,  and 
in  part  by  the  history,  say  of  tuberculosis  or  syphilis  or  primarjr  growths 
elsewhere.  The  surface  temperature  is  of  uncertain  value  in  diagnosis. 
Death  may  be  sudden,  especially  from  growths  near  the  medulla  oblongata. 
It  is  usually  the  result  of  increasing  pressure.  The  X-ray  has  recently  been 
applied  to  the  diagnosis  of  brain  tumor  with  uncertain  results  in  most  cases ; 
a  change  in  the  percussion  note  over  a  tumor  is  also  of  doubtfvd  value. 

Prognosis. — This  is  generally  unfavorable.  It  is  true  that  in  some  rare 
instances  the  brain  tumors  cease  to  grow  after  a  time.  Various  observers 
find  the  ratio  of  removable  tumors  from  5  to  lo  per  cent.  Of  1121  cases 
collected  from  different  authors  by  M.  Allen  Starr  in  his  article  on  "Tumor 
of  the  Brain"  in  Dercum's  "Nervous  Diseases,"  80,  or  4.25  per  cent.,  were 
regarded  as  operable,  but  four-fifths  of  all  persons  operated  on  perish. 
Calcification  is  a  rare,  but  happy,  termination  of  tuberculous  growths. 
The  duration  of  tumor  averages  two  or  three  years;  the  extremes  range 
from  a  month  to  many  years. 

Treatment. — This  is  medicinal,  hygienic,  and  operative.  The  first  is 
limited  in  its  purpose  to  the  cure  of  syphilitic  conditions,  simulating  tumor 
and,  perhaps,  in  a  slight  degree,  to  tuberculosis.  The  astonishing  effect  of 
the  mercurial  and  iodin  treatment  upon  syphiHtic  new  formations  is  no- 
where so  well  shown  as  upon  cerebral  gumma,  but  probably  only  in  its  early 
structure.  Unless  syphilis  can  be  excluded  with  absolute  certainty,  the  iodid 
of  potassium  should  be  given  in  any  case  in  ascending  doses,  limited  only  by 
their  effects.  In  the  absence  of  syphilis  the  larger  doses  are  not  well  borne. 
In  addition,  mercury  should  be  used,  at  first  preferably  by  inunction  until 
the  specific  effect  is  produced,  after  which  it  may  be  discontinued,  to  be 
renewed  as  indicated.  Instead  of  inunction,  the  bichlorid  may  be  given  in- 
ternally in  doses  of  1/12  grain  (o  005  gm.)  three  times  daily,  or  until  the 
physiological  effects  are  produced,  or  the  salicylate  of  mercury  may  be  given 
hypodermically.  When  the  tumor  is  once  under  control,  it  is  still  necessary 
to  keep  up  the  treatment  in  such  doses  as  experience  may  determine  to  be 
necessary.  Usually  the  iodid  of  potassium  is  sufficient  for  this  purpose. 
When,  however,  the  symptoms  of  tumor  disappear  and  remain  absent  many 
years  under  iodids,  the  diagnosis  of  tumor  may  be  doubtful.  This  would 
seem  to  be  verified  by  the  following  case :     Tyson  had  under  observation 


1072  DISEASES  OF  THE  .\ERVOUS  SYSTEM 

for  30  years  a  patient  in  whom  the  disease  has  been  kept  in  check  by  a  dose 
of  60  grains  (4  gm.)  a  day,  which  had  occasionally  to  be  doubled  for  a  time. 
The  evidence  of  a  syphiHtic  lesion  in  this  case  seemed  conclusive,  since 
following  acknowledged  infection  there  occurred  secondary  symptoms  of 
syphilis,  the  full  train  of  classic  symptoms  of  brain  tumor,  including  ophthal- 
mic symptoms  studied  by  an  experienced  ophthalmologist.  The  case, 
however,  came  to  necropsy  and  only  meningitis  was  found.  If  mercury  is 
necessary  in  this  stage,  the  hiniodid  may  also  be  used  in  doses  of  from  1/24 
to  1/12  grain  (0.0025  to  0.005  grn-).  as  required,  though  I  have  not  the  con- 
fidence in  it  that  I  have  in  the  separate  use  of  the  iodid  of  potassium  and  the 
bichlorid  of  mercury. 

In  tyroma  the  usual  constitutional  treatment  of  tuberculosis  by  cod- 
liver  oil,  iron,  and  other  tonics,  with  nourishing  food  and  healthful  indoor 
and  outdoor  life,  is  to  be  carried  out. 

The  usual  remedies  indicated  to  relieve  pain  are  to  be  used,  bromids, 
if  necessary,  in  large  doses,  phenacetin,  antifebrin,  and  antipyrin,  and,  if 
necessary,  morphin.  The  ice-cap  may  be  used.  Other  symptoms  should 
be  treated  by  appropriate  remedies. 

The  hygienic  treatment  is  of  the  greatest  importance.  Excesses  of 
every  kind  should  be  avoided,  alcohol  should  be  rigidly  excluded,  as  well  as 
all  sexual  excitement  and  mental  excitement  of  any  land,  for  a  sHght  in- 
crement of  blood  in  the  brain  may  bring  on  a  convvdsion  and  cause  death. 
Exploratory  operation  being  much  less  dangerous  than  formerly,  with 
the  aseptic  precautions  of  the  present  day,  shovdd  be  made  whenever  the 
tumor  can  be  localized  with  any  approach  to  accuracy.  Although  cerebral 
localization  has  been  developed  to  a  very  high  degree,  it  must  still  happen 
that  we  frequently  fail  to  locate  a  tumor  accurately.  Cerebral  decompres- 
sion is  important  for  relief  of  symptoms,  especially  when  the  location  of 
the  tumor  cannot  be  determined,  and  if  performed  early  may  save  the  eye- 
sight as  well  as  remove  some  other  symptoms. 


SUPPURATIVE  ENCEPHALITIS. 

Synonyms. — Suppurative  Inflammation  of  the  Brain;  Cerebritis;  Abscess  of 

the  Brain. 

Definition. — By  encephalitis  is  meant  inflammation  of  the  substance  of 
the  brain  as  contrasted  \\'ith  inflammation  of  its  membranes.  What  is 
spoken  of  as  inflammation  of  the  brain  in  popular  parlance  is  really  inflam- 
mation of  the  membranes  of  the  brain,  or  meningitis.  A  literal  application 
of  the  term  encephalitis  is  here  intended. 

Etiology. — The  causes  of  cerebritis  are:  (i)  Traumatic;  (2)  and  adja- 
cent focus  of  inflammation  extending  to  the  brain  substance;   (3)  pyemia. 

Under  traumatic  causes  are  included  blows  upon  the  head  and  falls, 
more  commonly  those  attended  bj'  fracture  or  punctured  wound;  although 
it  is  not  necessarj^  that  there  should  be  even  a  scratch  upon  the  skin. 

Under  adjacent  disease,  whence  extension  of  inflammation  is  especially 
frequent,  is  to  be  included  caries  of  the  petrous  portion  of  the  temporal 
bone  due  to  disease  of  the  middle  ear  or  labyrinth,  the  most  common  of  all 


ENCEPHALITIS  1073 

causes  of  abscess  of  the  brain.  Disease  of  the  orbit  or  of  the  nasal  pas- 
sages is  another  focus  of  the  same  kind.  The  route  of  such  a  communica- 
tion may  be  through  either  the  sinuses  of  the  brain  or  the  lymph  paths. 

Pyemic  abscess  of  the  brain  is  rare.  Causal  foci  are  malignant  en- 
docarditis, gangrene  of  the  lung,  chronic  bronchitis  with  bronchiectasis,  bone 
disease,  suppuration  of  the  liver,  and  the  specific  fevers,  among  which  may 
be  included  la  grippe. 

Encephalitis  occurs  most  frequently  between  the  ages  of  lo  and  40, 
and  about  three  times  as  often  in  the  male  sex  as  in  the  female. 

Morbid  Anatomy. — Abscesses  of  the  brain  are  usually  solitary,  though 
there  may  be  two  or  three,  or  even  more.  The  abscesses  may  be  from  one- 
half  to  three  inches  (one  to  eight  cm.)  in  diameter,  rarely  more,  though  an 
entire  lobe  has  been  involved.  The  abscess  itself  is  a  very  interesting 
product.  Unless  very  recent,  it  is  surrounded  by  a  distinct  wall  which  is 
composed  of  three  layers.  The  inner  is  smooth,  made  up  for  the  most  part 
of  granular  fatty  cells.  Outside  of  this  is  a  layer  of  germinal  tissue  con- 
taining spindle  cells  and  more  perfect  fibrillated  tissue.  ExtemaUj'  again 
is  another  layer  of  fatty  cells.  The  pus  within  the  abscess  is  usually  green- 
ish-yellow in  color  and  acid  in  reaction,  while  its  corpuscles  are  distinctly 
nucleated.  The  zone  outside  of  the  abscess  is  edomatous,  the  cells  are  swollen,  ^ 
sometimes  disintegrated,  with  blood  points  scattered  throughout,  becoming 
sparser  as  the  periphery  is  extended. 

The  locality  of  the  abscess  may  be  preceded  by  the  condition  known  as 
red  softening,  which  is  often  spoken  of  as  the  first  stage  of  the  inflammation, 
but  it  is  most  important  to  remember  that  red  softening  is  not  peculiar  to 
abscess.  It  consists  simply  of  brain  substance  broken  down,  into  a  reddish, 
blood-stained  pulp.  In  this  substance  are  found  fragments  of  nerve-fibers, 
drops  of  myelin,  pus-corpuscles,  and  granular  fatty  cells.  The  termina- 
tion of  cerebritis  is  not  always  in  abscess.  It  is  barely  possible,  before  the 
stage  of  abscess  is  reached,  for  a  condition  of  yellow  softening  to  supervene, 
and  the  so-called  apoplectic  cyst  ma3'  be  the  final  result,  or  even  cicatricial 
tissue  may  develop. 

The  cerebrum  is  involved  four  times  as  often  as  the  cerebellum,  the  left 
hemisphere  more  frequently  than  the  right,  and  the  temporo-sphenoidal 
lode  more  than  any  other.  The  cause  has  something  to  do  with  the  loca- 
tion: Ear  disease  places  the  abscess  in  the  temporal  lobe  or  cerebellum;  if 
in  the  tympanum,  the  cerebrum  rather  than  the  cerebellum;  if  the  mastoid 
cells  and  labyrinth,  the  cerebellum. 

Symptoms. — While  inflammation  of  the  brain  is  spoken  of  as  acute 
and  chronic,  more  strictly  speaking  it  is  rather  primary  and  delayed,  the 
symptoms  of  the  so-called  chronic  form  being  essentially  the  same  as  those 
of  acute  cerebritis,  but  characterized  by  their  late  appearance  after  the 
cause  which  precedes  them.  In  acute  cases  the  symptoms  develop  rapidly 
and  may  run  their  course  in  a  few  days,  while  in  the  forms  known  as  chronic 
the  symptoms  are  scarcely  less  rapid  after  they  once  set  in,  which  may  be 
weeks,  months,  and  even  longer,  after  the  operation  of  the  cause. 

These  symptoms  are  the  result  of  pressure — direct  or  indirect — of 
destruction  of  the  brain  substance,  or  of  poisoning  by  absorbed  putrid 
matter.     They  are  much  the  same  as  those  of  meningitis,  with  which,  indeed, 


1074  DISEASES  OF  THE  NERVOUS  SYSTEM 

abscess  is  often  associated,  especially  if  there  is  injury.  The  most  striking 
are  headache,  often  severe  and  persistent;  vomiting;  vertigo;  mental  dullness, 
succeeded  sometimes  by  delirium  and  sometimes  by  coma.  Convulsions 
are  often  present,  and  are  epileptoid  in  character.  Optic  neuritis  is  also 
one  of  the  symptoms.  Other  cranial  nerves  beside  the  optic  arc  sometimes 
involved. 

There  is  usually  jever,  as  shown  by  elevation  of  temperature.  At  other 
times  the  temperature  is  normal  or  subnormal.  The  pulse  is  usually 
slow — from  60  to  70.  The  symptoms  may  set  in  with  a  chill  after  the 
latent  period.  The  toxic  symptoms  are  those  usual  to  toxic  states — viz., 
chill,  irregular  fever,  prostration,  emaciation,  exhaustion.  Paralysis  in 
the  form  of  hemiplegia  sometimes  occurs.  The  paralysis,  however,  is  not 
always  hemiplegic,  and  may  be  limited  to  the  arm  and  face,  especially  in 
abscess  of  the  temporo-sphenoidal  lobe,  which  may  compress  the  internal 
capsule.     If  on  the  left  side,  there  may  be  aphasia. 

When  the  abscess  is  in  the  parieto-occipital  region,  there  may  be  hemi- 
anopia.  It  is  especially  in  abscess  of  the  cerebellum  that  vomiting  occurs, 
and  staggering  if  the  middle  lobe  is  affected. 

Of  the  chronic  form  it  has  already  been  said  that  the  symptoms,  though 
long  delayed,  are  the  same  as  those  of  the  acute  form.  Such  dela}',  how- 
ever, does  not  always  cover  all  symptoms,  since  during  the  latent  stage  the 
patient  may  have  headache  or  vertigo  in  a  mild  degree,  and  especially  may 
be  irritable  and  depressed,  while  he  may  even  have  a  con\'Tilsive  seizure 
during  this  preliminary  period.  It  occasionally  happens  that  there  are 
no  symptoms  at  aU,  and  cases  have  occurred,  more  particularly  of  abscess 
in  the  frontal  lobe,  in  which  there  were  no  signs  or  symptoms  before  death. 

Phlebitis  of  the  superior  petrosal  and  lateral  sinuses  is  especially  com- 
mon when  the  abscess  is  caused  by  disease  of  the  ear,  since  the  former  re- 
ceives a  vein  from  the  internal  ear,  and  the  latter  receives  the  mastoid  veins. 
Edema  about  the  ear  and  neck  and  hardness  of  the  jugular  veins  should  sug- 
gest plilebitis,  while  rigidity  of  the  neck  and  cranial  nerve  paralysis  even 
more  unerringly  point  to  meningitis. 

Diagnosis.- — This  is  easy  in  acute  cases,  being  substantiated  by  the 
history  of  injury,  rigor,  and  fever,  followed  by  the  brain  symptoms  described. 
Almost  as  certain  is  the  diagnosis  when  such  symptoms  follow  chronic 
ear  disease  or  localized  putrid  lung  disease.  It  is  to  be  remembered,  that 
general  cerebral  symptoms  may  be  produced  by  pus  in  the  middle  ear. 
These  should  be  treated  by  puncture  of  the  tympanum,  and  should  the 
symptoms  persist,  after  puncture  abscess  ma}'-  be  suspected.  In  like 
manner  meningitis  and  abscess  may  be  confounded,  and  with  reason,  be- 
cause meningitis  may  be  produced  by  the  causes  that  produce  abscess; 
and  may  be  caused  by  abscess,  and  both  may  occur  together.  Meningitis, 
however,  affects  the  cranial  nerves  more  than  abscess,  unless  the  abscess 
is  seated  in  the  pons,  and  usually  meningitis  succeeds  more  promptly  upon 
its  cause.  It  is  to  be  remembered  that  tumor  of  the  brain  may  produce 
symptoms  identical  %vith  those  described.  The  chief  distinctive  sj^mp- 
tom  in  abscess  is  the  presence  of  fever. 

Prognosis. — This,  unless  we  admit  a  curable  form  described  by  Strtim- 
pell,  is  always  ultimately  fatal  unless  we  have  the  rare  good  fortune  to  reach 
the  abscess  by  operation. 


HYDROCEPHALUS  1075 

Acute  cases  last  from  eight  to  14  days,  rarely  30  days;  the  delayed 
cases  may  not  show  their  first  symptoms  for  months.  In  the  curable 
form  referred  to,  Strumpell  says  pronounced  symptoms  of  focal  disease 
exist  for  a  time  and  suggest  a  tumor,  but  after  some  months  or  even  a 
longer  time  they  gradually  abate,  and  recovery  is  complete.  The  nature  of 
the  symptoms  is  such  as  to  suggest  a  seat  in  the  cortex,  for  theie  is  usually 
paresis  of  some  part  of  the  body,  often  associated  with  symptoms  of  motor 
irritation  and  impairment  of  speech. 

Treatment. — A  certain  prophylaxis  may  be  exercised  in  the  proper 
treatment  of  disease  of  the  ear,  for  it  is  often  the  neglect  of  this  which  leads 
to  the  abscess.  Such  prophylaxis  includes  measures  which  secure  free  dis- 
charge and  antisepsis.  Beyond  this  the  only  treatment  for  abscess  which 
promises  an^^hing  toward  a  favorable  result  is  operation,  on  which  account 
the  surgeon  should  be  promptly  associated  in  the  treatment  of  the  case. 
The  use  of  the  trephine  has  saved  a  few  cases.  For  the  details  of  the  oper- 
ation the  student  is  referred  to  text-books  on  surgery. 

Encephalitis  without  Abscess. — When,  on  the  one  hand,  inflamma- 
tion of  the  surface  of  the  brain  accompanying  meningitis  is  eliminated,  and, 
on  the  other,  softening  of  the  brain,  formerly  thought  to  be  the  result  of  in- 
flammation, but  now  known  to  be  due  to  the  arrest  of  blood-supply,  a  num- 
ber of  cases  of  encephalitis  without  abscess  remain,  in  some  of  which  a 
necropsy  was  obtained. 

CHRONIC  HYDROCEPHALUS. 

Definition. — A  collection  of  serous  fluid  either  between  the  meninges 
or  in  the  ventricles  of  the  brain.  The  former  constitutes  intermeningeal 
hydrocephalus,  or  hydrocephalus  externus,  or  hydrocephalus  ex  vacuo.  The 
latter  is  ventricular  hydrocephalus,  or  hydrocephalus  internus.  The  seat  of 
effusion  in  hydrocephalus  externvis  may  be  either  in  the  subdural  space — ■ 
i.  e.,  between  the  dura  mater  and  the  arachnoid — or  in  the  subarachnoid 
space.  The  first  was  formerly  regarded  as  the  most  frequent;  later  its 
occurrence  came  to  be  denied,  but  more  recently,  by  means  of  frozen  brain 
sections,  it  has  been  demonstrated.  Since  the  subarachnoid  space  com- 
municates with  the  ventricles  of  the  brain,  the  two  forms  of  hydrocephalus 
may  coexist.  Both  external  and  internal  hydrocephalus  may  be  diffuse  or 
circumscribed.  When  circumscribed  there  result  in  the  case  of  the  forner 
cystic  spaces  in  the  membranes,  and  in  the  latter  distention  of  portions  of 
the  ventricles. 

External  Hydrocephalus  occurs  in  connection  with  atrophy  of  the 
brain,  and  is  not  of  much  clinical  importance. 

Internal  Hydrocephalus. 
This  is  divided  into  congenital  and  acquired. 

Congenital  Hydrocephalus. 

This  develops  before  birth,  and  may  be  present  to  such  a  degree  as  to 
retard  the  birth  of  the  head.  More  frequently  it  is  not  fecognized  until 
some  time  after  birth. 


1076  DISEASES  OF  THE  NERVOUS  SYSTEM 

Etiology. — This  cannot  be  said  to  be  certainly  known.  Virchow  early 
ascribed  it  to  inflammation  of  the  ependyma;  Rindfleisch  rather  to  an  ob- 
struction to  the  circulation  in  the  choroid  plexus.  Drunkenness  and  syphilis 
in  parents,  and  accidents  in  pregnancy,  are  held  responsible;  occasionally, 
also,  tumors  of  the  brain.  More  than  one  child  in  a  family  is  sometimes 
affected. 

Morbid  Anatomy. — The  head  is  characterized  externally  by  its  spherical 
shape  and  large  size,  its  smooth  eyebrows  and  protruding  eyes,  the  last 
being  due  to  depression  of  the  orbital  plate  of  the  frontal  bone.  The  pro- 
trusion is  often  so  great  that  the  eyelids  cannot  close  over  the  eyes.  The 
size  of  the  head  thus  obtained  is  often  enormous — from  eight  to  ten  inches 
(20  to  25  cm.)  in  diameter  in  a  child  of  three  or  four  years.  On  the  other 
hand,  the  face  appears  very  small.  On  closer  examination  the  cranial  bones 
are  found  separated  and  exceedingly  thin,  at  times  almost  as  thin  as  paper. 
In  the  membranous  interspaces  are  often  found  Wormian  bones.  The 
veins  may  be  seen  beneath  the  skin,  and  fluctuation  may  sometimes  be 
obtained  through  the  scalp.  On  incising  the  brain  a  variable  quantity  of 
limpid  fluid  passes  out.  The  quantity  is  sometimes  enormous,  reaching 
20  pounds  (40  koils)  or  more.  The  cerebral  cortex  is  greatly  thinned, 
the  thickness  on  the  convexity  being  reduced  to  but  a  few  millimeters.  The 
gyri  and  the  basal  ganglia  are  compressed,  and  the  ventricles  are  dilated. 
The  commissures  are  stretched  and  even  torn.  The  foramen  of  Monro  is  a 
wide  opening,  and  the  third  ventricle  is  dilated  and  sometimes  also  the 
fourth.  The  ependyma  is  thickened,  the  choroid  plexuses  are  vascular, 
sometimes  little  changed. 

Symptoms. — These  consist  largely  of  the  external  morbid  states  just 
described,  but  in  addition  there  is  slowness  of  physical  and  mental  develop- 
ment. The  child  learns  to  walk  late  and  is  very  feeble  and  likely  to  be 
mentally  deficient,  although  it  is  sometimes  bright.  The  weight  of  the 
head  is  sometimes  so  great  that  the  head  inclines  to  fall  to  the  side  or 
backward  or  forward,  and  must  be  supported  by  the  hands  of  the  patient. 
The  fontanelles  are  wide  open;  other  symptoms  may,  at  times,  be  de- 
cidedly delayed,  and  the  child  may  make  some  progress  in  studies.  Signs 
of  mental  imbecility  sooner  or  later  make  their  appearance,  manifested 
first,  perhaps,  by  absence  of  development,  but  progressing  until  the  child 
lives  an  almost  vegetative  existence,  having  to  be  fed  and  cared  for  like 
an  infant,  even  though  several  years  old.  At  times  there  is  early  head- 
ache. There  may  be  convidsive  contractions,  tremors,  ataxic  gait,  paresis, 
and  paralysis;  in  fact,  all  the  symptoms  which  succeed  on  irritative  and 
destructive  lesions  of  the  nervous  system.  So,  too,  if  life  is  sufficiently 
prolonged,  the  symptoms  of  tumor  of  the  brain  may  be  quite  closely  sim- 
ulated, especially  when  the  cranium  does  not  enlarge  with  the  growing 
distention  of  the  ventricles.  There  may  be  choked  disk,  atrophy  of  the 
optic  nerve,  or  total  blindness.  This  is  more  true  of  acquired  hydrocepha- 
lus. There  may  be  prolonged  attacks  of  drowsiness,  or  coma,  with  slow 
pulse,  while  sudden  death  is  not  uncommon  during  epileptiform  convulsions 
or  apoplexy. 

Diagnosis  and  Prognosis. — The  rachitic  head  may  be  mistaken  for  the 
hydrocephalic,  but  the  latter  has  not  the  broad  forehead  with  prominent 


HYDROCEPHALUS  1077 

frontal  eminences;  it  is  rather  spherical  and  smooth.  A  child  with  con- 
genital hydrocephalus  raraly  lives  to  be  more  than  four  or  five  years  old, 
though  it  may  attain  adult  life. 

Acquired  Hydrocephalus. 

Etiology. — This  is  also  commonly  ascribed  to  some  inflammatory  proc- 
ess, although  it  is  said  to  be  sometimes  idiopathic.  Especially  is  it  a  conse- 
quence of  suppurative  and  tuberculous  meningitis,  when  it  is  spoken  of  as 
acute  acquired  hydrocephalus,  though  chronic  inflammatory  processes  may 
also  cause  it.  Derangements  in  the  circulation  in  the  choroid  plexus  and 
changed  in  the  ependyma  of  the  ventricles  may,  however,  be  responsible. 
Especially  may  a  tumor  in  the  third  ventricle,  at  the  base  of  the  brain, 
pressing  upon  the  venae  Galeni  or  on  the  straight  sinus  of  the  dura  mater,  be 
a  cause;  or  closure  of  the  foramen  of  Monro  or  of  the  aqueduct  of  Sylvius. 
Even  lung  or  heart  affections  and  growths  in  the  mediastinum  and  neck  may 
produce  the  needed  obstruction. 

Morbid  Anatomy. — In  cases  of  acquired  hydrocephalus,  even  though 
beginning  tolerably  early  in  life — say  the  seventh  year — as  well  as  in  adults, 
the  skull  does  not  necessarily  expand,  and  the  head  may  not  enlarge. 
Indeed,  the  head  may  even  be  smaller  than  natural,  as  in  cretins.  In  these 
instances  the  brain  substance  must  yield,  and  is  reduced  in  thickness,  at 
times  to  a  few  millimeters  only.  In  other  cases  the  skull  yields,  its  plates 
become  thin,  the  fontanels  grow  larger,  and  an  appearance  like  that  of  con- 
genital hydrocephalus  may  result. 

Symptoms. — The  symptoms  of  acute  acquired  hydrocephalus  are  never 
distinctive,  on  account  of  the  rapidity  in  the  course  of  the  disease  which 
produces  and  obscures  it. 

Of  chronic  acquired  hydrocephalus  as  of  congenital  the  most  striking 
symptom  is,  as  a  rule,  the  marked  distortion  in  the  size  and  shape  of  the  head 
already  described. 

Other  symptoms  are  those  of  congenital  hydrocephalus  influenced  by 
the  greater  age  the  patient  may  attain. 

Spontaneous  evacuation  of  the  fluid  sometimes  takes  place  by  the  nose, 
mouth,  ear,  or  orbit. 

Diagnosis. — This  is  commonly  easy.  It  is  only  in  cases  in  which  the 
cranium  does  not  expand  that  the  symptoms  of  brain  tumor  may  lead  to  a 
diagnosis  of  the  latter  condition  instead  of  hydrocephalus. 

Prognosis. — This  is  usually  unfavorable.  Generally  the  child  lives 
from  two  to  five  years,  though  it  may  perish  in  a  few  months  or  live  for 
lo  to  IS  years,  or,  as  in  a  case  of  Bright's,  to  29  years,  or  even  longer. 
It  has  happened  that  spontaneous  recovery  has  followed  the  evacuation  of 
fluid  previously  described.  The  absorption  of  small  amounts  of  fluid  is 
also  possible. 

Treatment. — This  consists  primarily  in  the  treatment  of  the  disease 
which  is  responsible  for  th^  hydrocephalus  if  it  can  be  discovered;  sec- 
ondly, in  the  treatment  of  the  symptoms  which  may  arise,  and  next,  in 
attempts  to  cure  the  malady.  Some  favorable  results  have  followed  the 
removal  of  the  fluid  by  puncture  of  the  ventricles,  although  there  has  been 
failure  in  the  majority  of  instances.     Measures  should  be  taken  to  make 


1078  DISEASES  OF  THE  XERVOUS  SYSTEM 

the  removal  gradual,  if  possible,  thus  attempting  to  imitate  the  spontane- 
ous efforts  of  nature,  which  have  occasionally  been  followed  by  recover^'. 
To  this  end  the  slow  removal  of  the  fluid — by  puncture  of  the  subarachnoid 
space  between  the  third  and  fourth  lumbar  vertebrae — has  been  recom- 
mended and  practised  by  Quincke.  At  this  point,  too,  the  spinal  cord  is 
not  ver}'  likely  to  be  injured.  It  is  more  particularly  in  congenital  hydro- 
cephalus that  operation  may  be  employed,  but  operation  has  not  resulted 
in  much  improvement. 

If  operation  is  deemed  undesirable,  attempts  may  be  made  to  ged  rid 
of  the  fluid  by  diuretics  and  purgatives,  although  with  little  prospect  of 
success.  lodid  of  potassium  may  be  tried,  with  the  faint  hope  that  the 
hydrocephalus  is  due  to  a  syphilitic  tumor  which  might  thus  be  melted  away. 
Blisters  may  also  be  applied. 

GENERAL  AND  FUNCTIONAL  DISEASES— NEUROSES. 

The  term  neuroses  is  applied  to  nervous  affections  in  which  there  are 
functional  disturbances  corresponding  to  which  there  is  no  known  anatom- 
ical lesion. 

ACUTE  CHOREA. 

Synonyms. — Chorea  minor;  Mild  Chorea;  Sydenham's  Chorea;  St.   Vitus' 

Dance. 

Definition. — A  disease  chiefly  of  the  young,  characterized  by  irregular, 
involuntary  muscular  contractions,  associated  at  times  with  psychical  dis- 
turbance, often  with  rheumatism  and  endocarditis.  The  term  chorea  is 
derived  from  the  Greek  i/'opeta,  dancing. 

Etiology. — The  disease,  though  not  confined  to  children,  occurs  far 
more  frequently  among  them,  notably  from  the  time  of  the  second  den- 
tition— the  sixth  or  seventh  year — to  the  isth  year.  More  than  three- 
fourths  of  the  entire  number  of  cases  occur  during  this  period.  Among 
adults  it  is  relatively  more  frequent  from  the  isthto  the  24th  year.  Oc- 
casionallj'  it  occurs  in  old  age,  when  it  is  known  as  chorea  senilis.  Chorea 
is  about  twice  as  frequent  in  the  female  sex  as  in  the  male  if  all  periods 
of  life  are  considered,  but  below  the  period  of  puberty  the  difference 
in  the  sexes  is  not  so  striking.  Heredity  has  always  been  an  acknowl- 
edged factor  in  its  causation,  but  is  probably  less  significant  than  was  once 
supposed.  It  has  even  been  claimed  that  the  disease  is  sometimes  congen- 
ital in  the  offspring  of  a  choreic  mother.  It  is  more  frequent  in  neurotic 
families.  As  to  temperament,  it  is  well  known  that  high-strung,  excitable, 
nervous  children,  as  contrasted  with  the  dull  and  phlegmatic,  are  especially 
liable  to  the  disease.  It  is  principally  in  these  that  overstudy  is  seen  to 
have  a  predisposing  effect.  Psychical  influences  are  undoubtedly  potent; 
thus,  fright  causes  a  large  number  of  cases,  while  grief  causes  many,  and 
even  joy  some. 

The  so-called  Huntington's  chorea,  which  is  hereditary,  is  not  the  same 
as  Sydenham's  chorea,  although  Charcot  did  not  make  this  distinction. 
Sydenham's  chorea  affects  children  of  all  social  grades.  It  is  rare  in  the  negro. 
Wharton  Sinkler,  who  has  especially  investigated  this  point,  has  seen  but 


CHOREA  1079 

one  case  in  a  full-blooded  negro,  while  William  Osier,  at  the  Johns  Hopkins 
Hospital,  out  of  175  cases  found  five  in  the  negro  race.  It  is  apparently  un- 
known among  Indians  in  their  natural  state. 

The  season  of  the  year  appears  to  have  an  undoubted  influence.  Morris 
J.  Lewis,  whose  studies  have  been  most  thorough  in  this  direction,  finds 
that  the  fewest  attacks  occur  in  October  and  November  and  the  greatest 
number  in  March  and  April.  Hermann  Eichhorst,  on  the  other  hand,  says 
that  the  greatest  number  of  cases  occur  in  the  autumn  and  winter  months. 
The  disease  prevails  more  generally  in  towns  than  in  the  country. 

Imitation,  commonly  regarded  as  an  exciting  cause,  has  been  shown  by 
modern  studies  to  play  a  less  important  role  than  was  thought,  manj^  cases 
described  as  thus  originating  being  really  hysteria.  Trauma  precedes  a  cer- 
tain number  of  cases.  Reflex  irritation,  especially  digestive  disturbances, 
and  intestinal  worms  were  regarded  as  potent  causes  by  the  older  observers ; 
but  here  again  Osier's  studies  have  failed  to  find  any  causal  relationship. 
The  chorea  of  pregnant  women  has  been  referred  to  this  category.  The 
causal  relation  of  eye-strain  to  chorea  has  been  emphasized  by  Stevens,  but 
is  practically  denied  by  George  de  Schweinitz,  who  concludes,  from  an  ex- 
amination of  more  than  100  cases,  that,  while  ordinary  chorea  and  many 
forms  of  facial  spasm — habit  spasm,  etc. — are  materially  benefited  by  cor- 
recting refractive  errors  and  anomalies  of  the  ocular  muscles,  he  does  not 
believe  there  is  any  proof  to  show  that  eye-strain  is  of  itself  responsible  for 
their  origin,  with  perhaps  the  single  exception  of  habit  spasm  affecting  the 
orbicularis  and  adjacent  facial  area.  It  may  be  such  chorea  which  Howard 
F.  Hansell  cured  in  Da  Costa's  clinic^  by  atropin,  paralyzing  the  ciliary 
muscle  and  preventing  the  effort  at  accommodation  until  the  habit  was 
broken  up. 

The  association  of  arthritis  and  chorea  was  observed  by  the  earliest 
students  of  the  subject,  and  was  distinctly  recognized  in  England  as  early  as 
1802,  but  the  exact  causal  relation  of  the  two  diseases  has,  perhaps,  not  yet 
been  made  out.  That  they  are  frequently  associated  and  that  there  is  close 
connection  between  the  two  affections  is  admitted  by  English  and  French 
writers,  but  the  Germans  find  the  association  much  less  frequent.  Steiner, 
for  example,  found  only  four  cases  of  rheumatism  in  252  cases  of  chorea. 
English  observers  find  from  20  to  70  per  cent,  of  cases  of  associated  joint 
affection,  whUe  in  this  country,  where  rheumatism  is  apparently  less  fre- 
quent in  children,  the  range  of  percentage  found  by  various  observers  is 
from  15.5  to  54  per  cent.  That  the  arthritis  precedes  the  chorea  in  a 
large  number  of  cases  is  generally  conceded,  the  latter  disease  developing 
with  the  subsidence  of  the  former,  or  not  untH  convalescence  has  been 
well  established.  The  authors  believe  that  while  the  infectious  nature  of 
chorea  is  not  established,  there  is  enough  evidence  to  justify  the  belief 
that  it  is  the  result  of  some  unknown  infection,  possibly  the  same  as 
acute  rheumatism.  This  theory  is  further  sustained  by  the  fact  that  the 
infectious  diseases  play  an  acknowledged  role  in  the  etiology  of  chorea. 
Scarlet  fever,  diphtheria,  measles,  typhoid  fever,  gonorrhea,  secondary 
syphilis,  puerperal  fever,  pyemia,  mtdtiple  suppurative  polyarthritis,  have 
all  been  followed  by  chorea;  but  with  the  exception  of  acute  rheumatic 

^  Da  Costa's  *'  Medical  Diagnosis,"  eighth  ed.,  p.  221,  1895. 


1080  DISEASES  OF  THE  NERVOUS  SYSTEM 

polyarthritis  and  some  forms  of  septicemia,  the  number  of  cases  thus  asso- 
ciated is  not  large.  On  the  other  hand,  acute  exanthemata  developing  in 
the  course  of  chorea  usually  check  the  disease.  Anemia  has  been  held  to 
be  a  cause,  and  probably  is  a  predisposing  cause,  although  frequently  also  a 
result.  In  fact,  the  studies  of  Charles  W.  Burr  and  others  go  to  show  that 
anemia  is  less  frequently  associated  with  chorea  than  has  been  commonly 
supposed.  The  relation  of  hysteria  to  chorea  is  interesting  from  the  close 
resemblance,  at  times,  of  the  two  conditions.  It  has  already  been  said  that 
the  cases  of  so-called  imitation  chorea  are  often  examples  of  hysteria,  and, 
on  the  whole,  the  association  of  the  cohditions  is  rather  coincidental  than 
causal,  but  some  cases  may  be  truly  imitation  in  children  not  hysterical. 
Poisons  are  acknowledged  causes  in  a  few  instances.  Carbon  dioxid  and 
iodoform  are  among  those  which  appear  to  have  caused  acute  attacks  of 
chorea  of  short  duration. 

Morbid  Anatomy. — There  is  no  definitely  ascertained  morbid  anatomy 
for  chorea,  and  the  lesions  which  have  been  found  are  the  result  of  the  com.- 
plications  or  are  incidental.  The  most  constant  of  these  associated  lesions 
are  endocarditis,  in  85  per  cent,  of  Osier's  cases;  pericarditis,  26  per  cent.; 
combined  heart  lesions,  90.4  per  cent.;  pneumonia,  12  per  cent.;  less  numer- 
ous were  acute  pleurisy,  pyemia,  and  phlebitis,  also  noticed.  As  to  the 
nervous  system,  the  symptomatology  would  lead  us  to  expect  the  essential 
lesions  in  the  cortex  of  the  brain,  and  C.  L.  Dana  has  analyzed  the  recorded 
autopsies,  of  which  there  were  only  39  in  which  the  state  of  the  nervous 
system  was  accurately  described.  In  16  there  were  intense  cerebral  hypere- 
mia, periarterial  exudation,  erosions,  softened  spots,  minute  hemorrhages, 
and  occasional  emboli.  The  changes  were  most  marked  in  the  deeper 
parts  of  the  motor  tracts,  particularly  in  the  lenticular  nuclei  and  the 
thalami.  These  changes  are  the  same  as  those  described  by  W.  H.  Dickin- 
son in  1876.  Essentially  similar  were  the  lesions  found  in  two  of  Osier's 
cases.  In  two  reported  by  Bevan  Lewis  there  was  apoplexy,  one  cerebellar 
and  one  cerebral  and  extraventricular.  The  so-called  chorea  corpuscles 
described  by  Ellischer  are  in  no  way  characteristic.  The  same  may  be 
said  of  the  swelling  and  turbidity  of  certain  of  the  large  pjTamidal  cells 
in  the  deeper  layers  of  the  cortex  in  the  Rolandic  region  described  by  F.  C. 
Turner.  The  changes  in  the  ganglion  cells  of  the  spinal  cord  described  by 
H.  C.  Wood  in  canine  chorea  have  been  found  also  by  Triboulet,  but  he 
agrees  with  others  who  hold  that  canine  chorea  is  a  very  different  disease 
from  human  chorea. 

Nature  of  Chorea. — This,  it  must  be  admitted,  is  as  yet  unknown.  It 
has  been  intimated  that  the  symptoms  are  of  a  kind  which  would  naturalh' 
result  from  lesions  in  the  motor  cortical  area.  No  constancy  in  such  lesions 
is  demonstrable.  A  cerebral  seat  for  chorea  is  rendered  likely  by  the  exist- 
ence of  hemichorea,  the  association  of  chorea  with  mild  psychical  derange- 
ments, and  b}'  the  fact  that  choreiform  movements  are  sometimes  symp- 
toms of  undoubted  brain  lesions — posthemiplegic  hemichorea.  The  embolic 
theory  which  was  suggested  by  Senhouse  Kirkes,  and  supported  by  him, 
Hughlings  Jackson,  Broadbent,  Tuckwell,  and  others,  was  based  upon  the 
presence  of  foci  of  embolic  softening  found  in  a  few  instances  in  connection 
with  endocarditis,  but  has  gained  few  supporters. 


CHOREA  1081 

The  theory  which  is  at  the  present  day  naturally  attracting  most  atten- 
tion is  the  infectious  theory,  but  the  limits  of  a  text-book  do  not  permit  its 
developmental  consideration.  Suffice  it  to  say  that  Pianese,  of  Naples,  has 
apparently  isolated  from  the  nervous  system  of  a  choreic  patient  a  bacillus 
which  he  was  able  to  cultivate  successfully,  and  the  cultures  from  which 
caused  death  in  animals;  also  that  while  the  acuter  forms  present  many,  if 
not  all,  of  the  conditions  necessary  to  the  conception  of  an  infectious  disease. 
The  views  of  the  authors  have  been  briefly  set  forth  on  the  previous  page. 

Symptoms. — Premonitory  symptoms,  both  motor  and  psj'chical,  usually 
precede  the  onset  of  chorea.  They  include  restlessness  and  inabilitj''  to  sit 
still,  and  an  altered  disposition,  manifested  by  irritability  and  perversity. 
These  symptoms,  often  misunderstood  by  parents,  are  sometimes  the  occa- 
sion of  reproof  and  even  severe  punishment  to  the  child — a  course  which 
accelerates  and  aggravates  the  disease. 

A  close  study  of  the  symptoms  permits  of  their  division  into  three 
separate  groups,  determined  chiefly  by  their  severity : 

1.  A  mild  form,  including  the  majority  of  cases  in  which  the  affection 
of  the  muscle  is  slight,  the  speech  scarcely  involved,  and  the  general  health 
slightly  disturbed. 

2.  The  severe,  in  which  the  choreic  movements  are  general,  power  of 
speech  is  lost,  and  the  patient  is  unable  to  go  about  and  help  himself. 

3.  The  maniacal,  or  chorea  insaniens,  characterized  by  intense  cerebral 
excitement. 

It  is,  however,  unnecessary  to  separate  the  symptoms  of  each  variety. 

The  motor  phenomena  are  those  first  observed.  They  consist  in  pe- 
culiar jerky  movements  which  begin  most  frequently  in  the  upper  extrem- 
ities, especially  in  the  right  hand,  rarely  in  the  legs.  They  may  even  be 
general  from  the  first,  though  the  earliest  symptoms  often  escape  notice. 
Speech  is  affected,  sooner  or  later,  in  one-fourth  of  the  cases.  The  extent 
varies  greatly  from  slight  hesitancy  to  incoherency — the  difficulty  being  in 
the  muscles  of  articulation  rather  than  in  phonation.  As  a  rule,  the  move- 
ments cease  during  sleep,  though  they  sometimes  persist  even  then.  It  is 
not  generally  believed  that  the  movements  extend  to  the  muscles  of  organic 
Hfe,  though  associated  irregiilar  and  rapid  action  of  the  heart  has  been 
ascribed  to  choreic  spasm  of  the  papillarj'  muscles.  As  the  disease  con- 
tinues muscular  weakness  becomes  manifest  in  a  general  want  of  strength 
rather  than  paralysis,  though  the  weakness  may  affect  both  limbs  of  the 
same  side,  or  orAy  one  limb.  It  may  even  precede  the  jerking  movements. 
Very  rarely  the  pulse  may  be  slow  in  the  feeble  state  that  follows  chorea. 

Sensory  sym.ptoms  axe  less  conspicuous  than  motor.  Pain  is  rare,  though 
its  presence  has  been  characteristic  enough  in  some  cases  to  obtain  the 
name  "painful  chorea"  from  Weir  Mitchell.  Painful  points  over  the  sites 
of  emergence  of  spinal  nerves  have  been  pointed  out,  though  thej'  must  be 
rare.  Numbness,  tingling  and  prickling  sensations  are  occasionally  met,  and 
may  be  a  part  of  the  phenomena  of  multiple  neuritis  sometimes  present. 
Headache,  sometimes  very  severe  and  paroxysmal,  may  occur,  while 
epileptijorm  seizures  are  also  a  rare  symptom,  and  when  they  occur  are  prob- 
ably not  a  part  of  the  chorea.'  The  reflexes  are  variously  affected,  the 
knee-jerk  being  normal  in  about  half  the  cases,  in  the  remainder  increased 


1082  DISEASES  OF  THE  AERVOUS  SYSTEM 

or  absent.  Trophic  lesions  arc  almost  unknown.  Mental  symptoms,  in  the 
majority  of  cases,  are  not  very  conspicuous,  though  there  are  in  some  severe 
cases  extreme  manifestations,  including  melancholia,  hallucinations,  and 
even  mania,  which  have  their  climax  in  chorea  insaniens. 

Most  important  are  the  symptoms  of  cardiac  disease,  in  regard  to  which 
WiUiam  Osier  makes  the  startling  statement:  "There  is  no  disease  in 
which  endocarditis  is  so  constantly  found  postmortem  as  chorea.  It  is 
exceptional  to  find  the  heart  healthy."  The  symptoms  which  are,  therefore, 
to  be  always  carefully  sought  include  a  systolic  apex  murmur,  palpitation, 
and  irregular  heart  action,  although  the  child  rarely  complains  of  the  latter 
or  of  pain  about  the  heart.  It  is  further  important  to  note  that  in  a  major- 
ity of  these  cases  the  endocarditis  is  independent  of  acute  arthritis,  unless 
we  hold  with  Bouillaud  that  in  young  subjects  the  heart  acts  as  a  joint. 
Organic  murmurs  at  the  base  are  very  much  more  uncommon,  most  of  the 
murmurs  here  being  functional.  They  are  heard  with  greatest  intensity 
in  the  area  of  the  pulmonary  artery,  but  are  audible  sometimes  in  the  aortic 
area  as  well.  In  a  large  proportion  of  all  cases  in  which  a  murmur  is  heard 
at  the  base  or  along  the  left  margin  of  the  sternum  in  the  second,  third, 
and  fourth  interspaces  it  is  functional,  but  a  soft  systolic  murmiir  in  this 
area  with  systolic  pulsation  in  the  cervical  veins  may  be  caused  at  the  tri- 
cuspid orifice. 

On  the  other  hand,  endocarditis  sometimes  occurs  without  symptoms  or 
physical  signs,  while  the  disappearance  of  physical  signs  does  not  prove 
that  endocarditis  was  not  present.  A  presystolic  murmur  is  also  at  times 
present,  indicating  mitral  stenosis — in  19  per  cent,  of  Osier's  cases.  On  the 
other  hand,  the  comparative  rarity  of  simple  aortic  valve  involvement  is  con- 
spicuous, this  being  more  uncommon  than  combined  aortic  and  mitral  dis- 
ease, or  even  combined  mitral  and  tricuspid  disease.  The  tricuspid  valves 
may  alone  be  attacked. 

A  to-and-fro  murmur,  indicating  pericarditis,  may  be  present  in  from  8 
to  25  per  cent.,  and  in  more  than  half  of  these  it  is  associated  with  endocar- 
ditis. It  is  to  be  remembered  that  both  forms  of  organic  heart  disease,  and 
especially  endocarditis,  may  occur  in  chorea  without  rheumatism — e.  g,.  in 
66  per  cent,  of  Osier's  cases — also  that  such  endocarditis  may  lay  the 
foundation  of  permanent  organic  disease. 

W.  S.  Thayer,  in  his  studies  of  689  cases  at  Johns  Hopkins  Hospital 
or  Dispensary,  found  evidence  of  cardiac  involvement  in  25.4  per  cent,  of 
the  cases,  and  in  the  wards  of  the  Hospital  50  per  cent.  The  cardiac  in- 
volvement occurred  with  somewhat  greater  frequency  in  cases  where  there 
was  acute  polyarthritis  than  where  such  history  was  absent. 

Cardiac  involvement  was  commoner  in  cases  of  chorea  with  frequent 
recurrences  than  in  those  in  which  there  was  but  a  single  attack. 

In  no  cases  treated  in  the  wards  there  was  fever  of  moderate  degree 
in  almost  every  instance,  and  where  there  was  high  fever  there  was  evi- 
dence of  cardiac  involvement.  There  is  good  reason  for  the  belief  that 
the  presence  of  fever  in  otherwise  uncomplicated  chorea  is  in  a  large  pro- 
portion of  cases  associated  with  complicating  endocarditis. ' 


I  "Journal  Am.  Med.  Assoc,"  Oct.  27,  1906.' 


CHOREA  1083 

Occasional  skin  affections  make  their  appearance  in  chorea,  the  larger 
proportion  being  due  to  the  prolonged  administration  of  arsenic,  so  much  used 
in  the  treatment  of  this  disease.  The  forms  for  which  the  arsenic  treat- 
ment is  more  or  less  responsible  are  erythematous  and  papillary  eruptions, 
herpes,  and  the  pigmentation  frequently  resulting  from  the  prolonged  ad- 
ministration of  this  drug.  Eruptions  also  occur  independent  of  arsenic 
administration.  They  are  usually  purpuric  and  associated  wdth  arthritis, 
similar  in  form  to  the  purpura  so  often  associated  wdth  rheumatism,  and 
include  some  of  the  forms  of  multiple  erythema — as  er}i;hema  nodosum, 
purpuric  urticaria,  or  simple  purpura.  C.  H.  BrowTi^  has  reported  a 
•remarkable  case  of  subcutaneous  nodules  composed  of  young  grantilating 
tissue  in  a  case  of  chorea  in  a  boy  of  1 1 . 

Fever  is  a  rare  symptom  in  chorea,  except  as  the  result  of  complications, 
of  which  arthritis  is  the  most  common,  but  endocarditis  and  pericarditis 
may  also  cause  fever.  The  rare  instances  are  cases  of  chorea  insaniens, 
in  which  the  temperature  may  rise  to  105°  F.  (40.5.°  C). 

Diagnosis. — This  is  usually  easy.  Simple  tremor,  athetosis,  paralysis 
agitans,  as  well  as  alcoholic,  senile,  saturnine,  and  mercurial  tremor,  are  not 
likely  to  be  confounded  with  the  movements  of  chorea.  The  sjTnptomatic 
choreiform  movements  due  to  cortical  irritation  by  meningitis,  tubercle, 
hemorrhage,  softening,  tumor,  or  parasites,  are  attended  by  other  sjinptoms 
which  distinguish  them  from  chorea.  Friedreich's  ataxia  might  be  mistaken 
for  chorea,  but  it  is  easily  recognized  hy  the  lost  knee-jerks,  the  slowness 
and  inco-ordination  of  movements,  talipes,  nystagmus,  and  family  distribu- 
tion. Huntington's  chorea  is  characterized  by  its  heredity,  its  Hmitation 
to  adult  life,  and  laltimate  gradually  developing  dementia. 

Prognosis. — Except  in  chorea  insaniens,  which  is  always  fatal,  recover}^ 
is  the  rule  in  from  eight  to  ten  weeks.  It  happens,  too,  sometimes  that  the 
severest  cases  of  the  ordinary  forms  are  intractable,  and  rarely  that  they  ter- 
minate fatally  after  a  few  days'  illness,  it  may  be  from  exhaustion  or  it  may 
be  from  the  complicating  heart  disease.  Chorea  of  the  pregnant  woman 
is  more  serious  than  the  chorea  of  children. 

The  duration  of  the  disease  may  be  from  eight  to  ten  weeks  for  the 
ordinary  cases  and  from  three  to  six  months  for  the  very  severe  ones. 
Remissions  occur,  and  relapses  as  well,  pointed  out  by  Sydenham.  A  dis- 
position to  vernal  recurrence  has  been  noticed. 

Treatment. — All  cases  should  be  carefully  examined  for  causes  of  re- 
flected irritation,  which  should  be  removed;  then  rest  is  essential.  It  is  not 
necessary  that  in  the  mildest  cases  the  patients  be  put  to  bed,  but  thej' 
should  be  withdrawn  from  school  and  guarded  from  excitement  and  the  curious 
gaze  of  friends  and  strangers,  for  the  movements  almost  invariably  in- 
crease when  the  patient  is  under  observation.  In  more  serious  cases  con- 
finement to  bed  should  be  employed — a  more  thorough  exclusion  as  well 
as  rest  is  thus  secured.  Not  only  is  recovery  thus  facilitated,  but  a  dimin- 
ished liability  to  heart  complication  is  also  attained. 

Of  drugs,  arsenic  and  iron  hold  the  first  place.  The  former  is  given  in 
slowly  ascending  doses  of  Fowler's  solution  until  its  physiological  effect  is 
produced,  after  which  the  dose  should  be  gradually  diminished.     Some  one 

1  "Journal  of  Mental  and  Nervous  Disease,"  August,  1893. 


1084  DISEASES  OF  THE  NERVOUS  SYSTEM 

of  the  preparations  of  iron  should  be  j^ven  continuously  in  moderate  doses. 
The  bromids  are  also  indicated,  especially  when  there  are  restlessness  and 
want  of  sleep,  when  chloral  may  also  be  added,  and  in  severe  cases  may  be 
given  continuously.  Opiates  should,  however,  never  be  employed.  An  old 
remedy  in  this  country  is  black  snakeroot  or  cimicifuga  racemosa,  first 
recommended  by  the  late  Hiram  Corson,  who  wrote  Tyson  that  he  had  used 
it  for  50  years  without  a  failure.  Tyson  has  sometimes  used  it  in  the  shape 
of  the  infusion  in  mild  cases,  with  apparently  satisfactory  results,  in  doses 
of  I  or  2  fluidounces  (30  to  60  c.c).  Modern  remedies  are  aspirin,  anti- 
pyrin  and  physostigma.  The  former  is  given  to  adtilts  in  doses  of  from 
7  to  IS  grains  (0.5  to  i  gm.),  much  reduced  for  children.  Physostigma 
has  been  given  in  doses  of  from  1/70  to  1/35  grain  (0.0094  to  0.0188  gm.) 
hypodermically.  Hyoscyamin  in  doses  of  i/ioo  grain  (0.00065  g™-)- 
three  times  a  day,  has  apparently  been  followed  by  good  results.  The 
oxid  of  zinc,  valerianate  of  zinc,  nitrate  of  silver,  and  sidphate  of  copper, 
formerly  much  recommended,  have  fallen  into  disuse.  In  consequence  of 
the  close  relations  between  chorea  with  its  attending  arthritis  and  rheu- 
matic arthritis  it  is  reasonable  to  expect  that  the  salicylates  might  be  useful, 
but  such  expectation  has  not,  as  yet,  been  realized. 

Montrose  Graham  Tule  attaches  great  value  to  apomori^hin.  He  ad- 
ministered in  a  desperate  ease,  a  girl  of  15,  hypodermically  1/40  grain 
(0.0016  gm.)  which  allayed  the  spasms  in  three  minutes.  This  was  fol- 
lowed up  by  1/20  grain  (0.0033  gni)  by  the  mouth  every  three  hours,  fol- 
lowed by  prompt  recovery.  Chloralose  has  also  controlled  the  spasms  in 
an  acute  case  in  my  hands. 

CHOREIFORM  AFFECTIONS. 

There  remain  to  be  considered  some  forms  of  convulsive  contractures 
several  of  which  are  included  under  the  term  "habit  spasm"  or  "habit 
chorea,"  and  "tic."  The  term  tic,  as  originally  understood,  means  /a«a/ 
spasm.  It  has,  however,  been  extended  by  the  French  school  (whose  lead 
in  these  affections  seems  at  present  acknowledged)  to  include  "an  habitual, 
conscious,  convulsive  movement,  resulting  in  the  contraction  of  one  or  more 
muscles  of  the  body,  reproducing,  most  frequently  in  an  abrupt  manner, 
some  reflex  or  automatic  action  of  common  life"  (Guinon).  It  is  char- 
acteristic of  these  motions  that  they  are  more  or  less  under  the  control  of 
the  will,  and  the  tic  movements  have  a  purposeful  character,  in  which 
respect  they  differ  from  the  contractions  of  chorea  minor. 

I.  Simple  Tic. 

Tic  should  not  be  confused  with  habit  spasm.  Tic  is  a  quick  move- 
ment, of  a  purposeful  character,  usually  in  the  same  group  of  muscles,  and 
occurring  in  a  neurotic  individual;  its  prognosis  is  often  bad.  Habit  spasm 
is  often  in  different  groups  of  muscles,  is  not  purposeful,  is  slower,  is  often 
sign  of  nervous  child  and  often  outgrowii.     Oppenheim  gives  description. 

Simple  tic  may  be  localized  or  general. 

Localized  tic  begins  usually  in  young  persons,  most  frequently  in  girls 
from  seven  to  14  years  of  age,  and  may  persist  through  life.     The  spasm 


CONVULSIVE  TIC  1085 

is  confined  to  a  single  muscle,  a  group  of  muscles,  or  a  group  of  associated 
muscles,  most  frequently  the  muscles  of  expression.  The  mild  forms  are 
looked  upon  as  simply  peculiarities  of  the  individual;  but  the  more  severe 
forms,  in  which  nearly  all  the  muscles  of  the  face  are  affected  and  even  the 
depressors  of  the  jaw  and  the  tongue  are  often  thrown  into  action  while 
speaking,  are  manifestly  pathological.  It  differs  from  the  idiopathic  facial 
spasm  of  adults  in  that  the  latter  is  rarely  seen  until  after  the  40th  year, 
and  is,  moreover,  slower  than  the  habit  spasm  of  the  facial  muscles.  It  is 
possible  for  the  simplest  forms  of  habit  spasm  to  be  a  childish  trick  per- 
petuated; such  may  be  a  blinking  of  the  eye  or  the  act  of  sniffing.  In 
other  simple  forms  there  is  a  drawing  aside  of  the  mouth  or  a  jerking  of  the 
head  to  one  side,  or  a  simple  shaking  of  the  head,  while  the  eye  is  winked 
at  the  same  time;  or  there  may  be  shrugging  of  one  shoulder.  More  rarely 
the  contraction  occurs  in  the  legs,  as  in  the  very  characteristic  "string-halt " 
like  in  which  at  times  the  leg  is  suddenly  drawn  up.  Localized  tic  may  be 
transient,  gradually  disappearing  after  a  few  months.  The  French  school 
has  devised  a  method  of  treatment  of  these  localized  tics,  consisting  of 
educational  movements  of  the  affected  muscles. 

Generalized  Tic,  Electric  Chorea  (Henoch). — In  this  there  is  sudden 
electric-like  spasm  of  the  muscles  of  the  trunk  and  limbs,  but  especially 
of  the  neck  and  shoulders,  causing  an  instantaneous  start,  which  affects 
the  patient  for  an  instant  only,  when  it  passes  off  and  leaves  him  quiet  and 
motionless.  The  contraction  is  like  that  produced  by  a  galvanic  shock. 
It  may  be  associated  mth  facial  spasm.  It  occurs  especially  in  children, 
but  also  in  adults,  particularly  in  women,  and  may  persist  for  years. 

Paramyoclonus  Multiplex;  Myoclonia. — This  term  was  applied  by 
Friedreich  in  1882  to  a  disease  first  observed  by  him,  in  which  there  are 
clonic  convulsions  in  symmetrical  muscle  groups  in  the  arms  and  legs  with- 
out loss  of  consciousness.  It  occurs  usually  in  males,  and  follows  emotional 
disturbances  like  fright.  In  addition  there  is  a  considerable  increase  in 
the  tendon  reflexes.  In  order  that  a  case  may  be  one  of  true  paramyoclonus 
it  is  necessary  that  the  contractions  in  the  single  muscles  should  be  sudden — 
lightning-like.  The  muscles  affected  are  commonly  those  of  the  trunk  and 
extremities.  The  contractions  are  usually  bilateral,  and  vary  from  50  to 
150  a  minute.  There  are  no  sensory  symptoms.  Between  the  attacks 
there  may  be  tremors.  These  cases  are  allied,  on  the  one  hand,  to  the 
electric  chorea  just  described,  and,  on  the  other,  to  the  different  forms  of 
convtalsive  tic,  clonic  facial  cramp,  and  clonic  cramp  of  the  neck  muscles. 
Some  cases  of  so-called  paramyoclonus  are  really  cases  of  hysteria.  This 
view  is  sustained  by  Arthur  Conklin  Brush,  ^  who  reports  three  cases  and 
reviews  several. 

Dubinins  Disease. — The  term  electric  chorea  is  applied  to  an  acute  in- 
fectious disease  occurring  in  Lombardy,  and  known  as  Dubini's  disease, 
in  which  there  are  sudden  contractions,  first  usually  in  the  arm,  but  passing 
thence  into  all  the  extremities,  followed,  in  several  weeks  or  months  by 
paralysis  and  muscular  atrophy,  occasionally  by  epileptiform  convulsions 
and  fever.     No  morbid  anatomy  has  been  determined. 


'The  Nature  of  Paramyoclonus  Multiplex,"  "American  Jour,  of  the  Medical  Sciences,"  December, 


1086  DISEASES  OF  THE  NERVOUS  SYSTEM 

II.  Tic  with  Explosive  Utterances,  Coprolalia,  Echolalia, 
Fixed  Ideas,  etc. 

SynonyiMS. — Maladie  de  la  tic  convulsif;  Gilles  de  la  Tonrette's  Disease. 

Definition. — In  addition  to  motor  spasm,  this  form  of  tic  is  charac- 
terized by  explosive  utterances  of  certain  words  and  sounds,  such  as  "fire, " 
"murder,"  "hah,"  "bow-bow";  or  profane  words,  such  as  "God  damn," 
"Jesus  Christ";  or  filthy  and  obscene  words,  when  it  is  known  as  coprolalia. 
There  may  also  be  mimicry  of  words,  when  it  is  called  echolalia,  or  mimicry 
of  action,  echokinesis ;  or  the  patient  may  be  possessed  of  a  fixed  idea  of 
the  variety  known  as  arithmomania,  delire  du  toucher,  onomatomania,  and 
folie  pourquoi.  In  arithmomania  almost  every  action  is  preceded  by  per- 
forming a  certain  number  of  acts,  as  in  a  patient  of  Osier's,  who  before  she 
went  to  bed  had  to  tap  her  heel  upon  the  bedstead  a  given  number  of 
times;  before  drinking  a  tumbler  of  water,  to  rotate  the  glass  nine  or  ten 
times,  and  the  same  thing  when  sitting  it  down;  before  opening  a  door  a 
certain  number  of  knocks  had  to  be  given,  and  the  greatest  difficulty  was 
experienced  in  getting  her  to  brush  her  hair,  as  it  took  so  long  to  count  be- 
fore she  began.  In  the  delire  du  toucher  there  is  the  constant  fear  of  con- 
tamination from  contact  with  objects;  in  onomatomania  to  repeat  over  and 
over  again  names  which  arise,  and  in  the  folie  pourquoi  to  demand  a  reason 
for  every  one  of  the  simplest  acts.  ■  In  other  instances  the  patient  im- 
agines that  some  one  is  talking  to  her.  All  these  are  in  addition  to  the 
convtdsive  acts. 

The  involuntary  movements  themselves  vary  greatly  from  trifling  tic 
in  any  one  or  more  of  the  muscles  of  the  face  to  contractions  invohang  all 
the  muscles  of  the  body.  This  condition,  which  is  neither  chorea  nor  habit 
spasm,  is  at  times  mistaken  for  both.  It  is  commonly  easy  of  recognition, 
and  although  of  uncertain  prognosis,  recoveries  take  place. 

III.  Complex  Co-ordinated  Tic. 

Definition. — This  includes  a  number  of  forms  of  habit  movement  dif- 
fering from  ordinary  tic  in  the  more  complex  nature  of  the  actions  per- 
formed. It  includes  tricks  and  habits,  such  as  those  of  one  who  in  writing 
stops  at  every  few  words  and  looks  intently  at  his  finger  tips;  the  "head 
nodding"  of  children  (not  to  be  confounded  with  the  epilepsia  nutans  of 
children),  "thumb  sucking,"  "rocking  in  bed,"  and  similar  actions.  Of 
the  same  nature  is  the  so-called  "head-banging,"  in  which  the  child,  asleep 
or  awake,  while  in  bed,  will  turn  over  and  bang  the  head  violently  into  the 
pillow,  repeating  this  act  five  or  six  times  or  for  two  or  three  hours  at  a 
time;  or  the  chUd  may  strike  the  head  repeatedly  with  the  fist — krouo- 
niania;  or  it  may  rotate  the  head  violently  from  side  to  side,  balancing  or 
gyrating  the  body  with  great  rapidity.  This  practice  is  sometimes  com- 
municated from  one  child  to  another.  These  movements  are  met  especially 
in  feeble-minded  children,  in  whom  it  may  be  accompanied  by  nystagmus, 
and  is  sometimes  the  result  of  injury  after  birth.  When  these  phenomena 
do  not  occur  in  the  feeble-minded  or  after  injury  early  in  life,  the  prognosis 
is  said  by  Gee  and  Haden,  who  have  especially  studied  the  subject,  to  be 
favorable. 


HUNTINGTON'S  CHOREA  1087 

IV.  Spasm  op  the  Muscles  of  Respiration  and  Deglutition. 

Definition. — The  spasm  affects  the  muscles  of  respiration  and  pho- 
nation,  the  muscular  contraction  being  accompanied  by  more  or  less  noise, 
as  a  "sniffle"  or  "hiccough"  during  inspiration,  or  some  noisy  or  explosive 
sound  during  expiration.  Such  spasms  are  sometimes  part  of  a  hysterical 
state.  Among  those  described  as  thus  occurring  is  a  sort  of  rumbling  which 
comes  from  low  down  in  the  abdomen,  passes  up  the  stomach,  and  out  of 
the  mouth  as  an  explosive  loud  noise — something  like  belching,  but  louder. 
In  another  instance  there  was  a  peculiar  clucking  noise  in  the  throat  ac- 
companying motions,  particularly  those  of  swallowing,  which  disappeared 
only  during  sleep.  Again,  there  may  be  a  loud  inspiratory  cry  preceded 
by  three  or  four  deep  inspirations  and  followed  by  a  deep,  hoarse,  expiratory 
sound. 

V.  Chronic  Progressive  Chorea. 
Synonyms. — Huntington's  Chorea;  Chronic  Hereditary  Chorea. 

Definition. — A  disease  of  adult  life,  commonly  hereditary,  characterized 
by  irregular  movements,  deranged  speech,  and  ultimate  dementia  gradually 
developing. 

Etiology. — Its  frequent  hereditary  origin  has  been  mentioned.  Indeed, 
heredity  is  one  of  its  most  striking  features,  25  per  cent,  of  certain  families 
having  been  victims,  and  even  more  than  50  per  cent,  of  the  adults  in 
families.  It  is  especially  when  both  parents  were  affected,  and  seriously, 
that  one  or  more  of  the  offspring  almost  invariably'-  have  the  disease  if  they 
live  to  adult  age.  The  two  sexes  are  about  equally  affected,  though  in  some 
families  males  are  oftener  affected.  It  is  further  characteristic  that  if  a 
generation  is  skipped,  the  disease  never  manifests  itself  again  in  that  famil}', 
and  that  it  rarely  presents  itself  before  30  years  of  age.  Huet  has,  how- 
ever, collected  seven  cases  of  earlier  onset.  It  is  said,  also,  that  it  is  not 
invariably  hereditary,  being  sometimes  due  to  emotional  causes.  In  all  the 
families  in  which  this  choreic  tendency  has  been  found  the  nervous  tempera- 
ment prevails. 

Morbid  Anatomy. — This  is  somewhat  more  definite  than  that  of  chorea 
minor.  At  least,  there  has  been  found  at  necropsy  quite  frequently  a  con- 
dition of  pachymeningitis  and  hematoma  of  the  dura  mater  with  atrophy  of 
the  cortex,  and  less  frequently  a  disseminated  encephalitis ,  evidenced  by 
subcortical  foci  of  round  cells.  Nothing  has,  however,  been  found  which 
can  in  any  way  be  regarded  as  peculiar  or  as  accounting  for  the  disease 
occurring  at  a  certain  age  or  for  its  affecting  certain  individuals,  though 
the  lesions  do  explain  the  motor  phenomena.  It  should  be  stated  that 
Charcot  and  his  pupil  Huet  do  not  separate  this  chronic  progressive  chorea 
from  chorea  minor,  but  all  other  writers  do. 

Symptoms. — The  onset  is  gradual  in  hereditary  cases,  although  it  may 
be  sudden  in  cases  arising  otherwise.  As  in  chorea  minor,  motor  symptoms 
are  the  first  to  appear :  first  usually  in  an  unsteadiness  of  the  gait  or  slightly 
irregular  movements  of  the  hands.  Occasionally  only  the  mental  symptoms 
axe  the  first  to  appear,  not  usually  manifesting  themselves  until  the  motor 


1088  DISEASES  OF  THE  XERVOUS  SYSTEM 

are  well  established.  Motor  symptoms  include  also  spasm  of  the  muscles 
of  the  face.  The  movements  differ  from  those  of  chorea  minor  in  being 
slower  and  by  absence  of  co-ordination,  strikingly  manifested  in  walking. 
The  station  may  be  good,  except  for  a  slight  swaying  of  the  trunk,  but  an 
attempt  to  walk  is  followed  by  an  unsteadiness  characterized  by  marked 
lateral  deviation  from  the  straight  line,  by  swaying  of  the  body,  and  some- 
times by  precipitate  falling  movement  from  which  the  patient  may,  how- 
ever, recover  himself — in  brief,  a  typical  drunkard's  gait.  This  unsteadi- 
ness xiltimately  makes  locomotion  impossible,  and  the  patient  takes  to  his 
bed.  Yet  before  this  stage  is  reached,  although  ataxic,  he  may  be  able  to 
walk  long  distances.  While  at  rest  the  movements  cease  altogether.  They 
are  aggravated  by  emotion  and  excitement,  while  in  the  beginning  they 
may  to  a  degree  be  influenced  by  the  will.  Thus,  a  patient  said  lately: 
"If  I  put  my  mind  to  it,  I  can  stop  it." 

Speech  is  affected  in  most  instances,  being  at  first  slow  and  hesitating 
and  interrupted  by  interjections;  later  it  is  indistinct.  The  handwriting 
is  likewise  involved,  the  letters  being  irregular  and  badly  formed,  running 
into  one  another  and  off  the  line,  and  ultimately  writing  becomes  impos- 
sible. Sensation  and  the  special  senses  remain  intact,  as  does  the  muscular 
sense,  until  the  disease  is  advanced.     The  reflexes  are  usually  increased. 

The  tendency  to  insanity  and  suicide  has  been  referred  to  as  an  acknowl- 
edged symptom.  Beginning  as  a  simple  irritability  or  moodiness  with  de- 
pression, it  passes  slowly  over  into  feeble-mindedness.  The  suicidal  impulse 
is  sometimes  carried  out. 

Diagnosis. — This  is  easy  in  the  hereditary  cases  only.  Friedreich' s 
ataxia  resembles  it  slightly,  but  begins  earlier.  Idiopathic  double  athetosis 
also  occurs  in  elderly  persons,  but  in  it  the  movements  are  associated  with 
rigidity  and  are  of  a  peculiar  character,  and  the  gait  is  also  spastic,  while 
neither  rigidity  nor  spastic  gait  plays  any  part  in  progressive  chorea. 

Prognosis  is  ultimately  fatal.  The  progress  of  the  disease  is  progres- 
sively and  irresistibly  from  bad  to  worse. 

Treatment  is  of  no  avail. 


VI.  Chorea   Major. 

Synonyms. — Pandemic  Chorea;  Automatic  Chorea;  St.  \'itits'  Dance;  Rhyth- 
mical or  Hysterical  Chorea;  Lata;  Miryachit;  Jumpers;  Jerkers;  Holy 
Rollers. 

We  prefer  to  include  under  this  heading  all  the  different  varieties  of  sal- 
tatorial  spasm  of  which  the  historical  St.  Vitus'  dance  of  Paracelsus,  preva- 
lent in  the  fourteenth,  fifteenth,  and  sixteenth  centuries,  is  the  most  familiar 
illustration. 

All  are  neuroses,  in  which  strong  contractions  take  place  in  the  leg 
muscles  when  the  patient  attempts  to  stand,  causing  a  jumping  or  spring- 
ing action,  and  are  illustrated  by  the  "jumping  Frenchmen"  of  Maine  and 
Canada,  the  subjects  of  which  are  liable,  on  any  sudden  emotion,  to  jump 
violently  and  utter  a  loud  cry  or  sound  and  obey  anj'  command  or  imitate 
any  action  without  regard  to  its  nature.     The  jumping  prevails  in  certain 


POSTPARALYTIC  CHOREA  1089 

families.  Similar  were  the  "jerkers"  who  appeared  during  the  religious 
revivals  in  Kentucky  in  the  early  part  of  the  present  century;  and  the  "holy 
rollers,"  in  New  Hampshire  and  Vermont.  The  disease  known  as  lata 
among  the  Malays,  and  miryachit  in  Russia  are  similar.  In  the  true  St. 
Vitus'  dance,  chorea  major,  or  chorea  Germanorum,  the  paroxysm  arises 
spontaneously;  so,  also,  in  the  salaam  convulsions  of  children,  in  which 
the  muscles  of  the  abdomen  are  affected,  and  in  which  there  is  a  bowing 
forward  of  the  head  and  body  as  many  as  a  hundred  times  or  more.  The 
paroxysms  may  occur  several  times  a  day,  lasting  from  a  few  seconds  to 
as  many  minutes.  In  the  others,  as  the  American  jumpers,  etc.,  it  is  in 
response  to  some  external  impression.  During  the  paroxysm  the  affected 
person  sings,  dances,  jumps  from  the  ground,  rolls  from  side  to  side,  ham- 
mers with  his  hands,  stamps  with  his  feet,  or  whirls  madly  around  until  he 
falls  exhausted  to  the  ground. 

VII.  Postparalytic  Chorea  and  Postchoreai:  Paralysis. 
Synonym. — Posthemiplegic  Mobile  Spasm  (Gowers). 

Definition. — By  this  are  meant  choreiform  movements  which  are  the 
result  of  cerebral  disease,  most  frequently  hemorrhage.  They  may  imme- 
diately precede  or  follow  the  stroke. 

Posthemiplegic  chorea,  on  the  other  hand,  ordinarily  appears  in  the 
limbs  previously  paralyzed,  at  the  time  when  they  again  begin  to  be  capable 
of  motion.  It  is  generally  sudden,  and  either  continues  throughout  life  or 
disappears  gradually.  Often  it  is  associated  with  contractures.  Not  in- 
frequently the  affected  side  of  the  body  is  anesthetic,  and  even  the  organs 
of  special  sense  may  take  part  in  the  hemianesthesia,  in  which  cases  it  is 
probably  a  hysterical  hemianesthesia. 

The  movements  are  more  frequent  in  the  hand  than  in  the  leg,  though 
sometimes  they  occur  in  both,  most  marked  in  the  fingers  and  toes,  and 
diminish  toward  the  shoulders  and  hips.  They  are  really  more  athetoid 
than  choreic,  but  quicker,  consisting  mainly  in  inco-ordinate  gyrations  of 
the  fingers  and  thumbs,  flexion  and  extension  of  the  wrist  and  elbow, 
shrugging  and  other  movements  of  the  shoulder.  They  always  cease 
during  sleep.  Carcot  considers  posthemiplegic  chorea  as  identical  with 
athetosis. 

Symptoms. — The  prehemiplegie  form  is  rarer  and  more  serious  in  sig- 
nificance. The  movements  vary  greatly,  and  the  milder  degrees  can  be 
recognized  only  on  close  examination.  In  this  form  the  symptoms  pre- 
cede, usually  by  a  few  days,  the  apoplectic  stroke,  and  cease  as  soon  as 
paralysis  appears. 

The  lesion  causing  these  symptoms  is  regarded  as  cerebral,  and  in  that 
portion  of  the  cerebrum  within  the  internal  capsule  in  which  the  fibers  of  the 
pyramidal  tract  pass  between  the  lenticular  nucleus  and  the  optic  thalamus. 
Sometimes,  however,  similar  phenomena  are  associated  with  disease  else- 
where, as  in  the  pons  or  even  in  the  spinal  cord;  but  under  any  circum- 
stances it  would  seem  to  be  necessary  that  there  should  be  irritation  of  the 
pyramidal  tracts  somewhere  in  their  course. 


1090  DISEASES  OF  THE  XERVOUS  SYSTEM 

EPILEPSY. 
Synonyms. — Morbus  cadticus  sive  sacer;  Morbus  dhinus;  Falling  Fits. 

Definition. — Epilepsy  is  a  chronic  paroxj^smal  disease,  characterized  in 
its  typical  form  by  sudden  loss  of  consciousness  and  by  violent  general 
convulsions  (grand  mal);  but  both  unconsciousness  and  con\ailsions  may 
be  so  fleeting  as  to  be  barely  recognized  (petit  mal);  while  convulsions 
may  be  localized  and  unattended  by  loss  of  consciousness  (Jacksonian  or 
focal  epilepsy);  finally,  seizures  may  be  substituted  by  conditions  of  un- 
controllable violence  or  somnambulastic  acts  (psychical  epilepsy). 

Epilepsy  is,  strictly  speaking,  a  syndrome  or  group  of  symptoms  of 
which  the  morbid  basis  is  not  always  the,  same.  Formerly  it  was  considered 
essential  to  the  diagnosis  of  epilepsy  that  the  convulsions  should  not  be 
toxic,  reflex,  traumatic,  the  result  of  previous  brain  disease,  or  heart  failure. 
At  the  present  day  toxic  convulsions,  which  are  essentially  covered  in  actual 
practice  by  uremic  convulsions,  are  not  regarded  as  epileptic,  nor  are  pure 
reflex  convulsions  which  are  due  to  such  causes  as  teething,  constipation, 
worms,  and  other  forms  of  peripheral  irritation.  On  the  other  hand,  cer- 
tain con\mlsions  due  to  cortical  brain  lesions,  which  will  be  further  con- 
sidered, are  acknowledged  to  be  epileptiform.  For  most  cases  of  epilepsy 
no  anatomical  basis  has  as  yet  been  discovered. 

Etiology. — From  one  to  six  persons  out  of  every  looo  have  epilepsy. 
The  tendency  of  modern  studies  is  to  diminish  the  importance  of  heredity, 
formerly  so  conspicuous  as  a  supposed  cause  of  epilepsy.  Gowers'  statistics, 
which  may  still  be  regarded  as  representing  the  older  pathology,  drawn 
largely  from  his  own  practice,  ascribe  to  heredity  a  percentage  of  35,  while 
the  range  in  the  older  statistics  is  from  9  to  40.  Osier's  observ^ations,  on 
the  other  hand,  on  cases  at  the  Infirmary  for  Nerv'ous  Diseases  in  Philadel- 
phia, and  in  the  Institution  for  Feeble-minded  Children  at  Ewlyn,  Pa.,  give 
the  percentage  in  the  two  institutions  as  a  little  over  i  per  cent.,  and  in  five 
cases  out  of  435  in  which  the  epileptics  were  children  of  epileptic  parents 
it  was  traceable  to  the  mother  in  every  instance.  The  comparative  unim- 
portance of  heredity  as  a  cause  is  upheld  bj'  the  modem  French  school, 
notably  by  Marie.  On  the  other  hand,  the  disease  is  of  frequent  occur- 
rence in  neurotic  families,  including  those  subject  to  insanity,  hysteria,  and 
neuralgia.  So,  too,  vices  of  constitution  and  vicious  habits  in  parents, 
especially  alcoholism  and  syphilis,  are  acknowledged  causes.  The  inter- 
marriage of  relatives  is  also  an  element.  More  certainly  responsible  is  local 
disease  of  the  brain  cortex,  including  tumors  and  traumatic  disease,  such  as 
are  produced  by  fractures,  and  the  conditions  described  as  causing  the 
cerebral  palsies  in  children. 

All  of  these  are  causes  which  may  be  both  essential  and  exciting. 
Among  the  more  purely  exciting  causes  arc  fright,  irritation  by  worms  in 
the  intestinal  tract,  dentition,  constipation,  and  the  like,  all  of  which  may 
provoke  attacks  in  an  epileptic.  Some  would  regard  the  reflex  epileptiform 
attacks  excited  by  these  causes  as  true  epilepsy,  and  call  it  reflex  epilepsy. 
But  at  present  these  cases  should  not  be  called  epileptic,  since  they  do  not 
recur  after  the  exciting  cause  is  removed.     These  are  Yery  different  from 


EPILEPSY  1091 

others  in  which  attacks  are  brought  on  by  like  exciting  causes,  but  occur 
also  independently  of  these  causes. 

True  exciting  causes  are  infectious  diseases,  alcoholism,  and  syphilis. 
The  influence  of  infectious  diseases  is  thus  shown :  Given  an  epileptic  who 
is  subject  to  seizures  once  a  month,  who  acquires  typhoid  fever,  the  pro- 
dromal symptoms  are  almost  always  sure  to  include  frequently  recurring 
epileptic  seizures.  Masturbation  is  included  among  the  true  causes,  but  is 
probably  only  an  exciting  cause.  Ocular  and  aural  irritations  are  exciting 
causes.  Cardiac  epilepsy  is  a  variety  in  which  there  is  disturbance  of  the 
heart's  action,  either  palpitation  or  slowing,  prior  to  attacks;  but  such  de- 
rangements are  symptoms  rather  than  causes,  or  they  may  be  a  mode 
of  manifestation  of  the  aura  to  be  presently  described. 

Epilepsy  is  pre-eminently  a  disease  of  childhood  and  youth,  and  after 
20  it  is  most  unlikely  to  arise.  Most  cases  begin  between  the  ages  of 
10  and  16.  Yet  idiopathic  epilepsy  may  occur  after  60.  It  seems  to  be 
slightly  more  frequent  in  boys  than  girls,  although  all  statistics  do  not 
point  this  way,  whence  it  may  be  concluded  that  the  numbers  in  each  sex 
are  nearly  equal. 

Morbid  Anatomy. — The  cortical  lesions  described  as  causing  the  cere- 
bral palsies  of  children  and  some  resvdting  from  trauma  are  found  in  con- 
nection with  most  cases  of  Jacksordan  or  focal  epilepsy.  Tumors,  espe- 
cially those  involving  the  motor  layer  of  the  cortex,  are  among  these 
causes ;  so  are  localized  syphilis,  pachymeningitis,  and  tyroma  or  tuberculous 
tumor,  and  sometimes  tuberculous  meningitis,  pointed  out  by  J.  Hendrie 
Lloyd.  Lloj^d  would,  however,  exclude  the  gross  deformities,  such  as  por-. 
encephalia;  and  diffuse  processes,  such  as  lobar  sclerosis,  which  manifest 
themselves  by  idiocy  and  arrested  development,  and  are  not  infrequently 
provocative  of  epileptic  seizures. 

Sclerosis  of  different  parts  of  the  brain  and  medulla  oblongata  is  also 
found  in  cases  of  epilepsy.  This  is  especially  true  of  the  hippocampus 
major,  this  being  probably  a  conspicuous  local  focus  of  a  more  diffuse  lesion. 
Similar  sclerosis  is  sometimes  found  in  the  cerebellum.  A  nuclear  degenera- 
tion and  vacuolation  of  the  cells  of  the  second  layer  of  the  cortex  has  been 
claimed  by  Bevan  Lewis  as  a  distinctive  lesion  of  epilepsy.  Man^r  cases  of 
so-called  idiopathic  epilepsy  are  still  without  a  demonstrable  morbid 
anatomy. 

Mechanism  of  the  Convulsion. — The  epileptic  seizure  itself  is  regarded 
in  the  light  of  our  present  knowledge  as  an  explosion  or  discharge  of  nerve 
force,  the  seat  of  discharge,  in  the  severe  seizures,  at  least,  being  the  large 
motor  cells  in  the  deeper  layers  of  the  cortex,  the  function^  of  which  is  to 
store  up  and  discharge  nerve  force.  The  same  mechanism  exists  in  sensory 
and  psychical  epilepsy.     The  explanation  is  not  entirely  satisfactory. 

Symptoms. — These  vary  in  the  four  varieties  known  as  grand  mal,  petit 
mal,  Jacksonian,  and  psychical  epilepsy. 

I.  Grand  Mal. — In  a  large  number  of  cases  the  epileptic  attack  is  pre- 
ceded by  what  is  known  as  the  aura,  a  peculiar  sensation  which  differs 
greatly  in  different  individuals.  Occasionally  it  is  like  what  the  word 
literally  means,  a  breath  of  air,  which  starts  from  a  particular  part  of  the 
body,  as  the  extremities  or  a  single  finger  or  toe  or  a  part  of  the  surfa,ce  of 


1092  DISEASES  OF  THE  XERVOUS  SYSTEM 

the  body,  such  as  the  nieghborhood  of  the  stomach  or  the  heart.  At  other 
times  the  atira  is  a  simple  epigastric  sensation,  a  sense  of  discomfort  or 
uneasiness  emanating  from  the  stomach  or  the  feeling  of  a  ball  arising 
therefrom,  and  this  is  not  a  very  uncommon  form.  It  may  be  a  flash  of  light, 
which  may  be  of  different  colors;  an  object,  as  a  face  or  faces,  and  even  a 
coffin — as  in  one  of  M.  Allen  Starr's  cases.  Auditory  aurse  are  manifested 
through  the  sense  of  hearing,  and  may  be  subjective  sounds  of  any  kind,  in- 
cluding musical  tones  or  even  voices.  Gustatory  and  olfactory  aurae  include 
subjective  tastes  and  smells,  mostly  of  an  unpleasant  character.  Aura;  are 
represented  also  by  tingling,  numbness,  or  simple  flushing  or  chilliness  any- 
where in  the  body.  "Intellectual  aurje"  so  called  by  Hughlings  Jackson, 
are  certain  mentla  conditions,  such  as  the  "  dreamy  state,"  and  the  conscious- 
ness of  a  certain  algebraic  formual,  which  always  presented  itself  to  a  pa- 
tient of  Starr. 

In  other  cases  there  is  a  more  prolonged  prodrome.  For  several  hours 
or  for  a  day  the  patient  may  be  the  subject  of  sensations.  He  may  feel  gen- 
erally miserable,  dispirited,  timid,  irritable,  or  dizzy,  or  he  may  be  pale  or 
qmet,  and  wait  patiently  for  the  dreaded  event,  known  to  him  rather  by  its 
consequences  than  its  phenomena,  of  which  he  is  unconscious.  There  is 
pathetic  sadness  often  in  this  patient  expectation.  The  aura  is  by  no  means 
always  present,  indeed,  perhaps  in  the  majority  of  cases  of  epilepsy  there 
occurs  no  warning  of  the  attack.  The  aura  may  be  substituted  by  certain 
movements,  such  as  running  rapidly  for  a  few  minutes  either  forward  or  in 
a  circle — the  so-called  epilepsia  procursiva — or  the  patient  may  stand  on 
his  toes  and  rotate  mth  great  rapidity. 

Following  the  aura  or  independent  of  it  occurs  the  convulsion  or  "fit," 
of  which  the  initial  event  is  often  the  epileptic  cry.  This  is  succeeded  by  the 
fall  which  may  be  sudden,  as  if  the  patient  were  shot,  while  serious  injun,' 
may  be  a  consequence.  Following  this  the  phenomena  of  the  fit  may  be 
quite  sharply  di\'ided  into  three  stages,  that  of  tonic  spasm,  of  clonic  spasm, 
and  of  coma. 

(a)  The  Tonic  Spasm. — In  this  the  head  is  drawn  back  or  to  the  right  or 
left  and  the  jaws  are  fixed ;  the  arms  are  flexed  at  the  elbow,  the  hand  is  flexed 
at  the  wrist,  and  the  fingers  are  clinched  into  the  palm,  while  the  legs  and  feet 
axe  extended.  The  muscles  of  the  chest  are  involved  and  respiration  is  sus- 
pended, and  the  face  becomes  dusky,  livid,  and  swollen,  contrasting  with  the 
initial  pallor.  The  muscles  of  the  two  sides  are  no^  equalh'  affected,  so  that 
the  neck  is  twisted  and  the  spine  curved.  This  stage  lasts  but  a.  few  seconds 
and  is  succeeded  by  clonic  spasm. 

(6)  The  Clonic  Spasm. — Now  the  muscular  contractions  become  inter- 
mittent. At  first  tremulous  and  vibratory,  they  soon  become  strong  and 
general,  tmtil  the  arms  and  legs  are  thrown  about  in  the  most  violent  man- 
ner, sometimes  so  \nolently  as  to  produce  dislocation,  usually  of  the  shoulder. 
The  muscles  of  the  face  are  also  involved  in  distorting  contractions,  while 
the  eyes  roll  and  the  lids  open  and  close.  The  jaw  muscles  contract  violently 
and  the  tongue  is  apt  to  be  caught  and  bitten.  A  frothy  saliva,  often  blood- 
stained, escapes,  and  the  patient  is  said  to  "froth  at  the  mouth."  There 
may  be  voluntary  discharge  of  feces  and  urine.  The  lividity  supervening 
in  the  first  stage  diminishes  somewhat  during  this  stage.     The  temperature 


EPILEPSY  1093 

rises  1/2°  to  1°  F.  (o.  28°  to  o.  55°  C.)-  Very  soon  the  contractions  become 
less  violent,  finally  abate,  and  this  stage  terminates,  in  one  or  two  minutes, 
in  the  stage  of  coma. 

(c)  Coma. — In  this  the  limbs  are  relaxed  and  there  is  profound  uncon- 
sciousness, but  the  breathing  is  noisy  and  stertorous.  The  face  remains  con- 
gested, but  is  no  longer  cyanotic.  The  patient  ma3^  after  a  time,  be  aroused, 
but  if  left  alone,  commonly  sleeps  several  hours,  awaking  after  a  time  in  a 
remarkably  natural  state,  feeling  bruised  and  aching,  but  othervidse  qiiite 
himself;  or  there  may  be  some  mental  confusion  and  even  headache. 

These  are  the  phenomena  of  the  attack  in  the  vast  majority  of  cases  of 
grand  mal.  There  may  not  be  another  attack  for  several  days  or  a  month 
or  more.  In  severe  cases,  on  the  other  hand,  there  may  be  daily  recurrence, 
though  not  until  the  disease  has  lasted  for  several  years.  In  a  few  instances 
the  attacks  may  follow  one  another  in  rapid  succession  without  a  return  of 
consciousness,  lasting  from  12  hours  to  a  day  or  more,  producing  the  status 
epilepticus,  in  the  course  of  which  the  patient  may  die  from  exhaustion. 
In  this  state  there  is  often  decided  fever.  In  some  instances  the  Jacksonian 
form  of  epilepsy  may  appear  as  status  epilepticus. 

After  the  attack  the  reflexes  may  be  increased  and  ankle  clonus  may  be 
obtained;  at  other  times  the  reflexes  are  absent.  The  urine  is  also  often 
increased,  and  a  small  amount  of  albumin  is  quite  common  after  the  fit. 
There  is  also  sometimes  an  increase  in  the  amount  of  uric  acid  in  the 
urine  after  the  convulsion  in  grand  mal. 

Inequality  of  pupils  (anisocoria)  has  been  considered  a  symptom  of  epi- 
lepsy. This  symptom,'  however,  occurs  in  healthy  individuals,  and  too 
much  value  should  not  be  attached  to  it. 

2.  Petit  Mal. — The  symptoms  in  minor  attacks  varj'  somewhat,  but 
commonly  the  patient  stops  in  the  midst  of  what  he  may  be  doing,  the  eyes 
become  staring  and  fixed,  the  pupils  dilated,  the  countenance  pale,  there 
may  be  some  twitching  of  the  facial  muscles  or  the  limbs,  and  consciousness 
is  lost,  but  there  is  no  convulsion.  Anything  that  is  in  the  hand  may  be 
dropped,  but  in  a  minute  or  two  consciousness  returns  and  the  patient  re- 
sumes what  he  has  been  doing  as  though  nothing  had  happened.  Here, 
too,  though  rarely,  there  may  be  aur^  of  various  kinds  and  even  an  epileptic 
cry;  also  forced  movements — procursive  epilepsy.  There  may  be  dizziness 
without  unconsciousness,  and  the  patient  may  fall.  An  increase  of  uric 
acid  in  the  urine  is  said  also  to  be  quite  frequently  associated  with  this 
form  of  epilepsy.  As  the  disease  continues  the  attacks  of  petit  mal  gener- 
ally become  grand  mal,  or  the  two  forms  of  attack  may  alternate. 

3.  Jacksonian  or  Partial  or  Focal  Epilepsy. — In  this,  consciousness 
is  retained,  though  it  is  thought  by  some  that  there  is  always  a  momentary 
period  of  unconsciousness  while  convulsions  occur,  though  circumscribed  to 
a  single  group  of  muscles  or 'to  a  single  limb.  It  is  almost  always  symp- 
tomatic of  some  focal  lesion  in  the  cortical  motor  area,  which  may  be  a 
tumor,  an  injury  or  inflammatory  process  in  the  membranes  or  brain  sub- 
stance, softening,  hemorrhage,  abscess,  or  sclerosis.  It  is  especially  likely  to 
be  a  sign  of  a  growing  tumor.  Hence  it  is  also  called  symptomatic  epilepsy. 
Previous  to  the  twitching  there  may  be  a  numbness  or  tingling  in  the  part  to 

'  See  a  paper  by  Wendell  Reber,  "The  Pupil  in  Health  and  Epilepsy,"  "  Med.  News,"  August  24,  1895. 


1094  DISEASES  OF  THE  XEKVOUS  SYSTEM 

be  involved,  which  has  been  called  the  "  signal  symptom"  by  Seguin,  because 
it  ushers  in  the  attack.  It  may  remain  during  the  attack,  and  is  of  value  in 
determining  the  seat  of  the  lesion,  and  therefore  the  place  for  operation.  Its 
seat  is  usually  the  same  in  the  same  patient  in  all  the  attacks. 

The  spasm  or  convtdsion  begins  uniformly  in  one  part — it  may  be  the 
face,  the  thumb,  the  toes — thence  slowly  invades  an  entire  limb.  It  con- 
tinues sometimes  for  three  or  four  minutes  or  longer.  The  movement  is 
tonic  and  clonic,  extending  from  the  part  in  which  it  begins  to  other  parts  in 
a  definite  order  of  extension.  Thus,  if  it  begins  in  a  part  of  the  face,  it  ex- 
tends thence  to  the  whole  face,  then  to  the  shoulder,  arm,  forearm,  and  hand, 
and  possibly  the  leg  from  the  trunk  down  to  the  toes ;  or  it  may  start  in  the 
fingers  and  go  in  the  opposite  direction.  Jacksonian  epilepsy  also  occurs  in 
uremia  and  progressive  paralysis  of  the  insane,  and  it  has  already  been  spoken 
of  as  following  the  hemiplegia  of  children.  After  the  convulsion,  the  parts 
con\ailsed  and  especially  that  in  which  the  spasm  begins  maj'  be  partially 
paralyzed  and  awkward  in  movement,  and  quite  often  the  numbness  and 
palsy  continue  for  some  time,  with  a  moderate  degree  of  tactile  or  thermal 
anesthesia.  More  rarely  this  paresis  is  permanent,  when  it  is  evidence  of 
changes  in  the  cortex  such  as  may  be  caused  by  a  growing  tumor.  The 
opposite  side  of  the  body  may  also  be  affected,  and  if  this  occurs,  conscious- 
ness may  be  finally  lost. 

4.  Psychical  Epilepsy. — This  occurs  either  as  a  later  symptom  follow- 
ing the  more  common  forms  of  grand  nial  and  especiall}"  petit  mal,  or  as  an 
independent  state  or  as  what  is  known  as  a  "psychical  epileptic  equivalent, " 
where  the  usual  seizure  is  substituted  by  a  somnambulistic  state  in  which  the 
patient  performs  various  acts,  sometimes  of  great  complexity,  including 
driving,  walking,  and  the  like,  of  which  he  is  totally  oblivious  after  he  passes 
into  the  natural  condition.  Some  striking  instances  of  psychical  epileptic 
equivalent  are  related  by  M.  Allen  Starr  in  his  book  on  "Familiar  Forms  of 
Nervous  Disease."  Other  manifestations  of  psychical  epilepsy  are  repre- 
sented by  violent  maniacal  excitement  and  uncontrollable  violence,  in  which 
criminal  acts,  including  even  homicide,  are  committed.  See  also  under 
Prognosis. 

Relative  Frequency  and  Time  of  Attacks. — The  major  form  of  attack  is 
the  most  frequent,  after  this,  mixed  forms  of  major  and  minor,  and  then 
minor  and  Jacksonian;  the  most  infrequent  are  the  psychical  forms. 

Two-thirds  of  the  attacks  occur  between  8  a.m.  and  8  p.m.;  many  attacks 
occur  early  in  the  morning  after  awaking,  some  between  3  and  5  a.  m.,  and 
others  in  the  night  at  unknown  hours — nocturnal  epilepsy.  In  true  epilepsy 
the  patient  generally  feels  perfectly  well  between  the  attacks — indeed,  he 
not  infrequently  feels  better  for  a  time  after  the  spell. 

Diagnosis. — The  epileptic  fit  is  of  itself  in  no  way  characteristic  of  the 
disease.  The  uremic  convulsion  is  identical,  as  is  also  the  reflex  convulsion 
due  to  teething  and  other  causes.  Even  hysterical  convulsion  closely  re- 
sembles it,  but  there  are  points  of  difference.  Something  more,  therefore, 
than  the  con^allsion  is  necessary  to  prove  the  presence  of  the  disease.  The 
aura  is  distinctive,  and  when  present,  is  almost  conclusive.  Scarcely  less  so 
is  the  epileptic  "cry"  although  it  is  less  constant  than  the  aura.  The  relaxa- 
tion of  the  spincters  belongs  rather  to  the  epileptic  fit,  while  the  bitten  tongue, 


EPILEPSY  1095 

the  dilated  pupil,  and  sudden  unconsciousness  belong  to  uremia  as  well; 
and  it  is  from  uremia  that  it  is  most  important  to  distinguish  epilepsy. 
The  occurence  in  the  midst  of  apparent  health  of  a  convulsion  with  the 
features  described,  followed  by  prompt  recovery  without  albuminuria  or 
casts,  can  hardly  be  anything  but  epilepsy.  Here  the  use  of  the  phtha- 
lein  test  described  in  another  place  will  help  to  make  the  diagnosis.  At 
other  times,  when  other  signs  of  Bright's  disease  are  absent,  it  may  be 
necessary  to  defer  the  diagnosis  a  little  longer  in  order  to  examine  the 
urine.  Finally,  epileptics  may  have  Bright's  disease,  when  errors  are  still 
more  likely  and  sometimes  unavoidable.' 

The  reflex  convulsion  in  children  is  likely  to  be  repeated  until  the  cause  is 
removed,  and  in  this  respect  the  condition  resembles  the  status  epilepticus, 
but  in  the  former  a  little  careful  searching  will  probably  discover  the  cause. 
The  isolated  reflex  convulsion  may  be  more  difficult  to  account  for  at  first, 
but  in  these  cases  immediate  decision  is  less  important.  The  very  short 
duration  of  the  petit  mal  separates  it  sharply  from  the  uremic  fit.  Nocturnal 
convulsions,  occurring  as  they  do  often  without  the  knowledge  of  the  patient, 
are  usually  epileptic. 

The  hysterical  convulsion  sometimes  simulates  closely  the  epileptic. 
But  the  hysterical  patient  rarely  loses  consciousness  completely,  the  fall  is 
not  so  sudden,  the  victim  rarely  if  ever  hurts  herself,  and  never  bites  her 
tongue ;  nor  is  there  any  rise  of  temperature,  while  even  the  pulse  and  respi- 
rations commonly  remain  quite  normal.  There  is  rigidity,  but  it  is  unlike 
that  of  epilepsy — it  is  not  more  conspicuous  in  the  beginning  of  the  attack. 
Opisthotonos,  or  arching  of  the  back,  does  not  occur  in  the  epileptic  convul- 
sion. Finally,  the  hysterical  convulsuon  is  of  longer  duration,  lasts  lo 
minutes  or  more,  while  the  duration  of  the  epileptic  fit  is  not  usually  more 
than  three  or  four  minutes. 

The  petit  mal  is  most  frequently  mistaken  for  fainting,  but  after 
two  or  three  occurrences  it  should  be  recognized.  The  vertigo  of  Meniere's 
disease  and  of  attacks  of  indigestion  resembles  it,  but  in  the  former  there 
is  deafness,  while  in  neither  is  there  actual  unconsciousness,  as  is  alwa^^s 
the  case  in  petit  mal. 

Jacksonian  epilepsy  is  sui  generis  and  is  not  simulated  by  any  except 
the  rare  instances  of  localized  uremic  convulsions  and  similar  spasms  in 
general  paresis;  however,  it  has  been  described  as  occurring  in  hysteria. 
A  further  study  of  each  instance  must  quickly  dissipate  the  error.  While 
the  approximate  seat  of  the  lesion  may  be  inferred  in  many  cases  of  Jack- 
sonian epilepsy,  the  precise  cause  cannot  generally  be  determined,  because 
all  sorts  of  lesions  produce  the  same  symptoms.  Recurring  epilepsy  in 
persons  over  30  is  probably  due  to  organic  causes,  and  in  nine  cases  out 
of  ten,  according  to  H.  C.  Wood  and  also  Fournier,  is  due  to  syphilis. 

The  highest  refinement  of  diagnosis  in  the  study  of  epilepsy  attempts 
to  determine  from  the  character  of  the  aura  the  seat  of  beginning  cortical 
irritation.  Thus,  a  visual  aura,  it  is  claimed,  might  indicate  that  the  ner- 
vous discharge  began  in  the  occipital  lobes;  a  vertigo  might  indicate  that 
it  began  in  the  cerebellum;  a  sense  of  numbness,  the  sensory  area  of  the 

s  of  the  Association  of  American  Physi- 


1096  DISEASES  OF  THE  NERVOUS  SYSTEM 

cortex.  The  "intellectual  aurae, "  as  they  are  called  by  Hughlings  Jackson, 
are  regarded  by  him  as  affording  evidence  of  a  nervous  discharge  from  the 
highest  cerebral  centers. 

Prognosis. — The  true  epileptic  rarely  gets  well.  Tyson  has  seen  two 
cases  of  recovery  in  his  experience.  In  such  statement  epileptiform  at- 
tacks due  to  peripheral  irritation  are  rigidly  excluded  as  not  being  true 
epilepsy.  These  invariably  get  well  with  the  removal  of  the  irritation, 
while  true  epilepsy,  in  which  attacks  are  readily  excited  by  such  irrita- 
tion, is  benefited  but  not  cured.  The  chances  of  recovery  are  said  to 
be  greater  in  the  young,  and  in  the  male  sex  than  in  the  female.  One  of 
the  cases  of  apparent  recovery  was  a  man  who  had  his  last  fit  after  40; 
the  second  a  woman  who  had  no  attack  after  14.  Both  live.  C.  L.  Dana 
places  the  recoveries  at  from  five  to  ten  per  cent.,  which  appears  to  me 
large.  Even  in  cases  of  combined  petit  mal  and  grand  mal,  in  which  the 
prognosis  is  most  unfavorable,  recovery  is  said  to  occur.  The  prognosis  of 
petit  mal  is  more  unfavorable  than  that  of  grand  mal ;  of  the  mixed  forms 
still  more  unfavorable,  and  posthemiplegic  epilepsy  most  unfavorable  of  all. 

On  the  other  hand,  an  epileptic  rarely  dies  of  his  disease.  He  may  fall 
in  the  water  during  an  attack  and  drown,  may  choke  to  death  if  attacked 
while  eating,  or  may  be  smothered  by  the  bed  clothes.  Death  sometimes 
occurs  from  exhaustion  in  the  status  epilepticus,  but  this  is  not  frequent. 
The  health  of  epileptics  usually  deteriorates  slowly,  and  life  is  shortened 
accordingly,  few  surviving  the  age  of  40  or  50.  They  rather  frequently 
die  of  tuberculosis.  Especially  frequent  is  mental  deterioration;  indeed, 
it  may  be  said  to  be  the  rule  when  the  patient  lives  long  enough,  and 
about  ten  per  cent,  become  demented  or  insane.  Changes  begin  with 
loss  of  self  control  succeeded  by  confusion  of  intellect.  Delirious  and 
passionate  outbreaks  precede  and  follow  the  convulsive  seizures  during 
which  criminal  acts  are  committed.  Much  may  be  done  by  treatment  to 
control  the  number  of  attacks,  and  the  less  numerous  they  are,  the  less 
serious  is  the  effect  upon  the  health.  Many  epileptic  persons  earn  a  living, 
and  more  could  if  properly  helped. 

The  more  infrequent  the  attacks,  the  better  the  prognosis.  Pure 
nocturnal  epilepsy  and  the  pure  diurnal  form  are  each  more  easily  cured 
than  the  mixed  forms.  Cases,  too,  which  arise  after  20  years  of  age  are 
more  likely  to  get  well. 

Treatment. — No  fact  in  therapeutics  is  better  established  than  that 
the  bromids  control  epilepsy  in  varying  degree — it  may  be  completely, 
it  may  be  simply  to  render  infrequent  the  seizures.  There  is  probably 
no  important  difference  in  the  efficiency  of  the  various  preparations,  but 
the  bromid  of  potassium  has  been  most  extensively  used.  The  bromid 
of  sodium  is  preferred  on  account  of  its  greater  solubility.  '  Bromid  of 
ammonium  is  slightly  more  stimulating.  More  recently  bromid  of  stron- 
tium has  been  highly  recommended.  Causes  of  peripheral  irritation  should 
first  be  sought,  and  if  possible  eliminated.  Gastro-intestinal  irritation 
shotdd  be  removed.  Phimosis  should  be  cured.  The  possible  practice 
of  masturbation  should  be  inquired  into.  These  eliminated,  the  bromid 
treatment  maj^  be  commenced.  The  doses  required  vary  greatly  and 
must  be  determined  by  trail.     Scarcely  less  than  15  grains  (i  gm.)  four  times 


EPILEPSY  1097 

a  day  are  required  for  adults,  and  from  this  point  the  dose  may  be  increased 
until  the  desired  effect  is  produced.  The  massive  doses  sometimes  given, 
amounting  to  ounces  in  a  day,  are  ultimately  harmful,  but  doses  of  a  dram 
(4  gm.)  are  sometimes  necessary  and  well  borne,  but  if  long  continued  arc 
likely  to  produce  bromism.  It  is  sometimes  of  advantage  to  combine  the 
various  bromids  of  sodium,  potassium,  and  ammonium.  Greater  efficiency 
is  secured  if  the  drug  is  given  on  an  empty  stomach,  half  and  hour  before 
meals  or  two  hours  after,  and  smaller  doses  suffice  when  thus  administered, 
and  the  omission  of  sodium  chlorid  from  the  diet  is  believed  to  lessen  the 
amount  of  bromid  necessary  and  to  increase  its  efficiency.  Bromism,  shown 
by  drowsiness,  mental  torpor,  gastric  and  cardiac  distress  with  acne,  some- 
times results.  It  is  doubtful  whether  it  can  be  obviated  in  any  way  except 
by  omitting  the  drug.  The  bromid  eruption  may  sometimes  be  averted  by 
combining  arsenic,  but  this  does  not  always  suceed.  In  a  few  cases  the 
bromids  are  absolutely  useless,  more  especially  in  cases  in  which  they  pro- 
duce gastro-intestinal  derangement,  perhaps  in  about  five  per  cent,  of 
cases.  Chloral  adds  to  the  efficiency  of  the  bromids,  and  is  sometimes 
necessary  to  produce  the  desired  effect.  It  may  be  given  in  doses  of  from 
10  to  30  grains  (0.66  to  2  gm.). 

Of  late  dechloridation  or  elimination  of  chlorine  from  the  food  has 
been  recommended  as  an  adjuvant  to  the  treatment  of  epilepsy  by  the 
bromids.  It  is  accomplished  by  substituting  sodium  bromid  for  sodium 
chlorid  in  the  food  of  epileptics.  Sodium  chlorid  is  not  wholly  eliminated 
but  enough  bromid  is  added  to  the  food  to  make  each  patient  take  about 
15  grains  a  day.  It  is  claimed  that  the  bromid  is  rapidly  absorbed  and 
becomes  part  of  the  body  tissue  when  thus  given,  and  that  only  one-half 
the  usual  quantity  is  necessary  to  produce  the  sedative  effect. 

Flechsig  claims  for  the  associated  use  of  opium  and  bromid  superior 
results,  but  the  possibility  of  an  opium  habit  will  restrain  the  cautious  physi- 
cian from  adopting  its  use. 

To  treatment  by  the  bromids  should,  of  course,  be  added  proper  hygienic 
measures.  Suitable  food,  especial  attention  to  the  bowels,  fresh  air,  and 
outdoor  life  are  indispensable.  It  is  of  importance  that  the  patient  be 
put  upon  milk  diet  at  first — later,  the  diet  can  be  carefully  adapted  to 
each  individual  case.  Bathing  is  important,  and  cold  baths — particularly 
douches  and  shower-baths,  cold  sponge-baths  or  wet  packs  should  be 
judiciously  used.     Vasomotor  tone  and  circulation  are  thus  strengthened. 

Of  other  remedies  recommended  may  be  mentioned  antifebrin  and 
antipyrin.  A  trial  of  the  former  in  the  Vanderbilt  Clinic  in  New  York, 
by  M.  Allen  Starr,  was  unsatisfactory.  On  the  other  hand,  in  the  hands 
of  Charles  S.  Potts,  at  the  Dispensary  of  the  University  of  Pennsylvania, 
it  was  apparently  useful.  Especially  efficient  at  the  latter  proved  a  com- 
bination of  antipyrin  and  bromid  of  ammonium,  suggested  by  H.  C.  Wood. 
For  adults  a  dose  of  6  grains  (0.39  gm.)  of  the  former  and  10  grains 
(0.66  gm.)  of  the  latter,  three  times  a  day,  in  a  number  of  cases  averted 
the  seizure  for  months.  Continuous  exhibition  seems  necessary.  These 
drugs  at  least  merit  a  trial  where  the  bromids  are  for  any  reason  unsatis- 
factory. Monobromated  camphor  has  been  recommended  by  Hasle.  The 
best  mode  of  administration  appears  to  be  in  a  capsule  or  emulsion,  the 
dose  being  2  to  5  grains  (0.13  to  0.32  gm.). 


1098  DISEASES  OF  THE  XERVOUS  SYSTEM 

Starr  has  also  used  the  tincture  of  simulo  (Capparis  coriacea)  at  the 
Vanderbilt  CHnic  with  the  effect  of  reducing  the  number  of  attacks  in 
grand  mal,  but  to  no  purpose  in  petit  mal.  It  was  used  in  doses  as  large 
as  1/2  ounce  (13.5  c.  c.)  daily.  In  petit  mal  the  same  observer  found 
nitro-glycerin  the  only  remedy  of  any  service.  He  appears  to  have  used 
it  in  doses  of  i/ioo  grain  (0.00065  gin.)  three  times  a  day.  In  my  ex- 
perience this  regulation  dose  fails  in  a  large  number  of  cases  to  produce 
the  physiological  effect,  and  the  larger  doses — from  1/50  to  1/25  grain 
(0.0013  to  0.0026  gm.) — may  be  given.  It  is  to  be  remembered  that  epilepsy 
is  one  of  the  diseases  which  are  nearly  always  influenced  for  a  time  by  new 
remedies.  The  preparations  of  valerian  may  also  be  tried  in  the  event  of 
failure  with  the  bromids.  Others  which  have  been  used  are  borax,  iodid  of 
zinc,  and  sulphonal.  Chloretone  is  sometimes  of  great  service  in  doses 
of  3  grains  once  or  twice  daily. 

The  nitrite  of  amyl  has  been  employed  to  abort  the  attack  in  cases 
where  there  was  an  aura,  and  in  a  certain  number  of  cases — about  25  per 
cent,  in  Starr's  experience — has  proved  efficient. 

Operation,  usually  trephining,  is  increasingly  practised,  and  many  suc- 
cessful cases  have  been  reported,  chiefly  of  Jacksonian  epilepsy.  When  a 
well-defined  lesion  can  be  located,  operation  should  promptly  be  done. 
Even  in  doubtful  cases  operation  may  be  justified,  as  with  modern  surgical 
precautions  it  is  attended  with  much  less  risk.  It  should  be  remembered, 
too,  that  operation,  per  se  has  proved  curative — that  is,  cases  have 
apparently  recovered  after  trephining  where  no  lesion  was  found  after 
removing  the  disk,  and  that  practically  all  cases  are  temporarily  improved. 

Food  should  be  simply  and  easily  assimilated,  overeating  should  be 
especially  avoided.  Stale  bread,  wheaten  grits,  and  similar  foods,  rice, 
potatoes,  fresh  succulent  vegetables  like  string  beans,  peas  and  tomatoes, 
with  an  abundance  of  milk,  are  suitable.  Water  should  be  freel}-  drunk 
by  the  patient,  and  a  glassful  is  advised  between  meals  and  at  bedtime. 
Constipation  must  be  avoided. 

Asylum  Provision. — It  is  exceedingly  important  that  some  systematic 
provision  should  be  made  for  epileptics  either  by  the  State  or  by  private 
charity.  They  are,  as  a  rule,  unwelcome  inmates  of  hospitals  because 
of  their  incurability  and  the  disturbance  they  occasion.  Doubtless  the 
neglect  to  which  they  are  subjected  at  home  aggravates  in  many  instances 
their  condition,  while  it  makes  even  their  lot  more  unhappy.  Provision 
should  be  made  to  enable  them  to  pursue  some  vocation,  the  tendency  of 
which  has  been  shown  to  be  curative.  A  hospital  with  such  provision 
has  been  inaugurated  near  Philadelphia,  and  similar  institutions  exist 
in  some  other  States.  The  mind  should  be  kept  occupied;  nothing  is 
more  baneful  to  the  epileptic  than  idleness,  and  it  is  said  that  cures  have 
been  effected  by  giving  the  patient  something  to  do. 

Treatment  of  the  Convulsion. — Of  no  small  importance  is  the  treatment 
of  the  eclamptic  attack.  The  first  measure  is  to  secure  protection  against 
biting  the  tongue.  Unfortunately,  this  is  often  the  initial  event  in  the 
convulsion.  The  end  of  a  towel  may  be  twisted  and  inserted  between  the 
teeth,  or  a  suitable  piece  of  wood  or  a  clothes-pin  maj^  be  similarly  used. 
A  small  object  like  a  cork  is  unsafe,  as  it  may  be  swallowed  or  drawn  into 


CONVULSIONS  IN  CHILDREN  1099 

the  larynx  and  cause  death  by  suffocation.  Some  patients  carry  such  an 
appliance  ready  for  use.  The  patient  should  be  controlled  sufficiently 
to  protect  him  from  injury. 

Given  a  case  that  under  the  bromids  has  yielded  to  treatment,  what 
course  shall  be  pursued  as  to  its  interruption  ?  The  most  experienced 
clinicians  urge  that  the  drug  should  be  continued  at  least  two  years  after 
the  fits  have  disappeared,  and  Seguin  even  advises  that  there  should  be 
no  reduction  in  the  bromids  until  three  years  have  elapsed  without  symp- 
toms. My  own  practice  has  been  to  continue  a  dose  of  from  15  to  20  grains 
(i  to  1.32  gm.)  at  bedtime  for  an  indefinite  period  after  cessation  of  the 
fits.  The  friends  of  the  patient  should  be  impressed  with  the  importance 
of  such  a  course,  as  he  himself  is  almost  sure  to  grow  indifferent  after  the 
long  absence  of  attacks. 


REFLEX  CONVULSIONS  OF  CHILDREN. 

Synonyms. — Infantile  Convulsions;  Epilepsia  Acuta. 

Definition. — Convulsions  in  children  due  to  peripheral  irritation. 

Etiology. — Eichhorst  says:  "Epileptiform  convulsions,  which  have  the 
same  genesis  as  true  epileptic  attacks,  are  excited  by  irritation  of  the 
cortical  motor  brain  areas."  He  then  names,  among  the  causes  of  these, 
toxic  agencies,  including  uremia  and  lead-poisoning,  but  also  says  he  will 
treat  onl}^  under  eclampsia  of  the  convulsions  of  infants  (s  to  20  months), 
among  the  causes  of  which  he  names  heredity;  psychical  causes,  as  fright 
or  anger;  but  most  frequently  reflex  irritation,  as  of  the  skin  or  gastro- 
intestinal tract  (dentition,  intestinal  worms,  inflammation,  and' the  like); 
foreign  bodies;  fecal  accumulation;  stone  in  the  bladder,  etc;  and  finally, 
the  infectious  fevers  and  rickets.  This  class  of  cases  we  have  taken  great 
pains  to  exclude  from  the  epilepsies,  and  prefer  to  include  at  present  under 
the  heading  of  Reflex  Convulsions  of  Children.  The  convulsions  which 
attend  diseases  of  the  brain  are  a  part  of  the  symptomatology  of  these 
affections,  and  do  not  require  separate  consideration. 

Debility  and  malnutrition  maybe  considered  as  predisposing  causes  of 
the  form  of  convulsion  under  consideration. 

Symptoms. — These  demand  no  detailed  consideration,  since  the  con- 
vulsion is  epUeptiform  and  has  been  described.  It  is  much  oftener 
partial  than  the  typical  fit  of  true  epilepsy,  but  it  has  the  same  stages 
of  the  tonic  and  clonic  spasm  followed  by  drowsiness.  It  is  most  fre- 
quently single,  but  the  fits  may  follow  one  another  in  rapid  succession, 
and  though  rarely,  terminate  fatally.  As  in  epilepsy,  the  temperature 
rises  slightly  during  the  fit.  It  may  come  on  suddenly  without  warning, 
or  be  preceded  by  restlessness  and  fever.  It  not  infrequently  occiors 
during  sleep. 

Diagnosis. — This  is  usually  easy,  the  convulsion  coming  on  suddenly 
in  the  midst  of  health,  yet  traceable  to  some  such  event  as  the  ingestion 
of  some  indigestible  food,  to  teething,  or  to  some  other  source  of  peripheral 
irritation. 

The   convulsion  is  distinguished  from  that  of  infantile  hemiplegia  by 


1100  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  absence  of  hemiplegia.  A  transient  paresis  docs,  however,  sometimes 
follow  the  reflex  convulsion. 

These  convulsions  most  frequently  occur  between  the  fifth  and  twentieth 
months,  and  toward  the  end  of  the  second  year,  though  they  may  occur  as 
late  as  the  fifth  year.  Convulsions  occurrinfi;  after  this  period  arc  more 
likely  to  be  true  epilepsy. 

Prognosis. — Cases  of  infantile  convulsions  are  always  alarming,  yet 
most  get  well,  and  doubtless  many  cases  among  the  poor  recover  which 
do  not  come  under  the  notice  of  the  physician.  On  the  other  hand,  not 
a  few  deaths  are  caused  by  them — according  to  Morris  J.  Lewis,  8.5  per 
cent,  of  all  deaths  in  children,  under  10;  and  according  to  West,  22.35  per 
cent,  of  all  who  die  under  one  year.  Cases  of  infectious  disease  ushered 
in  by  convulsions  are  almost  always  serious,  but  the  convulsions  them- 
selves are  rarely  fatal.  Convulsions  due  to  gastric  derangement  are  gen- 
erally followed  by  recovery. 

Treatment. — The  first  step  in  the  treatment  must  always  consist  in 
finding  and  removing  the  cause.  If  it  be  undigested  food,  an  emetic  and 
an  enema  indicated;  if  dentition  is  at  fault,  the  lancet  should  be  promptly 
applied  to  the  gums.  The  next  step  is  immersion  in  a  warm  bath,  at 
95°  F-  (35°  C.),  increased  to  100°  F.  (38.8°  C),  to  which  mustard  may  be 
added.  At  the  same  time  cold  should  be  applied  to  the  head  by  means  of 
an  ice-bag  or  cold  water.  To  control  the  convulsion,  chloral  is  the  remedy 
par  excellence,  but  while  waiting  for  its  effect,  it  may  be  necessary  to  per- 
mit the  child  to  inhale  a  few  drops  of  chloroform.  The  dose  of  chloral 
should  be  sufficient — 2  1/2  to  5  grains  (0.165  to  0.33  gm.)  to  a  child  of  one 
year,  frequentlj^  repeated  until  the  effect  is  produced.  It  may  be  given  in 
enema  in  double  this  dose,  the  buttocks  being  compressed  until  it  is  ab- 
sorbed. The  bromids  may  be  given  in  combination  with  chloral,  but  they 
are  altogether  too  feeble  to  be  relied  upon  alone.  Should  these  measures 
fail,  opium  may  be  used  and  even  morphin,  hypodermically.  in  minute 
doses;  but  these  drugs  should  be  used  only  as  a  last  resort.  Generally, 
the  attack  is  relieved  the  moment  the  peripheral  irritation  is  removed. 


MIGRAINE. 

Synonyms. — Sick  Headache;  Bilious  Headache;  Hcmicrania;  Megrim; 
Migran;  Paroxysmal  Headache. 

Definition. — Migraine  is  an  intermittent,  sensory  neurosis,  of  which 
headache,  commonly  hemieranial,  is  the  most  invariable  symptom.  Al- 
most as  constant  are  aggravated  nausea  and  vomiting,  to  which  may'  be 
added  other  sensory  symptoms,  especially  deranged  vision.  Ophthal- 
moplegic migraine  is  a  rare  form,  in  which  paralysis  of  ocular  muscles 
occurs. 

Etiology. — This  is  obscure.  The  disease  is  more  common  in  females — 
apparently  three  times  as  frequent  as  in  males.  It  begins  early  in  life, 
commonly  at  puberty,  and  even  earlier — as  early,  in  fact,  as  at  two  years, 
It  affects  vigorous  and  strong  as  well  as  nervous  and  anemic  subjects. 
Exciting   causes   are   fatigue,   mental   and   physical,   including   eye-strain, 


MIGRAINE  1101 

digestive  derangements,  and  menstrual  disorders.  What  is  known  as 
the  uric  acid  diathesis  plays  an  undoubted  role  in  certain  cases.  As  often 
none  is  discoverable. 

It  is  usual  to  speak  of  migraine  as  a  vasomotor  disturbance,  because 
there  are  symptoms  which  point  to  involvement  of  the  sympathetic  system, 
but  this  is  a  matter  of  inference  rather  than  demonstration.  The  attacks 
are  characteristically  paroxysmal.  It  appears  to  be  more  frequent  in  the 
winter  season  in  this  climate,  when  it  is  not  infrequently  associated  with 
a  gouty  or  rheumatic  attack.  Caries  of  the  teeth  and  nasal  troubles  are 
a  cause  in  children. 

Morbid  Anatomy. — No  lesions  other  than  those  described  as  causal 
are  found.  The  precise  seat  of  the  pain  is  not  known,  but  is  believed  to 
be  in  the  meninges  of  the  brain. 

Symptoms. — The  attack  is  often  ushered  in  without  an}^  warning,  at 
others  with  prodromal  symptoms  familiar  to  the  patient.  They  are  various 
and  not  distinctive  of  the  disease,  but  so  characteristic  for  each  case  that 
the  individual  foretells  the  attacks  on  their  approach.  They  include 
general  discomfort,  vertigo,  a  sense  of  pressure,  tinnitus,  spots  before  the 
eyes,  chilliness,  and  the  like.  Hemianopia  and  scotoma  may  be  among 
them. 

Then  the  pain  starts  in  suddenly  and  is  continuous,  usually  in  one 
side  of  the  forehead,  but  it  may  also  be  in  the  occiput,  whence  it  extends 
to  the  half  or  whole  head.  It  is  extremely  severe,  sometimes  described 
as  blinding,  at  others  sharp  and  boring  or  shooting.  It  is  sometimes  at- 
tended by  flashes  of  light.  Light  and  noise  aggravate  it,  and  a  darkened 
room  is  always  sought.     Hemianopia  is  not  infrequent. 

Along  with  pain  there  is  generally  total  want  of  appetite,  and  intense 
nausea  succeeded  by  ■vomiting.  The  vomited  matter  includes  first  the 
contents  of  the  stomach  (if  the  stomach  is  empty,  mucous  matter),  and 
later  yellow  and  bitter  bile,  whence  the  term  "bilious  headache."  If  the 
stomach  happens  to  be  full,  the  pain  may  be  relieved  by  the  vomiting. 

The  vasomotor  symptoms  are  conspicuous  in  some  cases,  and  are  assigned 
by  some  an  important  role  in  the  causation  of  migraine.  From  this  stand- 
point two  subdivisions  are  made,  angiospastic  hemicrania  and  angioparalytic 
hemicrania.  In  the  first  form,  described  by  Dubois-Reymond  from  obser- 
vations on  himself — some  of  the  best  descriptions  have  been  by  sufferers — 
the  forehead  and  ear  on  the  affected  side  are  pale,  the  skin  is  cool,  the  tem- 
poral arteries  are  contracted,  the  pupil  is  often  dilated,  and  the  secretion 
of  saliva  is  increased — in  a  word,  there  are  the  symptoms  of  irritation  of 
the  sympathetic.  In  hemicrania  angioparalytica,  described  by  MoUen- 
dorfl,  also  from  observations  on  himself,  the  face  is  reddened  on  the  affected 
side,  it  feels  warm,  the  temporal  arteries  are  dilated  and  pulsate  strongly, 
there  is  sometimes  unilateral  sweating  of  the  face,  with  the  pupils  con- 
tracted— symptoms  suggestive  of  paralysis  of  the  sympathetic.  By  no 
means  all  cases  are  capable  of  being  thus  classified,  and  mixed  forms  are 
met. 

The  frequency  of  the  attacks  varies  greatly;  usually  they  do  not  occur 
oftener  than  once  in  two  weeks  or  once  a  month.  They  may,  however, 
occur  every  ten  days  or  even  weekly. 


1102  DISEASES  OF  THE  XERVOUS  SYSTEM 

The  duration  of  the  attack  varies.  Very  often  the  patient  goes  to  bed 
at  night,  and  in  the  morning,  or  at  the  end  of  12  hours,  is  relieved;  or  the 
attack  may  last  24  hours  or  even  two  or  three  days.  The  attacks  continue 
over  a  period  of  many  years,  sometimes  ceasing  in  women  after  the  climac- 
teric is  passed,  and  in  men  after  so- 
Further  speculation  as  to  the  true  nature  of  migraine  would  be  un- 
profitable here,  though  mention  should  be  made  that  the  arteries  on  the 
affected  side  sometimes  become  the  seat  of  arteriocapillary  fibrosis,  a 
condition  giving  some  force  to  the  view  of  vasomotor  origin. 

Diagnosis. — The  symptoms  of  brain  tumor  sometimes  closely  simu- 
late migraine.  Ophthalmoscopic  examination  may  discover  papillocdcma 
in  cases  of  brain  tumor  and  thus  settle  the  diagnosis.  vSuch  examination 
should  always  be  made. 

Prognosis. — This  is  favorable  so  far  as  life  is  concerned,  but  it  is  not 
always  easy  to  prevent  the  attacks  or  diminish  the  frequency  of  their  oc- 
currence.    It  often  happens  that  they  cease  after  middle  life. 

Treatment. — Before  treatment  is  instituted  every  case  should  be  thor- 
oughly investigated  with  a  view  to  discovering  causal  conditions.  Should 
such  search  be  successfvd,  their  elimination  may  result  in  a  cure.  Such 
accessible  causes  are  eye-strain,  affections  of  the  nose,  mental  and  physical 
fatigue,  and  indiscretions  in  diet. 

The  attack  itself  is  more  likely  to  be  warded  off  the  earlier  the  treat- 
ment is  instituted.  Sometimes  a  dose  of  salts,  taken  as  soon  as  the  first 
symptoms  appear,  wards  off  an  attack,  or  the  attack  may  be  relieved  by 
vomiting.  Acetphentadin  in  from  10  to  15  grain  (0.66  to  i  gm.)  doses  re- 
lieves some  attacks.  Byrom  Bromwell  in  a  very  impressive  paper  recom- 
mends 30  grain  (2  gm.)  doses  of  this  drug  as  curative.  After  the  first  dose 
it  may  be  continued  in  smaller  doses.  Antipyrin  and  antifebrin  are  similarly 
successful,  and  I  am  informed  by  apothecaries  that  many  women  purchase 
these  drugs  regularly  to  relieve  their  attacks.  Such  practice  should,  how- 
ever, be  discouraged. 

Sometimes  a  hypodermic  injection  of  morphin,  even  so  small  a  dose  as 
1/8  grain  (o.oi  i  gm.),  acts  magically,  and  on  the  whole  it  is  the  most  reliable 
remedy.  This,  however,  shoidd  practically  never  be  given,  better  attacks 
of  migraine  which  are  painful  but  which  do  not  kill,  rather  than  a  morphin 
habit  which  is  death  dealing.  Cafein  is  a  less  efficient  remed}-,  but  may 
be  used  in  conjunction  with  morphin  or  immediately  after  it  to  counteract 
the  unpleasant  effect  of  this  drug.  It  maj-  be  given  in  3  to  5  grain  (0.2  to 
0.33  gm.)  doses,  and  is  sometimes  administered  hy]3odermically  in  the  shape 
of  caffein-sodio-benzoate  in  the  same  dose.  Salicylate  of  caffein  is  also 
recommended  in  like  doses.  Cannabis  indica  is  a  remedy  much  recom- 
mended, but  is  unfortunately  of  uncertain  strength.  We  may  begin  math 
I  /4  grain  (0.016  gm.)  and  increase  rapidly.  Bromids  may  be  tried.  Giiarana 
is  more  efficient  in  from  30  to  60  grain  (2  to  4  gm.)  doses  of  the  powder  and 
similar  doses  of  the  fluid  extract. 

If  the  spastic  form  can  be  distinctly  recognized  as  present,  nitrite  of 
amyl  may  be  expected  to  be  serviceable — 3  to  s  drops  by  inhalation.  In 
the  opposite  or  paralytic  form  ergot  has  been  advised,  and  may  be  given  in 
doses  of  from  10  minims  to  i  dram  (i  to  4  gm.).     Nitroglycerin  in  doses  of 


WRITER'S  CRAMP  1103 

from  i/ioo  to  i/so  grain  (0.00066  to  0.0013  grn-).  and  nitrite  of  sodium  in 
doses  of  from  3  to  5  grains  (0.2  to  0.33  gm.),  may  be  useful  in  the  class  of 
cases  benefited  by  nitrite  of  amyl.  Cold  to  the  head  is  sometimes  grateful, 
and  when  there  is  nausea,  cracked  ice  or  cold  carbonated  or  apoUinaris 
water  or  small  doses  of  iced  champagne  are  sometimes  efficient. 

Electricity  is  said  to  have  been  useful  in  a  few  cases.  It  is  recom- 
mended that  in  the  spastic  form  the  anode  should  be  applied  to  the  sympa- 
thetic, and  in  the  paralytic  form  the  kathode,  the  other  pole  being  applied 
to  the  cervical  cord  as  high  as  possible  on  the  occiput. 

Preventive  Treatment. — General  treatment  between  attacks  should  not 
be  neglected.  When  there  is  anemia,  the  judicious  use  of  iron  and  arsenic. 
continued  for  some  time,  has  occasionally  been  followed  by  a  disappearance 
of  the  tendency  to  the  disease. 

The  urine  should  be  carefully  examined,  and  if  concentrated  and  tending 
to  deposit  uric  acid  or  oxalates,  diluents  and  the  alkaline  mineral  waters 
are  indicated.  In  a  few  instances  in.  the  daily  use  of  natural  Vichy  water, 
to  the  extent  of  a  bottle  a  day,  had  the  effect  of  diminishing,  and  in  one 
instance  of  eliminating,  the  attacks.  The  conditions  of  a  healthful  life, 
bathing,  fresh  air,  and  simple  wholesome  food,  should  be  observed.  Many 
persons  are  totally  free  from  attacks  while  traveling.  A  course  at  Con- 
trexville,  Vichy,  or  Carlsbad  may  be  of  service  in  averting  attacks. 

OCCUPATION  NEUROSES. 
Synonyms. — Professional  Spasm;  Copodyscinesia. 

Definition. — A  term  applied  to  a  group  of  diseases  characterized  by 
symptoms  excited  by  an  effort  to  perform  some  oft-repeated  muscular 
act,  commonly  one  involved  in  the  occupation  of  the  patient.  The  most 
usual  symptom  is  cramp  or  spasms  in  the  muscles  concerned,  whence 
this  word  is  preceded  by  that  of  the  various  occupations,  to  indicate  its 
special  variety.  Thus  we  have  writer's  cramp  or  scrivener's  palsy,  tele- 
grapher's cramp,  pianoforte-player's  cramp,  typewriter's  cramp,  seam- 
stresses' cramp,  milker's  cramp,  etc. 

Writer's  Cramp. 

Synonyms. — Graphospasmus;  Cheirospasmus;  Mogigraphia;  Scrivener's 
Palsy. 

Definition. — The  professional  neurosis  of  clerks  and  scriveners.  It 
is  the  most  frequent  of  the  occupation  neuroses  and  may  serve  as  the  type 
for  all. 

Etiology. — There  is  no  predisposition  to  sex,  the  disease  being  more 
frequent  in  men  in  occupations  where  more  men  are  employed,  and  more 
frequent  in  women  in  occupations  where  more  women  are  employed ;  and 
it  is  likely  that  since  an  increasing  number  of  women  have  become  tele- 
graph operators,  more  cases  may  be  expected  among  them,  in  whom, 
perhaps,  also,  the  neuropathic  temperament  may  favor  it.  The  majority 
of  all  cases  occur  between  20  and  50 — 154  out  of  177  cases  collected  by 
Berger  from  Gowers,  Poore,  and  his  own  cases.     Predisposition  is  caused 


1104  DISEASES  OF  THE  NERVOUS  SYSTEM 

by  previous  injury  and  a  neurotic  disposition,  while  even  heredity  is  said 
to  predispose.  An  especially  important  factor  is  a  faulty  method  of 
writing,  while  cases  have  occurred  which  were  apparently  independent 
of  the  usual  exciting  cause.  Steel  pens  are  said  to  be  responsible  for 
an  increased  number  of  cases  since  their  introduction.  The  disease  is  be- 
coming less  frequent  as  clerical  exactions  grow  less. 

Morbid  Anatomy  and  Pathology. — No  distinctive  anatomical  changes 
have  ever  been  discovered  in  writer's  cramp.  Three  theories  are  held 
regarding  its  nattire.  According  to  the  first,  it  is  essentially  a  local  disease: 
weakness  in  certain  muscles  permitting  overaction  on  the  part  of  their 
antagonists,  an  overaction  which  increases  to  spasm.  According  to 
a  second  theory,  the  spasm  is  reflex  and  due  to  an  irritation  of  the  sensory 
nerves  concerned  in  the  act  of  writing.  The  third,  and  usually  accepted 
theory,  makes  the  affection  primarily  and  essentially  central,  due  to  de- 
ranged function  in  the  centers  concerned  in  the  act  of  writing,  and  there- 
fore in  the  central  nervous  system. 

The  only  discoverable  mobid  change  is  an  occasional  atrophy  of 
muscles  concerned. 

Symptoms. — Spasm  is  almost  always  the  initial  disturbance,  commonly 
affecting  the  forefinger  and  the  thumb;  but  the  onset  is  gradual,  and  the 
first  effect  is  an  awkwardness  in  which  the  pen  does  not  move  quite  as 
intended.  It  is  irresistibly  grasped  too  tightly,  yet  the  forefinger  has  a 
tendency  to  slip  off,  the  pen  passing  between  it  and  the  middle  finger, 
while  an  attempt  to  mend  matters  by  taking  a  new  hold  only  increases 
the  difficulty,  and  the  hand  labors  as  if  tied  down.  It  feels  tired,  and  there 
is  often  an  aching  pain  throughout,  extending  even  to  the  arm.  The 
writing  is  irregular  and  uneven.  These  symptoms  may  continue,  mth  more 
or  less  difficulty  in  writing,  lasting  for  weeks  or  months,  coming  earlier, 
however,  after  each  eft'ort,  and  with  gradual  increasing  severity  until  the 
intolerable  spasm  sets  in.  This  may  be  so  violent  in  a  combined  move- 
inent  of  flexion  and  adduction  in  the  thumb  that  the  pen  may  be  wrested 
from  the  grasp  and  thrown  to  a  distance,  or  there  may  be  a  lock  spasm, 
described  by  S.  Weir  Mitchell,  in  which  the  pen  is  firmly  locked  between 
the  fingers.  The.  spasm  is  almost  always  tonic  in  character,  although 
it  may  now  and  then  be  varied  bj^  a  slight  start  or  jerk.  It  is  sometimes 
associated  with  tremor.  Rarely  tremor  occurs  alone,  and  it  may  be  the 
premonitory  symptom  of  atrophy.  The  spasm  may  be  limited  to  the 
act  of  writing,  while  other  actions  are  well  performed;  but  absolute  limi- 
tation to  this  act  is  seldom  met  in  severe  cases. 

Special  difficulty  attends  the  performance  of  acts  requiring  delicate 
co-ordination  of  the  muscles.  Sometimes  a  patient  can  write  with  a 
pencil,  but  not  with  a  pen.  Paresis  and  paralysis  may  occur  with  spasm 
or  alone.  On  the  other  hand,  the  strength  of  the  hand  may  be  quite 
unimpaired.  Such  loss  of  power  varies  greatly,  being  sometimes  trifling, 
at  other  times  considerable. 

Sensory  symptoms  are  almost  always  present  in  various  degrees.  They 
may  even  exist  alone,  producing  a  sensory  form.  They  are  manifested 
at  first  by  the  distressing  fatigue  alluded  to,  or  by  dull  pain  often  referred 
to  the  bones  or  joints,  very  often  to  the  metacarpal  bones  or  to  the  wrist. 


WRITER'S  CRAMP  1105 

ceasing  with  cessation  of  writing.  Sometimes  there  is  local  tenderness 
or  a  tingling  sensation.  Again,  the  pain  is  more  severe,  neuralgic  in  char- 
acter, and  distributed  along  the  course  of  the  nerve,  induced  at  first  by  the 
act  of  writing,  later  by  any  muscular  act  of  the  part.  There  may  also  be 
tenderness  in  the  course  of  the  nerve. 

Vasomotor  disturbances  are  seen  in  severe  cases,  manifested  by  hyper- 
esthesia, a  glossy,  shining  skin,  or  a  cyanosed,  chilblain-like  appearance; 
or  the  hand  may  become  blue  and  hot  on  attempting  to  write. 

In  the  beginning  the  electrical  reactions  are  normal,  but  in  advanced 
cases  there  is  a  diminished  faradic  and  sometimes  increased  galvanic 
irritability  of  the  motor  nerv'-e  endings  ditributed  to  the  muscles.  It  is 
to  be  remembered  that  the  radial,  ulnar,  and  median  ner\'es  all  supply 
muscles  employed  in  writing. 

Diagnosis. — This  is  usually  easy,  the  initial  limitation  of  the  symp- 
toms to  the  act  of  writing  sufficiently  indicating  the  nature  of  the  case. 
More  frequently  other  paralytic  and  painful  affections  of  the  arm  and 
hand  are  mistaken  for  writer's  palsy.  Among  these  may  be  included 
hemiplegia  of  gradual  onset,  commencing  insular  sclerosis,  earh^  tabes  dorsalis 
affecting  the  arms,  or  pressure  palsy  of  the  musculo-spdral  nerve. 

In  most  of  these  cases,  however,  other  symptoms  are  present  or  are 
soon  added.  ]More  frequently  nervous  persons  imagine  they  have  writer's 
palsy.     In  some  cases  the  condition  is  really  one  of  myositis. 

Prognosis. — A  well-established  case  of  scrivener's  palsy  rarely  gets  well. 
There  are,  however,  exceptions,  even  under  the  most  unfavorable  condi- 
tions. The  prognosis  is  more  favorable  when  sensory  symptoms  predomi- 
nate.    Relapses  are  prone  to  occur  when  the  patient  returns  to  work. 

Treatment. — Prevention,  as  usual,  is  much  more  effectual  than  cura- 
tive treatment.  The  disease  is  confined  almost  exclusively  to  those  who 
write  in  a  cramped  manner,  and  is  said  to  be  unknowTi  in  those  who  write 
from  the  shoulder.  The  curative  treatment  consists  essentially  in  rest 
promptly  adopted — a  long  rest  being  often  sufficient  to  effect  a  cure, 
while  no  other  treatment  can  take  its  place.  Various  mechanical  devices 
to  aid  in  writing  while  the  cure  is  going  on  have  not  accompHshed  much, 
and  the  patient  may  learn  to  write  mth  the  left  hand,  although  the  dis- 
turbance may  occur  in  his  hand  also.  Typewriting  is,  as  a  rule,  as  easUy 
learned  with  the  affected  hand  as  before  disability  and  should  be  practiced. 
The  devices  referred  to  may  be  Such  as  a  very  thick  penholder  which  can 
be  directed  by  the  whole  hand;  or  a  pen  attached  to  a  ring,  which  is  slipped 
over  the  index  or  middle  finger,  and  the  thumb  is  thus  permitted  to  rest. 
The  typewriting  machine  has,  however,  rendered  all  such  devices  of  less 
consequence.  The  usual  nerve  tonics,  such  as  strychnin,  m.a.Y  be  given. 
Hygiene  of  the  part,  including  hydrotherapy,  frictions,  especially  massage, 
and  sometimes  electricity  are  useful. 

The  important  position  assigned  by  all  neurologists  to  the  electrical 
treatment  of  writer's  cramp  demands  some  special  consideration,  especially 
as  the  methods  advised  are  by  no  means  luiiform.  The  preference  given 
to  the  galvanic  current  over  the  faradic  is,  however,  almost  unaminous, 
and  unless  the  latter  is  especially  mentioned,  the  former  is  intended. 
Berger  recommends  a  stabile  current — i.  e.,  a  current  in  which  the  elec- 


1106  DISEASES  OF  THE  NERVOUS  SYSTEM 

trodes  are  not  moved  about — with  the  positi\^e  pole  in  the  neck  and  the 
negative  partly  in  the  fossa  supraclavicularis,  partly  on  the  affected  nerves 
and  muscles  of  the  arm;  the  length  of  sitting,  from  five  to  ten  minutes 
daily,  or  every  other  day. 

Benedict  recommended  galvanization  along  the  spinal  column,  wnth 
especial  reference  to  sensitive  vertebras,  but  also  localization  of  the  galvanic 
current,  as  recommended  by  Berger;  duration  of  sitting,  three  to  four  min- 
utes, current  strong  enough  to  be  easily  felt.  He  also  found  subsequent 
faradization  to  the  affected  muscles  useful.  Eulenberg  also  advised  gal- 
vanization of  the  muscles  affected  with  chronic  cramp  and  of  the  involved 
nerve-trunk  with  the  positive  pole.  In  cases  with  tremor  and  rapid  exhaus- 
tion the  negative  pole  is  to  be  applied  to  the  spinal  column  and  the  positive 
on  the  peripheral  nerve-trunks  and  muscles  affected.  Erb  advised  galvani- 
zation of  the  cervical  vertebral  column,  with  ascending  stabile  and  labile 
currents  combined  with  peripheric  galvanization.  In  several  cases  it 
appeared  to  him  that  transverse  and  longitudinal  currents  through  the  head 
were  followed  by  favorable  resiilts. 

Onimus  used  an  ascending  current  through  the  aft'ected  arm,  with  the 
negative  pole  in  the  neck  and  the  positive  pole  upon  the  muscles  of  the  fore- 
arm, especially  the  ball  of  the  thumb,  in  addition  to  a  current  of  moderate 
strength  along  the  cervical  vertebrae.  M.  Meyer  employed  a  stabile  gal- 
vanic current  with  the  anode  to  the  tender  spots  on  the  vertebral  column 
when  these  were  present,  and  the  kathode  on  the  sternum.  Althouse  sought 
to  reach  the  cervical  cord  by  placing  the  anode  upon  the  cervical  spine  and 
the  kathode  on  the  depression  between  the  angle  of  the  jaw  and  the  sterno- 
cleidomastoid muscle — a  position  corresponding  to  the  superior  cervical 
ganglion  of  the  sympathetic.  The  current  should  be  mild,  uniform,  and 
uninterrupted  for  from  three  to  five  minutes  at  a  time.  The  method  should 
not  be  reversed.  In  cases  of  paresis  of  certain  muscles  it  is  sometimes  of 
benefit  to  have  the  patient  make  voluntary  movements  of  these  muscles 
simultaneously  with  the  closing  of  the  galvanic  current  applied  to  the  ner\-e 
innervating  these  muscles. 

Testimony  is  united  to  the  effect  that  the  galvanic  treatment  must  be  kept 
up  for  a  long  time,  even  for  months  continuously,  with  a  current  of  moderate 
strength,  say  a  maximum  of  four  milliamperes,  and  section  electrode  of  about 
three  cm.  in  diameter. 

Faradization  is  recommended  only  in  cases  where  there  is  demonstrable 
paresis  and  anesthesia,  and  then  in  weak  currents.  In  anesthesia  the  brush 
maybe  used.  Erb  found  that  many  of  his  patients  were  benefited  by  wearing 
on  the  arms,  for  several  hours  daily,  a  simple  galvanic  element,  such  as  a  zinc 
and  copper  plate,  united  by  wire,  and  under  it  a  moist  piece  of  linen. 

Gowers  has  much  less  confidence  in  electricity,  especially  in  the  spasmodic 
form  of  the  disease,  and  is  probably  right  when  he  says  if  the  patient  goes 
on  writing  electricitj^  has  not  the  slightest  infiuence  on  the  disease.  Tyson's 
experience  with  electricity  has  not  been  very  encouraging. 

The  position  according  to  gymnastic  exercise  of  the  arm  and  hand  muscles 
is  scarcely  second  to  that  of  electricity — indeed,  it  is  preferred  by  some. 
Especially  efficient  appears  to  be  that  of  a  German  writing-master,  Julius 
Wolff.     The  gymnastics  are    of    two    kinds:  First,   active,   in    which    the 


HYSTERIA  1107 

patient  moves  the  fingers,  hands,  forearms,  and  arms  in  all  directions  pos- 
sible, each  muscle  being  made  to  contract  from  six  to  twelve  times  with  con- 
siderable force,  and  with  a  pause  after  each  movement,  the  whole  exercise 
not  exceeding  30  minutes,  and  repeated  two  or  three  times  daily.  Second, 
passive,  in  which  the  same  movements  are  made  as  in  the  former,  except  that 
each  one  is  arrested  by  another  person  in  a  steady  and  regular  manner.  This 
may  be  repeated  as  often  as  the  active  exercise.  Massage  is  practised 
daily  for  about  20  minutes,  beginning  at  the  periphery;  percussion  of  the 
muscles  is  considered  an  essential  part  of  the  massage.  Combined  with  this 
are  peculiar  lesions  in  pen-prehension  and  writing.  Priority  for  this  method 
is  claimed  by  Roman  Vigoroux  and  Th.  Shott.  The  testimony  of  some  of 
the  best  authorities  in  Europe  is  given  in  behalf  of  this  method.  Poore 
secured  good  results  by  combining  gymnastic  exercises  with  the  use  of  elec- 
tricity. Tenotomy  and  nerve-stretching  have  been  attempted  and  abandoned 
as  useless. 

HYSTERIA. 

Definition. — Hysteria  is  a  morbid  state  of  the  nervous  system  in  which 
may  be  manifested  every  variety  of  nervous  symptom  due  to  deranged 
function  of  the  cerebral,  basal,  and  spinal  centers,  associated  with  lowered 
will-power  and  exaggerated  emotional  tendencies. 

Etiology. — Hj'steria  is  a  disease  of  civilization  and  of  certain  races. 
It  is  unknown  in  the  barbarian,  and  is  more  rare  in  Northern  races,  while  the 
volatile  Southern  temperament  favors  its  development.  Thus,  the  French 
and  Italians  of  the  Latin  race  furnish  many  subjects,  while  it  is  rarer  among 
Germans,  English  and  Americans.  The  disease  is  also  frequent  among 
Hebrews. 

The  sexual  organs  of  women  have  been  held  responsible  for  hysteria  in 
the  female,  and  the  name  hysteria  is  derived  from  vorepa,  a  womb;  but 
this  conception  is  erroneous.  In  males  the  disease  assumes  more  the  form  of 
hypochondriasis,  but  in  them  also  convulsions,  contractures,  and  paralysis 
occur.  It  is  found  in  boys  as  well  as  in  adult  males,  especially  in  alcoholic 
males.  About  half  of  all  cases  occur  in  the  second  decade,  especially  after 
puberty,  though  it  may  also  occur  earlier;  one-third  between  20  and  30; 
while  boy  subjects  are  commonly  under  the  age  of  puberty.  Masturbation 
is  held  responsible  for  many  cases  in  boys.  Heredity  plays  a  certain  part, 
while  the  neurotic  constitution  especially  favors  hysteria. 

Among  the  exciting  causes  are  included  diseases  of  the  generative  organs 
in  women,  especially  deranged  menstruation.  Ovarian  disease  has  been  held 
responsible,  and  tenderness  in  the  ovarian  region  is  undoubtedly  a  frequently 
associated  symptom,  but  it  is  questionable  whether  this  tenderness  is  of  ova- 
rian origin.  Association  with  others  similarly  affected  is  an  undoubted  fac- 
tor, and  it  is  not  unusual  for  the  disease  to  spread  itself  from  one  to  a  number  of 
girls  living  under  the  same  roof.  Various  diseases  other  than  those  mentioned 
also  predispose  to  hysteria.  Even  local  affections,  including  injuries,  may 
thus  operate,  and  hysterical  joint  affections  may  follow  trauma  of  a  joint. 
Striimpell  relates  an  instance  of  a  girl  who,  from  having  inhaled  smoke,  ac- 
quired hysterical  paralysis  of  the  vocal  cords.     General  disease  of  an  ex- 


1108  DISEASES  OF  THE  NERVOUS  SYSTEM 

hausting  kind,  such  as  fevers,  nervous  diseases,  functional  and  organic, 
act  as  exciting  causes  in  hysterical  subjects.  Hysteria  is  common  in  prosti- 
tutes. Among  psychical  nervous  causes  are  fright,  such  as  attends  a  runa- 
way or  a  fire;  an  angry  scene;  the  constant  operation  of  trifling  mental  causes, 
including  worry  and  anxiety,  but  such  causes  act  only  on  a  person  predisposed 
to  hysteria. 

Explanation  of  Symptoms. — Always  a  favorite  subject  of  theory  and 
speculation,  modern  times  are  as  rich  as  older  dates  in  developing  theories  in 
explanation  of  the  varied  symptoms  of  the  disease.  As  the  French  nation 
furnishes  the  largest  number  of  cases  of  hj'steria  so  the  French  physicians 
have  given  correspondingly  of  their  time  to  the  study  of  the  subject.  The 
first  and  greatest  of  these  was  the  great  master  Charcot  who  defined  hysteria 
as  a  psychic  malady  in  which  morbid  states  are  excited  by  ideas,  and  as  an 
imitator  of  all  sorts  of  organic  disease,  so  closely  associated  with  "sug- 
gestion" that  the  capability  of  responding  is  the  test  of  the  presence  of 
hysteria. 

Janet  of  the  College  of  France  in  his  psj^chological  theory  of  hysteria 
says  "it  is  a  form  of  mental  depression  characterized  by  the  retraction  of  the 
field  of  personal  consciousness  and  a  tendency  to  the  dissociation  and 
emancipation  of  the  systems  of  ideas  and  functions  that  constitute  per- 
sonality." On  the  other  hand,  Babinski  of  la  Pitie  amplj'fj-ing  the  dictum  of 
Charcot  that  "to  be  hypnotizable  is  to  be  hysterical"  has  elaborated  a  defini- 
tion of  hysteria  to  the  effect  that  it  is  a  "  special  state  capable  of  giving  rise 
to  certain  sj-mptorns  that  have  features  of  their  own.  It  manifests  itself 
by  primary  and  by  secondary  disturbances,  the  former  being  characterized 
by  this,  that  it  is  possible  to  reproduce  them  by  suggestion  and  to  make 
them  disappear  under  the  sole  influence  of  persuasion."  He  therefore  sug- 
gested the  name  pithatisme,  from  two  Greek  words  ~£i^a  meaning  persua- 
sion and  taros,  curable.  The  primary  symptoms  are  anesthesia,  paralysis, 
contractures,  crises,  mutism,  etc.  The  secondary  are  those  strictly  subordi- 
nal  to  the  primary.  The  muscular  atrophy  in  the  hysterical  person  is  the 
type  of  these. ^  It  never  appears  primaril}'.  Suggestion  cannot  cause  it. 
It  is  secondary  to  hysterical  paralyses  and  never  precedes  them. 

Sigmond  Freud  of  Vienna,  during  the  last  15  years  has  developed  another 
psychical  hypothesis  of  hysteria  whose  contention  is  that  "in  a  normal 
vita  sexualis  no  neurosis  is  possible"  and  that  he  who  can  interpret  the  lan- 
guage of  hysteria  can  understand  that  the  neurosis  deals  only  with  repressed 
sexuality." 

Seeking  from  the  physiological  side  to  devise  a  pathogenic  theory,  "at 
once  comprehensive  and  satisfying,"  Sollier  of  Paris  defines  hj'steria  as 
"a  condition  of  cerebral  torpor  or  cerebral  inhibition  a  special  sort  of  sleep 
analagous  to  what  has  been  called  vigilambuliSm." 

On  the  other  hand,  Dubois  of  Berne,  says  "it  is  useless  to  make  an 
effort  to  give  hysteria  the  character  of  a  morbid  entity,"  in  other  words 
it  is  only  a  symptom,  in  which  he  is  seconded  by  Steyerthal. 

In  an  admirable  review  entitled  Some  Modern  French  Conceptions  of 

*  J.  Babinski,  Ma  Conception  de  THysterie  et  de  I'Hypnotismc  (Pithiatisme).     Conference  facte  a  la 
Societe  de  1'  Internat  des  H6pitaux  de  Paris,  June   28,  1901. 


HYSTERIA  1109 

Hysteria,  by  S.  A.  K.  Wilson  in  Brain,'  the  author  well  says,  "The  mere 
enumeration  of  these  conflicting  hypotheses  may  overwhelm  the  reader  with 
a  deep  sense  of  despair  at  their  hopless  dissimilarity,  and  he  ma}'  reasonably 
fear  that  finality  is  as  far  off  as  ever.  But  let  him  not  be  unduly  distressed. 
■  Odd  as  it  may  appear,  many  of  these  contradictory  opinions  have  one  feature 
in  common.  Not  only  are  the  respective  originators  alike  in  the  earnestness 
of  their  advocacy  of  them,  but  there  is  a  curious  similarity  in  their  appeal  to 
their  own  clinical  experience  subsequent  to  the  adoption  or  enunciation  of 
their  own  particular  theory,  and  in  their  resort  for  substantiation  of  its 
virtues  to  the  results  of  treatment." 

"To  the  individual  who  is  not  so  absorbed  in  science  as  to  lose  his  sense  of 
humor  it  may  seem  that  hysteria,  the  while  she  responds  so  nobly  to  the 
appeals  of  the  advocates  of  these  various  theories,  is  quietly  smiling  in  her 
sleeve.  As  of  old  the  ascetic  and  the  epicurean,  the  celibate  and  the  polyga- 
mist,  the  socialist  and  the  monarch  by  divine  right  turned  alike  to  the  pages 
of  Holy  Writ  for  support  of  their  particular  ways  of  living  and  views  on  life, 
and  found  it  therein,  so  the  exponents  of  the  sexual  theory,  the  suggestion 
theory,  the  sleep  theory,  and  the  "  hysteria-only-a-symptom "  theory, 
alike  appeal  to  experience  for  confirmation  of  their  opinion,  and  find  it.  It 
seems  to  us  that  not  only  does  the  mere  juxtaposition  of  the  above-selected 
passages  furnish  a  self-evident  proof  of  the  fallaciousness  of  this  appeal  to 
the  results  of  the  treatment,  as  SoUier  himself  has  clearly  recognized ;  it  also 
affords  a  significant  illustration  of  what  appears  to  be  as  unfortunate  a 
tendency  in  the  study  of  modem  hysteria  as  in  the  study  of  the  ancient, 
viz.,  the  introduction,  consciously  or  unconsciously,  of  the  subjective  ele- 
ment on  the  part  of  the  physician."  Wilson  says  moreover  that  more  than 
one  speaker  at  a  recent  Discussion  on  Hysteria  held  by  the  Neurological  and 
Psychiatrical  Societies  of  Paris  made  allusion  to  this  fact,  but  it  has  not  been 
emphasized  at  all  adequately.  It  is  not  merely  that  his  hypothesis  is  apt  to 
color  the  physician's  way  of  looking  at  a  case,  but  also  that  in  some  obscure 
and  little  understood  manner  the  patients  come  in  a  sense  to  respond  to  his 
hypothesis,  so  that  the  wider  his  experience  the  greater  is  the  apparent 
confirmation  of  its  truth.  How  else  can  we  explain  the  facts  so  familiar  to 
the  student  of  the  history  of  the  disease  ?  The  clinics  of  Paris  and  Vienna 
have  shown  us  how  hysteria  can  be  cultivated ;  the  hysterical  patients  of  the 
Salpetriere  differ  from  their  fellows  of  la  Pitie.  In  a  hundred  consecutive 
cases  Babinski  has  failed  to  discover  a  single  instance  of  hemianesthesia, 
and  says  moreover,  "as  for  constriction  of  the  visual  fields,  dyschromatopia, 
ovarian  tenderness,  and  so  on,  the  hysteriques  in  my  wards  simply  do  not 
have  them."  "Heureuses  hysteriques!"  says  SoUier  in  an  aside.  Wilson 
continues 

"There  is  I  think  a  profound  truth  in  the  remark  of  the  late  Professor 
Raymond,  that  the  patients  do  not  change  so  much  as  is  thought;  it  is  rather 
that  the  observer  changes  his  point  of  view.  Any  one  reads  the  contributions 
of  Freud  will  be  struck  by  the  way  in  which,  in  his  earlier  communications, 
he  describes  his  open-mindedness  in  approaching  the  problems  of  hysteria, 
and  how  the  juvenile  sexual  trauma  eventually  forced  itself  on  his  considera- 
tion till  he  became  convinced  of  its  essentialness.     Wherever  he  looks  now,  it 


iVol.  xxxiii,  1910-ir,  p.  295. 


1110  DISEASES  OF  THE  XERVOUS  SYSTEM 

meets  his  gaze.  We  may  say  if  we  will,  that  there  are  differing  hysterical 
types  but  the  interesting  thing  is  that  these  types  appear  wherever  the  dis- 
ease is  cultivated,  and  that  in  a  matter  of  this  kind  the  subjective  element 
must  enter  largely.  Nor  can  the  influence  of  environment,  circumstances 
and  that  indefinable  something  which  is  usually  called  the  "atmosphere" 
of  a  place  be  ignored.  Let  the  reader  turn  to  the  fascinating  essay  on 
"The  Wandering  Jew"  from  the  pen  of  Henry  Meige,  which  appeared  long 
ago  in  the  Nouvelle  Iconographic  de  la  Salpetriere,  to  appreciate  what  the 
reputation  of  Charcot  and  the  atmosphere  of  the  Salpetriere  meant  to  the 
world  of  hysteria." 

We  have  ventured  to  make  this  long  quotation  because  we  think  it  will 
convey  to  the  reader  in  the  most  satisfactory  exposition  possible  of  the 
theories  of  hysteria  and  their  significance  together  with  their  weak- 
nesses. 

Symptoms. — An  idea  of  the  number  and  variety  of  the  symptoms  of 
hysteria  has  probably  been  obtained  from  the  definition  given — a  variety 
which  belongs  to  no  other  disease,  and  which  may  include  almost  all  symp- 
toms excited  by  any  of  the  numerous  nervous  diseases.  The  hysterical  pa- 
tient is,  however,  characterized  by  certain  general,  corporal,  and  mental 
peculiarities  which  should  be  first  considered.  Such  persons  are  emotional, 
irritable,  capricious,  sensitive,  often  willfull,  sometimes  because  of  indiffer- 
ent early  home  training  and  overindulgence.  They  exaggerate  every  ill- 
ness and  demand  an  inordinate  amount  of  sympathy.  If  women,  they  are 
at  times  disagreeable  and  petulant  or  doggedly  silent,  while  at  others  they 
are  charming  and  fascinating.  They  are  often  intellectually  bright.  Hys- 
teria does  occur,  however,  among  intellectual  degenerates.  Other  hysterical 
cases  present  no  mental  peculiarities.  As  to  physical  development,  the 
hysterical  patient  is  by  no  means  always  delicate;  indeed,  some  of  the  most 
stubborn  cases  are  those  which  appear  in  blooming  health,  rosy,  and  well 
nourished . 

The  symptoms  of  hysteria  are  conveniently  arranged  in  five  di\-isions: 
I.  Derangements  of  sensation.  2.  Derangements  of  motion.  3.  Vaso- 
motor derangements.  4.  Visceral  derangements.  5.  Convulsive  seizures. 
6.  Joint  symptoms.     7.  Mental  symptoms. 

Some  of  these  symptoms  are  so  common  in  hysteria  and  so  peculiar  to 
it,  that  of  themselves  they  are  of  decided  diagnostic  value,  and  as  such  have 
received  the  name  of  "hysterical  stigmata."  Among  the  most  impor- 
tant of  these  are : 

I.  Derangements  of  Sensation. — The  symptoms  in  this  category  are, 
as  a  rule,  only  elicited  by  the  special  examination  of  the  physician,  being 
rarelj'  discovered  by  the  patient.  Thej^  include,  especiallj-,  alterations  of 
cutaneous  sensibility,  manifested  by  anesthesia  or  hj'peresthesia.  Most 
striking  is  insensibility  to  painful  impressions,  kno^Ti  as  analgesia.  It  is 
usually  tested  by  thrusting  a  pin  deeply  into  the  flesh — an  act  which  is  often 
totally  unfelt.  Less  invariably  is  there  failure  to  appreciate  the  sharp  irri- 
tation of  the  electric  current.  Such  analgesia  may  be  confined  to  definite 
parts  of  the  body,  half  the  body,  or  may  be  general.  It  may  extend  to  the 
mucous  surfaces  as  well,  and  even  to  the  deeper  tissues,  as  those  of  the  mus- 
cles and  joints.     While  analgesia  is  the  most  common  manifestation  of  de- 


HYSTERIA  1111 

ranged  sensibility,  there  may  be  absence  of  the  sense  of  temperature,  of  pres- 
sure, and  even  of  the  muscular  sense. 

Hyperesthesia  is  almost  equally  characteristic.  The  areas  involved  may 
be  exquisitely  sensitive  or  but  slightly  so,  requiring,  sometimes,  consider- 
able pressure  to  develop  the  tenderness,  while  at  other  times  it  is  elicited  by 
the  slightest  touch.  The  hyperesthesia  is  especially  noticeable  when  the 
attention  of  the  patient  is  directed  to  it  by  such  remarks  as,  "This  will 
hurt  you  very  much  when  I  touch  you."  The  sensitive  areas  may  also  be 
limited  or  extended  and  anywhere — on  the  head,  thorax,  limbs.  Inguinal 
tenderness  is  especially  frequent  on  the  left  side.  Even  more  characteris- 
tic is  the  hyperesthesia  of  the  spinal  column — the  so-called  "hysterical  spi- 
nal irritability" — which  effects  the  column  as  a  whole  or  in  segments,  not 
infrequently  a  single  vertebra.  The  sensitiveness  may  be  so  extreme  that 
the  slightest  contact  may  cause  the  patient  to  cry  out,  while  strong  pressure 
may  be  necessary  to  cause  it.  Of  special  interest  also  are  the  hysterical 
zones,  to  be  again  referred  to. 

The  special  senses  are  variously  involved.  There  may  be  simple  dimness 
of  vision  or  narrowing  of  the  field,  due  to  anesthesia  of  the  peripheral  part  of 
the  retina.  There  is  often  total  amblyopia,  but  never  hemianopia.  The 
cases  of  so-called  hysterical  hemianopia  are  rejected  by  some  competent 
observers.  Hysterical  achromatopia  is  not  infrequent.  According  to 
Charcot,  the  loss  of  the  appreciation  of  violet  is  the  most  common,  then  of 
green,  and,  lastly,  of  blue  and  yellow.  Loss  of  hearing  is  not  infrequent 
and  still  more  frequent  is  anesthesia  of  taste  and  smell,  even  bitter  sub- 
stances, like  quinin,  or  pungent  ones  like  vinegar,  producing  no  impression  or 
but  a  trifling  one. 

2.  Derangements  of  Motion. — The  most  striking  of  these  is  paralysis. 
It  commonly  comes  on  suddenly,  apparently  as  a  result  of  fright  or  other 
suddenly  acting  cause.  It  may,  however,  be  gradual,  and  take  weeks  for  its 
development.  It  is  most  frequently  hemiplegic,  but  may  be  monoplegic, 
rarely  diplegic,  while  every  form  of  organic  paralysis  may  be  simulated. 
Hemiplegia  is  more  usual  on  the  left  side — according  to  Weir  Mitchell, 
four  times  as  frequent  as  on  the  right.  The  face  is  not  usually  affected,  the 
neck  and  arms  rarely,  the  legs  oftenest.  The  patient  can  sometimes  move 
the  legs  in  bed  or  even  when  sitting  up,  while  all  attempts  at  walking  are  un- 
successful; or  she  may  be  able  to  move  the  arms  when  the  eyes  are  open, 
but  not  when  they  are  shut.  It  is  a  paralysis  of  the  will.  Sometimes  one 
leg  only  is  paralyzed,  giving  rise  to  a  peculiar  gait,  the  free  leg  making  long 
strides  while  the  paralyzed  one  is  dragged  along  with  a  shuffling  noise,  and 
not  swuug  outwardly  in  a  circle  as  in  true  hemiplegia.  Sometimes  there  is 
ataxia  with  paresis.  Paralysis  may  be  either  flaccid  or  spastic.  Though 
far  more  frequently  a  symptom  of  hysteria  in  women,  it  may  be  as  striking  in 
men.  Paralysis  of  the  vocal  cords  is  one  of  the  most  frequent  symptoms  of 
hysteria,  giving  rise  to  aphonia.  The  paralysis  is  easily  demonstrable  by 
laryngoscopic  examination,  because  of  anesthesia  of  the  pharynx.  It 
may  be  so  marked  that  the  vocal  cords  acutally  open  with  an  attempt  at 
phonation.     Anesthesia  and  motor  paralysis  are  commonly  associated. 

Contractures  and  spasms  are  a  form  of  motor  derangement;  they  may 
occur  alone  or  with  anesthesia  and  paralysis.     They  exhibit  every  variety, 


1112  DISEASES  OF  THE  NERVOUS  SYSTEM 

and  may  attack  any  group  of  muscles;  they  may  be  tonic  or  clonic,  and  sudden 
or  gradual  in  development.  The  tonic  contracture  is  most  usual  in  the  arm, 
which  is  flexed  at  the  elbow  and  wrist,  while  the  fingers  grasp  the  thumb  in 
the  palm  tightly.  In  the  feet,  also,  flexures  predominate,  the  feet  being  in- 
verted and  the  toes  flexed.  In  the  larger  joints,  on  the  other  hand,  the  ex- 
tensors are  involved,  as  a  rule.  Rarely  extensor  contractures  occur  in  the 
small  joints ;  all  disappear  with  chloroform  narcosis  unless  they  have  persisted 
a  long  time  and  shortening  of  the  muscles,  ligaments,  etc.,  has  occurred. 
The  reflexes  may  be  very  much  exaggerated  and  the  condition  closely  re- 
semble spastic  paraplegia.  Extreme  emaciation  may  occur  in  connection 
with  these  contractures,  as  witness  a  remarkable  case  related  and  illustrated 
by  Weir  Mitchell  in  the  "Medical  News,"  August  24,  1895. 

Even  hysterical  trismus  may  occur,  and  a  very  striking  result  of  abdomi- 
nal contracture  is  the  phantom  tumor,  which  is  found  usually  just  below  and 
in  the  neighborhood  of  the  umbilicus,  often  simulating  a  firm  and  solid 
growth.  The  mechanism  of  its  production,  according  to  Gowers,  is  a  re- 
laxation of  the  recti  and  spasmodic  contraction  of  the  diaphragm,  together 
with  inflation  of  the  intestines  and  an  arching  forward  of  the  vertebral 
column.  Women  have  even  been  prepared  for  surgical  operation  on  such 
tumors  when  the  delusion  was  dissipated  by  the  anesthetic,  and  the  abdo- 
men has  been  opened  for  purely  hysterical  conditions.  Such  tumor  is  not 
infrequently  associated  with  symptoms  of  spurious  pregnancy — pseudocyesis. 
Visible  tremor  may  be  present,  rarely  hysterical  athetosis. 

3.  Vasomotor  Derangements. — A  striking  pallor  is  often  present,  at 
other  times  hyperemia,  and  even  a  hot  skin.  Hemorrhage  from  internal 
organs,  especially  the  stomach  and  lungs,  often  alleged,  is  usually  at  least 
apocryphal.  Commonly,  the  blood  is  derived  from  the  gums,  and  its  amount 
is  never  considerable.  Yet  such  symptoms  have  been  the  basis  of  a  diagno- 
sis of  pulmonary  disease  or  gastric  ulcer.  Hemorrhages  into  the  skin  are  also 
alleged,  but  are  very  rare. 

Hysterical  fever  belongs  also  to  vasomotor  symptoms.  A  temperature  of 
115°  F.  (46.1°  C),  and  even  more,  has  been  reported.  Such  temperatures 
are  characterized  by  their  irregular  occurrence.  Actually  they  are  ex- 
tremely rare,  being  in  most  instances  traceable  to  deception,  and  many 
doubt  their  existence. 

Anomalies  of  secretion  include  profuse  and  scanty  perspiration,  the  latter 
resulting  in  a  pecuHar  dryness  of  the  skin;  the  salivary  secretion  is  similarly 
influenced,  and  modifications  in  the  urinary  secretion  are  some  of  the  most 
characteristic  phenomena  of  hysteria.  They  include  ischuria,  but  especially 
polyuria,  the  patient  passing  a  large  amount  of  very  light-colored  urine  of 
low  specific  gravity.  Excessive  thirst  is  also  frequent,  further  augmenting 
the  polyuria.  The  chemical  composition  of  the  urine  is  altered  in  many 
severe  cases;  thus,  the  phosphates  and  urates  have  been  found  diminished, 
while  the  ratio  of  earthy  to  alkaline  phosphates  may  be  changed  to  one  to 
two  or  one  to  one,  instead  of  one  to  three.  Such  changes  are  held  by 
Charcot's  school  to  be  diagnostic  of  convulsive  hysteria  as  contrasted  with 
epilepsy. 

4.  Visceral  Derangements. — The  digestive  system  is  especially  dis- 
turbed by  simple  indigestion,  depraved  appetite,  flatulence,  and  gastric  pain. 


HYSTERIA  1113 

Not  infrequently  there  is  spasm  of  the  esophagus,  causing  difficulty  in 
swallowing:  in  some  instances  expulsion  of  food  before  it  reaches  the  stomach. 
Hysterical  vomiting  is  very  common,  and 'alleged  vomiting  of  impossible 
substances  is  one  of  the  most  characteristic  symptoms.  An  antagonism  to 
food  is  sometimes  present,  so  extreme  that  death  by  starvation  has  been 
barely  averted;  indeed,  is  said  to  have  occurred.  Constipation  is  a  frequent 
and  troublesome  symptom.  Much  more  rare  is  the  opposite  condition  of 
diarrhea. 

Cardiovascular  and  pulmonary  symptoms  exhibit  every  variety,  including 
irregularity  of  the  heart's  action,  tachycardia  and  bradycardia,  precordial 
oppression  and  sense  of  suffocation,  with  extreme  frequency  of  breathing  and 
deranged  rhythm.  Laryngeal  spasm,  hysterical  cough,  and  hysterical  hic- 
cough are  frequent  symptoms.  Hysterical  cries  with  inspiration  or  expiration , 
and  imitation  of  the  sounds  produced  by  various  animals  are  described  bv 
the  French  neurologists. 

5.  Joint  affections,  purely  hysterical,  were  early  studied  by  Sir  B. 
Brodia,  and  later  by  Sir  James  Paget.  They  involve  the  knee  and  hip  and 
consist  of  fixation,  tenderness,  and  even  swelling, 

6.  The  MENTAL  SYMPTOMS  are  a  prominent  feature  of  hysteria,  and  vary 
greatly  in  their  manifestations.  Irritability  and  capriciousness  of  temper, 
maniacal  excitement,  hallucinaitons,  and  even  insanity  may  occur.  The 
hysterical  trance  is  a  well-known  condition.  It  may  come  on  spontaneously, 
but  more  frequently  it  follows  one  of  the  forms  of  hysteroid  attacks  to  be 
later  described.     The  cataleptic  state  may  be  associated  with  this  symptom. 

7.  Convulsive  Seizures. — Hysterical  convtdsions  are  a  recognized 
symptom,  while  in  some  they  are  the  only  manifestation  of  the  disease. 
Their  severity  varies  greatly;  but  two  degrees  are  described,  a  milder  or 
minor,  and  a  severer  or  major. 

(a)  Minor  Form. — This  may  come  on  suddenl}^  or  be  preceded  bj^  a 
prodrome,  including  hysterical  behavior,  such  as  laughing  and  crying;  a 
sense  of  constriction  about  the  throat,  or  that  of  a  ball  rising  in  it  (the  so- 
called  globus  hystericus) ;  a  feeling  of  anxiety  with  shortness  of  breath  with 
pain  and  discomfort  in  the  chest  or  abdomen  (pseudo-angina) . 

In  the  actual  seizure  the  patient  falls,  with  this  striking  feature :  that  she 
rarely  fails  to  find  a  soft  spot,  such  as  a  sofa  or  bed,  to  receive  her.'  The 
convulsion  consists  in  clonic  contractions  of  a  disordered  and  irregular  kind, 
in  which  all  four  extremities  and  even  the  trunk  may  take  part.  Though 
seemingly  unconscious,  the  patient  still  gives  to  the  careful  observer  the 
impression  of  a  certain  method  in  her  madness.  The  convulsion  lasts 
usually  a  few  minutes,  when  it  passes  off  spontaneously,  or  the  patient 
may  be  aroused  by  some  powerful  impression,  such  as  the  dashing  of  cold 
water  in  the  face,  or  by  a  sharp  galvanic  shock.  She  may  remain  emotional 
for  a  time,  but  the  period  of  torpidity,  so  characteristic  of  the  epileptic  fit, 
is  rare. 

(6)  Major  Form  (Hysterical  Epilepsy). — This  has  become  widely  known, 
more  particularly  from  the  graphic  descriptions  and  vivid  pictures  furnished 
by  the  French  school  of  neurology.  It  is  much  less  common  in  this  country; 
indeed,  it  is  rare  outside  of  hospital  walls,  where  prostitutes  are  the  usual 
subjects.     The  attack  may  be  preceded  by  prodromata  similar  to  those  that 


1114  DrSEASES  OF  THE  NERVOUS  SYSTEM 

precede  the  milder  attacks.     The  convulsion  is  described  bj'  French  writers 
as  having  four  distinct  stages: 

1.  The  epileptoid  state,  closely  simulating  a  true  epileptic  attack,  with 
apparent  unconsciousness,  tonic  spasm,  even  opisthotonos,  grinding  of  the 
teeth,  livid  face,  succeeded  by  clonic  convulsions,  relaxation,  and  coma; 
lasting  rather  longer  than  the  true  epileptic  attack. 

2.  The  period  of  "contortions  and  grand  movements,"  called  by  Charcot 
"clownism,"  characterized  by  emotional  display,  striking  contortions,  or 
cataleptic  poses. 

3.  The  period  of  spastic  positions  and  passionate  attitudes,  including 
those  of  ecstasy,  fright,  beatitude,  or  eroticism. 

4.  The  return  to  consciousness  and  a  stage  characterized  especiall)^  by 
manifestations  of  delirium  with  extraordinary  hallucinations,  and  by 
hypnotic  "suggestibility."  In  it  visions  are  seen,  voices  heard,  and  conver- 
sations carried  on  with  imaginary  persons.  Imaginary  events  are  related 
as  actualh'  true.  These  hallucinations  sometimes  persist  even  after  recovery. 
These  periods  are  not  sharply  separated  from  one  another. 

Suggestions  and  Hypnosis. — At  this  point  it  is  suitable  to  say  some- 
thing of  these  conditions,  so  closely  associated  with  the  hysterical  state  and 
which  have  attracted  much  attention.  By  suggestibility  is  meant  the  sus- 
ceptibility of  a  person  to  the  production  of  a  definite  psychical  or  physical 
state  dependent  upon  the  arousing  of  corresponding  ideas  in  the  mind.  It  is 
reaUy  a  further  development  of  the  hysterical  mental  constitution  already 
referred  to,  in  which  the  patient  permits  himself  to  be  dominated  by  his 
imagination.  Suggestion  is  merely  the  artificial  fostering  of  the  psychical 
peculiarity.  It  is  most  easy  during  the  part  of  the  hysterical  attack  when 
the  patients  speak,  hear,  and  answer.  At  such  times  a  definite  direction  may 
be  given  to  the  patient's  ideas.  If  he  is  told  in  an  emphatic,  convincing 
manner  that  he  is  in  a  certain  situation,  be  it  one  of  a  pleasurable  kind  or  a 
state  of  suffering  or  danger,  he  believes  it,  and  at  once,  by  behavior  or  ex- 
pression, shows  that  he  believes  it,  and  is  actually  experiencing  the  condi- 
tions named.  Physical  states  may  be  similarly  suggested,  such  as  paralysis, 
contractures,  and  anesthesias,  while  severe  pain  may  be  inflicted  without 
exciting  sensibihty.  After  the  attack  is  over  the  subject  is  totally  ignorant 
of  what  has  transpired,  but  during  another  attack  may  remember  the  events 
of  the  pre\'ious  one,  or  what  is  still  more  strange,  supposed  events,  fiirnish- 
ing  thus  an  instance  of  double  consciousness. 

Hypnosis  is  closely  allied  to  suggestion.  It  is  regarded  by  many 
as  nothing  more  or  less  than  the  intentional  production  of  a  hysterical  attack, 
or  a  hysterical  psychosis  by  suggestion.  As  Striimpell  graphically  puts  it, 
"  Hypnosis  is  an  artificial  hysteria."  This  view,  however,  is  not  held  bj''  all. 
The  French  school  makes  four  principal  forms  of  the  hj'pnotic  state  with 
many   transitions: 

1.  The  cataleptic  state,  in  which  the  limbs  retain  all  the  positions 
artificially  given  them. 

2.  The  state  of  suggestion  or  artificial  hallucination,  in  which  patients 
are  induced  to  eat  tasteless  and  unnatural  food  with  a  gusto. 

3.  The  lethargic  state:  a  state  of  apparent  unconsciousness,  with  the 
ej'es  closed,  the  muscles  relaxed,  yet  with  a  markedly  increased  excitability 


HYSTERIA  1115 

in  the  muscles  and  nerves,  in  which  a  light  tap  on  a  nerve  like  the  facial  is 
sufficient  to  put  all  the  muscles  supplied  by  it  into  a  tetanic  contraction  far 
outlasting  the  irritation. 

4.  A  state  of  hysterical  somnambtdism,  in  which  the  patient,  while 
remaining  half  unconscious,  still  answers  automatically  questions  put  to 
her,  obeying  orders  or  giving  them,  and  sometimes  exhibiting  certain 
sensory  hyperesthesias  (vigilambulism) .  It  will  be  seen  that  each  of  these 
corresponds  with  one  or  another  of  the  different  manifestations  of  the  hys- 
terical attack. 

Hysterogenous  Zones. — In  this  connection  some  further  reference  should 
be  made  to  the  so-called  hysterogenous  zones  already  alluded  to.  These 
are  hyperesthetic  areas  especially  studied  by  Richet,  on  which  persistent 
pressure  will  sometimes  excite  a  hysterical  attack.  While  the  submammary 
areas,  especially  the  left,  and  the  inguinal  region  are  favorite  hysterogenous 
zones,  the  zones  may  be  in  any  part  of  the  body:  as,  for  example,  the  sides  of 
the  trunk.  Pressure  in  such  a  zone  may  cause  an  existing  attack  to  sub- 
side.    Hysterical  spasm  may  be  localized  or  limited  to  groups  of  muscles. 

Diagnosis. — This  is  not  usually  difficult.  There  is  something  inde- 
scribable in  the  bearing  and  appearance  of  a  hysterical  patient  which 
enables  the  experienced  physician  often  to  recognize  the  disease  at  a  glance. 
While,  as  stated,  many  phenomena  of  any  organic  nervous  disease  may  be 
present,  yet  the  essential  symptoms  of  organic  lesion  are  stiU  wanting  and 
there  are  symptoms  which  are  peculiar  to  hysteria  alone.  The  anesthesias 
are  peculiar  in  their  area  of  distribution,  and  hysterogenous  zones  are  no- 
where else  found.  The  hysterical  convulsion  is  quite  sui  generis,  the  throat 
and  pharyngeal  symptoms  are  not  found  elsewhere,  and  the  emotional 
symptoms  are  tell-tale.  Cases  occasionally  occur  in  which  the  diagnosis 
between  hysteria  and  organic  disease  is  very  difficult. 

Prognosis. — This  is  very  rarely  serious,  though  the  course  and  duration 
of  the  disease  vary  greatly.  The  milder  cases  may  be  of  very  short  duration, 
while  the  more  serious  may  last  for  weeks  or  years,  often,  however,  with 
intermissions  and  changes.  Only  in  very  rare  instances  does  a  fatal  result 
occur,  and  reports  of  death  from  hysteria  demand  very  critical  examination. 

Treatment. — A  proper  prophylactic  treatment,  so  commonly  overlooked, 
wotdd  prevent  many  cases  of  hysteria.  The  counteracting  of  all  that  is 
mentioned  under  the  head  of  predisposition  constitutes  such  treatment. 
Wholesome  discipline  or  training  in  youth,  the  inculcation  of  self-denial  as 
contrasted  with  overindulgence  and  the  gratification  of  fancy,  and  careful 
exclusion  from  the  companionship  of  hysterical  persons  make  up  the  sum  of 
these. 

The  successful  curative  treatment  of  hysteria  also  more  frequently 
depends  upon  the  individuality  of  the  physician  than  on  the  remedies 
employed.  Indispensable,  however,  is  the  removal  of  the  causes  which 
predispose  to  the  disease,  whether  they  be  of  the  nature  of  moral  influences 
or  bodily  ailment.  Among  the  most  difficult  to  eliminate  of  the  former 
are  those  which  arise  from  the  fondness  and  sympathy  of  relatives  who 
have,  from  long  habit,  become  almost  slaves  to  the  fancies  of  the  hysterical 
subject,  and  with  whom,  in  consequence,  firmness  has  become  impossible. 
It  is  in  consequence  of  such  difficulties  that  the  isolation  plan  of  treatment, 


1116  DISEASES  OF  THE  NERVOUS  SYSTEM 

which  has  become  inseparably  associated  with  the  name  of  Weir  Mitchell, 
has  been  so  successful.  Originated  for  neurasthenic  cases,  it  is  as  applicable 
to  the  hysterical,  in  whom  neurasthenia  is  likewise  often  present,  while 
hysteria  also  often  forms  a  large  factor  in  the  neurasthenic  state.  Whenever 
possible,  the  patient  must  be  removed  from  her  previous  surroundings, 
her  family,  and  even  her  friends.  This  accomplished,  the  details  of  manage- 
ment largely  depend  upon  the  peculiarities  of  the  case,  but  in  a  general  way 
the  Weir  Mitchell  plan  may  be  said  to  be  as  follows : 

First,  and  indispensable,  is  the  care  of  an  intelligent  and  sensible  nurse. 
Under  her  charge  the  patient  is  put  to  bed  and  kept  in  a  condition  of  absolute 
rest,  even  reading  being  prohibited,  and  also  at  first  self-feeding.  Massage 
is  used  daily,  at  first  for  short  periods,  which  are  gradually  lengthened,  until 
an  hour  is  thus  consumed.  With  massage'  is  associated  electricity,  the 
faradic  current  with  slow  interruptions  being  usually  preferred.  Thus, 
with  a  small  electrode,  the  motor  nerve  points  can  be  picked  out,  and  the 
contraction  of  individual  muscles  produced.  Massage  and  electricity  both 
have  for  their  purpose  the  substitution  of  exercise,  to  which  end  the  former 
is  by  far  the  most  useful  and  important.  Both  are  discontinued  during 
menstruation.  The  food  at  first  is  milk,  which  has  been  usually  skimmed, 
but  in  my  own  experience  good  milk  unskimmed  and  diluted  with  one-fourth 
its  bulk  of  water,  or  aerated  water,  answers  the  purpose  better.  The  pro- 
portion of  casein  is  less,  and  the  oil,  which  is  so  valuable  for  the  nutrition 
of  the  patient,  is  retained  in  more  nearly  its  normal  quantity.  At  first 
from  four  to  six  ounces  of  milk  are  given  every  two  hours.  After  a  week 
or  ten  days  a  chop  or  a  few  raw  oysters  are  added  at  luncheon,  with  a  cup  of 
coffee  or  tea,  and  later  at  breakfast  an  egg,  bread  and  butter  or  biscuit  with 
the  milk,  the  latter  being  continued  at  two-hour  intervals.  The  patient 
should  have  a  thorough  sponge  bath  daily  at  the  hands  of  the  nurse.  It  is 
convenient  to  make  out  a  schedule  including  the  hours  for  nourishment, 
massage,  and  electricity,  of  which  the  last  two  should  be  separated  by  several 
hours.  Massage  should  be  followed  by  a  full  hour's  rest.  Under  this  forced 
feeding  the  patient  gradually  fattens,  and  concurrently  wdth  this  the  excita- 
bility of  the  nervous  system  usually  grows  less.  In  a  month  or  six  weeks 
the  patient  is  allowed  to  sit  up,  at  first  for  a  few  minutes  only,  but  each 
day  a  little  longer,  until  the  whole  day  is  thus  spent,  interrupted  by  periods 
of  rest.  Later  she  is  taken  out  to  drive,  and  then  to  walk  for  gradually 
increasing  distance,  until,  in  the  vast  majority  of  instances,  she  is  enabled 
to  perform  enormous  amounts  of  physical  exercise  without  fatigue.  Many 
patients  who  have  bedridden  for  months  and  even  years,  women  whose 
relatives  had  been  worn  out  with  nursing,  who,  after  a  few  weeks  of  this 
treatment,  acquired  the  most  vigorous  health,  walking  many  miles  a  day 
and  presenting  an  appearance  of  health  and  strength  which  would  be 
considered  absolutely  impossible  by  one  unfamiliar  with  the  results  of  this 
mode. of  treatment.  As  a  rule,  three  months  should  be  asked  for  its  fulfill- 
ment. As  has  already  been  said,  the  individuality  of  the  physician  has  much 
to  do  with  the  success  of  the  method.  One  who  has  a  firm,  earnest,  yet 
gentle  manner  will  do  more  \\'ith  such  cases  than  one  who  is  vacillating  and 
disposed  to  yield  to  the  caprice  of  the  patient.  An  element  of  "suggestion " 
must  perhaps  be  acknowledged  in  the  power  of  the  physician  thus  constituted. 


HYSTERIA  1117 

yet  the  full  application  of  this  principle  of  treatment  by  hypnotic  suggestion 
is  to  be  deprecated.  The  nurse  in  charge  must  be  similarly  constituted, 
and  it  not  infrequently  happens  that  a  nurse  otherwise  excellent  is  totally 
unadapted  for  the  management  of  a  case  of  this  kind. 

.  As  to  medicines,  the  number  that  are  useful  are  few.  Iron  and  arsenic, 
in  very  moderate  doses,  are  the  only  ones  which  are  actually  curative.  The 
various  nervous  sedatives,  including  valerian,  asafetida,  the  bromids,  the 
milder  hypnotics,  such  as  phenacetin ,  rarely  chloral ,  may  be  used  as  occasion 
requires;  morphin  should  never,  or  almost  never,  be  given.  A  convenient 
form  in  which  to  use  asafetida  is  the  suppository;  lo  grains  (0.66  gm.)  may 
be  put  in  a  single  one. 

The  paralysis  and  contractures  generally  require  some  time  to  overcome, 
and  in  some  cases  are  persistent  in  spite  of  all  treatment.  Cure  is  accom- 
plished mainly  by  manipulation  aided  by  electricity,  under  the  use  of  which 
the  symptoms  gradually  disappear  and  the  patient,  induced  at  first  to  walk 
for  a  few  steps,  will  slowly  acqmre  full  power  of  locomotion.  Anesthesia 
is  best  treated  by  faradization  and  the  electrical  brush.  Paralysis  of  the 
vocal  cords  is  also  best  treated  by  electricity,  suitable  electrodes  having  been 
devised  for  that  purpose. 

Allusion  should  be  made  to  metallotherapy,  a  treatment  instituted  by  a 
French  ph^J-sician  named  Burq,  who  years  ago  ascertained  that  by  la>dng 
plates  of  metal  upon  a  cutaneous  surface  affected  by  hysterical  anesthesia, 
sensation  is  sometimes  restored  at  once  not  only  in  the  immediate  region, 
but  also  sometimes  in  a  much  larger  area.  The  cases  so  treated  were  mosth- 
hysterical  hemianesthesias.  Iron  is  the  metal  most  frequently  efficient, 
but  sometimes  copper,  zinc,  or  gold.  The  selection  of  the  metal  essential 
to  each  case  was  called  metalloscopy,  and  Burq  held  that  this  metal  would 
also  have  the  same  effect  if  given  internally.  A  committee  of  the  Paris 
Society  of  Biology  confirmed  these  statements  in  1876,  except  as  to  the  inter- 
nal administration  of  the  metal.  A  similar  discovery  of  Charcot  showed 
that  the  return  of  sensation  to  an  anesthetic  area  after  applying  a  metal 
plate,  is  accompanied  by  a  simultaneous  development  of  anesthesia  upon  the 
opposite  side  and  in  an  exactly  corresponding  place.  This  is  known  as 
transfer.  Other  hysterical  symptoms  than  anesthesia  have  been  found  to 
exhibit  analogous  phenomena.  Thus,  transfer  can  sometimes  be  observed 
in  hysterical  amblyopia,  achromatopia,  deafness,  loss  of  the  senses  of  smell 
and  taste,  contractures,  and  paralysis,  while  such  transfers  may  be  induced 
by  other  means  than  metal  plates,  known  as  esthesiogenous  remedies. 
They  include  large  magnets,  feeble  galvanic  currents,  static  electricity, 
vibrating  tuning-forks,  and  sinapisms.  It  must  be  plain  to  any  thinking 
person  that  these  phenomena  are  merely  the  result  of  suggestion  produced 
by  ideas  similar  to  those  already  described.  Their  career  will  doubtless 
end  like  that  of  Perkins'  tractors.  Hypnotism  has  also  been  employed 
for  the  treatment  of  hysteria,  and  has  acquired  some  popularity  in  France, 
where  it  has  been  especially  practised  by  the  school  at  Nancy.  Wonderful 
cures  have  doubtless  thus  been  accomplished,  but  based  as  it  is  upon 
mysticism  and  imagery,  and  being  already  much  abused  by  charlatans, 
it  is  to  be  hoped  that  its  fate  will  be  that  of  metallotherapy  and  Perkins' 
tractors. 


1118  DISEASES  OF  THE  NERVOUS  SYSTEM 

NEURASTHENIA. 

Synonyms. — Nervous  Exhaustion;  Nervous  Weakness;  Encephalesthenia;  the 
American  Disease. 

Definition. — A  term  originally  suggested  by  George  M.  Beard,  in  1879, 
for  a  symptom  complex  without  anatomical  basis,  in  which  muscvilar 
weakness,  nervous  irritability,  and  pain  are  variously  manifested.  Beard 
defined  nervousness  as  "Deficiency  of  nerve  force,  manifested  chiefly  by 
undue  sensitiveness  to  external  impressions,"  and  neurasthenia  as  "A  sign 
and  type  of  functional  nervous  disease"  evolved  out  of  this  general  nervous 
sensitiveness.  The  line  of  demarcation  between  neurasthenia  and  hysteria 
is  not  always  definite.  Not  only  do  the  two  conditions  sometimes  merge, 
but  certain  cases  of  neurasthenia  are  in  no  way  distinguishable  from  thS 
minor  forms  of  hysteria.  The  condition  is  called  spinal,  cerebral,  cardiac,  or 
gastric,  according  as  the  symptoms  dependent  on  one  or  the  other  of  these 
systems  predominate,  but  the  line  of  demarcation  is  not  sharp. 

Etiology. — The  same  class  of  persons  who  are  predisposed  to  h\'steria 
are  predisposed  to  neurasthenia,  and  such  predisposition  may  be  inherited 
or  acquired.  So,  too,  many  of  the  exciting  causes  of  the  former  become  the 
exciting  causes  of  the  latter.  Among  these  are  overstrain  of  mind  and  bod3% 
overwork,  especially  overwork  associated  with  care  and  anxiety.  It  is 
distinctive  of  neurasthenia  as  contrasted  with  hysteria  that  it  is  more 
frequent  among  men,  on  whom  business  care  and  financial  worry  fall  more 
severely.  It  is  well  known  that  men  differ  greatly  in  their  power  to  bear 
the  mental  strain  incident  to  the  struggle  for  existence  or  business  success. 
From  the  special  prevalence  of  this  disease  in  America  it  has  been  called 
"the  American  disease,"  and  is  reasonably  ascribable  to  the  fact  that  mental 
and  physical  strength  in  this  country  is  more  taxed  than  in  any  other. 

Morbid  Anatomy. — Although  Beard  took  great  pains  to  prove  that 
neurasthenia  is  a  physical  and  not  a  mental  state,  and  that  these  phenomena 
do  not  come  from  emotional  causes  or  excitability,  but  from  nervous  debihty 
and  irritability,  there  has  been  found  no  distinctive  morbid  change  associated 
with  its  complexus  of  symptoms  any  more  than  with  hysteria.  It  is  barely 
possible  that  the  investigations  of  C.  F.  Hodge  and  others,  demonstrating 
changes  in  nerve  cells  during  functional  activity,  may  result  in  some  further 
knowledge  in  this  direction. 

Symptoms. — It  has  already  been  said  that  the  symptoms  of  the  minor 
fonns  of  hysteria  are  the  symptoms  of  many  cases  of  neurasthenia.  The 
appearance  of  the  patient  may  be  that  of  perfect  health;  less  frequently  he 
looks  worn  and  worried.  In  the  spinal  form  motor  phenomena  are  the  most 
conspicuous.  Of  this  and,  indeed,  of  all  forms,  the  most  constant  symptom 
is  muscular  weakness,  as  a  result  of  which  the  patient  complains  of  being  tired 
and  weary,  even  too  weak  at  times  to  keep  out  of  bed.  Such  weakness 
may  affect  the  gait,  making  it  uncertain  and  trembling,  and  the  acts  per- 
formed by  the  upper  extremities  may  be  similarly  embarrassed.  There 
may  be  hyperesthesia  and  paresthesia,  and  even  the  special  senses  may  be 
affected,  especially  vision  and  hearing.  The  latter  is  more  frequently  over- 
sensitive, and  vision  may  be  obscured  by  the  presence  of  scotomata  or 
muscjE  volitantes.     In  the  cerebral  form  especialh'  characteristic  is  a  low- 


NEURASTHENIA  1119 

spiritedness  or  despondency,  often  painful  to  witness,  and  which  may  alter- 
nate with  irritability  or  moodiness.  Another  symptom  is  sleeplessness, 
though  many  patients  sleep  well;  indeed,  there  is  occasionally  an  irresistible 
disposition  to  sleep.  A  disposition  to  seek  solitude  is  characteristic,  while 
at  other  times  the  patient  fears  to  be  alone.  Again,  he  is  restless,  unsettled, 
and  impelled  to  move  about  from  place  to  place,  while  there  is  sometimes  a 
pronounced  disposition  to  suicide.  Confusion  of  mind,  and  especially  a 
difficiilty  in  dealing  with  figures,  is  a  very  common  symptom,  sometimes  an 
initial  symptom,  the  simplest  arithmetical  problems  being  quite  impossible 
with  one  so  affected. 

The  cardiac  form  is  characterized  by  palpitation  and  frequent  irregtdar 
action  of  the  heart  and  precordial  pain,  which  give  rise  to  the  belief  in  the 
patient's  mind  that  he  has  cardiac  disease,  arteriocapillarj^ fibrosis,  or  "hard- 
ening of  the  blood-vessels,"  as  it  is  called  by  the  laity.  Of  vasomotor 
phenomena  there  may  be  flashes  of  heat,  sudden  sweats,  even  night -sweats, 
and  a  relaxed  state  of  the  peripheral  blood-vessels  to  an  extent  which  may 
cause  the  "water-hammer"  and  even  capillary  pulse,  similar  to  that  of  aortic 
regurgitation.  Epigastric  pulsation  is  often  an  annoying  symptom  in  women. 
In  the  gastric  form  are,  especially,  gastric  pain,  the  distinctive  symptom  of 
"nervous  dyspepsia,"  but  there  are  also  distention  and  discomfort  after 
eating,  or  a  constant  noisy  motion  of  gases — borborygmus.  Polyuria  is  a 
conspicuous  symptom.  A  slight  degree  of  glycosuria  and  even  intermittent 
albuminuria  have  been  reported.  The  opposite  condition  of  urine — a  dark 
hue  and  high  specific  gravity — is  more  rarely  present.  Hoarseness,  aphonia, 
and  very  frequent  breathing  are  regarded  as  sj'mptoms  of  neurasthenia  as 
well  as  of  hysteria. 

Diagnosis. — This  is  generally  easy,  and  is  arrived  at  by  the  exclusion 
of  the  objective  symptoms  of  organic  disease  and  by  the  etiology,  for  it 
will  be  observed  that  all  of  the  symptoms  which  have  been  narrated  are 
subjective  in  character.  The  so-called  spinal  irritation  is  a  condition  which 
resembles  neurasthenia,  and  probably  some  of  the  cases  so  named  which 
are  not  hysteria  are  cases  of  nervous  exhaustion.  Sensitiveness  of  the  verte- 
bras is  not  apt  to  be  present  in  neurasthenia,  whereas  it  is  the  most  distinctive 
symptom  of  spinal  irritation.  No  case  should  be  declared  neurasthenic 
without  the  most  searching  physical  examination.  Many  organic  condi- 
tions (tuberculosis,  brain  tumor,  etc.)  have  as  their  first  manifestation, 
neurasthenic  symptoms. 

Prognosis. — Recovery  from  neurasthenia  may  be  confidently  promised 
to  almost  every  patient  who  is  in  a  position  to  meet  the  indications  of  a 
successful  treatment,  which,  unfortunately,  are  likely  to  be  expensive, 
though  the  modern  hospital  affords  to  even  the  poorer  classes  an  asylum 
where  the  treatment  may  be  successfully  carried  out. 

Treatment. — The  first  essential  condition  of  a  successful  treatment  is 
removal  of  the  causes  which  are  responsible  for  the  illness.  To  this,  in  the 
case  of  women,  and  sometimes  of  men,  the  most  successful  adjuvant  is  the 
rest  treatment  of  Weir  Mitchell,  the  technic  of  which  has  been  already  described 
under  the  treatment  of  hysteria.  After  this  and,  in  the  case  of  men,  often 
even  before  this,  removal  from  the  scene  and  surroundings  which  attended 
the  development  of  the  disease  is  most  useful.     Travel  away  from  home, 


1120  DISEASES  OF  THE  NERVOUS  SYSTEM 

especially  in  foreign  countries,  a  sojourn  at  a  sanitarium  or  health  resort, 
the  seaside,  the  woods,  the  mountains,  for  prolonged  periods,  sooner  or 
later  been  followed  by  recovery  in  the  majority  of  cases.  For  the  poor, 
the  rest-cure  as  carried  out  in  hospitals  may  be  substituted  for  the  more 
expensive  methods  of  home  treatment. 

The  treatment  of  the  insomnia  of  neurasthenia  calls  for  brief  special 
consideration,  and  what  is  said  here  may  apply  to  the  treatment  of  any  form 
of  simple  insomnia,  by  which  is  meant  insomnia  not  the  result  of  pain. 
Modem  therapeutics  has  added  to  our  resources  a  number  of  drugs  which 
are  more  or  less  efficient  to  this  end.  The  best  of  these,  considered  from 
all  standpoints,  are  sulphonal,  trional  and  veronal.  Not  less  than  from  lo 
to  IS  grains  (0.66  to  i  gm.)  of  any  of  these  shovdd  be  given  to  an  adult, 
while  twice  as  much  may  be  given  if  needed.  We  prefer  to  give  this  dose 
and  repeat  it  in  an  hour  if  no  effect  follows.  They  are  bulk\%  soluble  with 
difficulty  in  cold  water,  but  readily  so  in  any  hot  menstruum,  and  especially 
stiitable  is  hot  milk.  They  should  be  given  an  hour  or  two  before  sleep 
is  desired,  but  associated  quietude  is  necessary  to  secure  its  effect.  Paral- 
dehyd  is  an  excellent  remedy,  but  very  disagreeable,  and  is  more  prompt  in  its 
action  than  siilphonal  or  trional,  or  veronal  and  should  be  given  in  dram  (4 
gm.)  doses.  Chloralamid  is  also  a  good  hypnotic;  its  dose  is  30  grains  (2 
gm.).  It  should  be  dissolved  in  alcoholic  menstruum  diluted  to  1/2  ounce 
(13.5  c.c).  Chloral,  as  a  simple  hypnotic,  is  better,  perhaps,  than  any  of 
those  named,  although  it  has  yielded  its  former  high  place  to  those  just  men- 
tioned because  of  their  harmlessness.  All  of  these  have  the  disadvantage  of 
sometimes  causing  drowsiness  the  next  day.  Chloralose,  a  modified  chloral, 
is  often  efficient  in  doses  of  5  grains  (0.33  gm.)  to  an  adult.  It  often  acts 
magically  but  sometimes  a  second  dose  excites.  Hydrobromate  of  hyoscin 
may  be  used  in  doses  of  i/ioo  grain  (0.00066  gm.)  if  the  drugs  named  fail. 
Sometimes  it  acts  like  a  charm,  at  other  times  it  produces  the  opposite  effect 
— exciting  the  patient.     One  trial  suffices  to  settle  the  question.' 

It  is  true  of  all  the  drugs  named  that  their  effect  is  apt  to  wear  off,  and 
increasing  doses  must  be  used,  and  the  hj^pnotic  habit  is  easily  formed. 
It  is,  therefore,  desirable  to  obviate  the  necessity  of  their  use  as  early  as 
possible,  and,  if  possible,  substitute  other  measures.  Often  the  patient 
simply  needs  a  start  to  put  him  in  the  way  of  sleeping,  while  sometimes  the 
simple  feeling  that  there  is  something  at  hand  which  he  can  use  if  he  wishes 
gives  him  the  needed  confidence  and  he  goes  to  sleep  at  once.  A  warm  hath 
before  retiring,  or  even  at  times  a  cool  bath  or  cool  sponging,  and  again  a  hot 
bath,  promote  sleep.  To  persons  residing  in  cities  sleep  is  often  favored  by 
a  sojourn  at  the  seaside,  many  being  able  to  sleep  there  when  they  cannot  do 
so  at  home.     The  same  is  true  of  the  country  or  the  mountains. 

It  is  important,  too,  in  our  efforts  to  secure  sleep  for  our  patients  to  in- 
vestigate the  various  functions,  derangement  of  any  of  which  Aay  keep  a 
neurasthenic  patient  awake.  Irregularities  of  digestion  and  circulation 
should  receive  attention.  An  undigested  meal  or  a  loaded  bowel  often  keeps 
one  awake,  while  an  excited  heart,  by  its  ceaseless  beating,  repels  the  restful 
sleep  without  which  life  is  wretched.  Often  a  light  meal  or  a  single  glass  of 
wine  seems  to  furnish  the  brain-cells  the  right  amount  of  stimulus. 


TRAUMATIC  NEUROSES  1121 

TRAUMATIC  NEUROSES. 

Synonyms. — "Railway    Brain";    "Railway   Spine";   Traumatic    Hysteria; 
Erichsen's  Disease. 

Definition. — A  neurasthenic  or  hysterical  state,  the  result  of  shock 
from  railroad  accident  or  accident  of  similar  alarming  character. 

Etiology. — Profound  nervous  shock,  however  induced,  by  railroad  acci- 
dents, shipwreck,  boiler  explosions,  and  the  like,  even  when  the  sufferer  him- 
self is  not  a  victim,  but  is  profoundly  impressed  by  it,  is  capable  of  producing 
this  nervous  state. 

Morbid  Anatomy. — In  the  vast  majority  of  cases,  anatomical  changes 
are  not  discoverable ;  in  fact,  as  most  cases  recover,  there  is  little  opportunity 
to  seek  them.  In  a  few,  however,  morbid  alterations  have  been  found  in  the 
brain  and  spinal  cord,  including  degeneration  of  the  pyramidal  tracts  of  the 
cord,  demonstrated  by  Edes  in  four  cases ;  multiple  sclerotic  areas  in  the  white 
matter,  and  arteriosclerosis  in  the  vessels  of  the  brain,  with  scattered  areas  of 
degeneration,  but  the  study  of  concussions  in  man  has  not  led  to  very  definite 
results.  The  effects  of  concussions  of  the  brain  and  spinal  cord  have  been 
studied  in  animals,  and  changes  in  the  nerve  cells  and  nerve  fibers  have  been 
found. 

Symptoms. — These  are  not  essentially  different  from  those  of  neuras- 
thenia from  other  causes.  The  most  remarkable  fact  with  regard  to  them 
is  that  they  do  not  necessarily  immediately  follow  the  accident,  and  there 
may  be  some  interval  of  time  between  the  two  events — ^the  accident  and 
its  results.  In  some  cases  the  symptoms  appear  suddenly,  in  others  they 
are  gradual  in  their  invasion.  All  the  symptoms  detailed  under  neurasthenia 
may  be  present,  especially  spinal  tenderness  and  pain  in  various  parts  of 
the  body,  principally  in  the  back  and  head ;  there  may  be  numbness  and  ting- 
ling in  the  extremities,  increased  muscular  irritability,  and  increased  knee- 
jerk.  The  latter  varies  from  day  to  day,  and  may  be  exhausted  by  repeated 
stimulation.  Extreme  depression  of  spirits  is  another  symptom.  Other 
patients  exhibit  active  hysterical  symptoms,  including  modifications  of 
sensation  and  motion,  hemianesthesia,  anesthesia,  paresis,  and  even  paralysis. 
In  the  more  severe  cases  in  which  there  is  actual  concussion  the  symp- 
toms suggest  organic  changes,  which  are,  indeed,  actually  found  at  times 
in  the  shape  of  pachymeningitis.  Such  cases  exhibit  diminished  superficial 
reflexes,  with  exaggeration  of  the  deep  ones.  There  maj^  be  severe  pain, 
variously  distributed.  Other  symptoms  are  alterations  in  the  temperature 
sense  and  in  the  muscular  sense,  both  of  which  may  be  bilaterally  distributed. 
There  may  also  be  modification  of  the  special  senses,  including  those  of  smell, 
taste,  and  vision,  with  inequality  of  pupils.  There  may  be  monoplegia  with 
or  without  contracture.  Symptoms  which  imply  true  organic  change  are 
optic  atrophy,  bladder-symptoms,  paresis,  and  exaggerated  reflexes.  Such 
cases  are  sometimes,  though  rarely,  fatal. 

Prognosis. — Most  cases  get  well.  The  effect  of  delayed  litigation  is 
often  to  delay  recovery,  while  successful  litigation  does  not  always  relieve  the 
symptoms,  and  when  it  does,  it  is  by  no  means  always  speedily — months  and 
even  years  elapsing  before  the  cases  recover.  A  few  cases,  where  there  is 
true  organic  disease,  perish. 


1122  DISEASES  OF  THE  NERVOUS  SYSTEM 

Treatment. — Rest,  mental  and  physical,  is  the  first  essential  condition  of 
recovery.  It  may  be  aided  by  the  measures  useful  in  other  forms  of  neuras- 
thenia, such  as  massage,  electricity,  and  proper  feeding.  Medicines  avail 
little,  except  for  their  moral  effect.     Narcotics  shoidd  be  avoided. 


OTHER  FORMvS  OF  FUNCTIONAL  PARALYSIS. 

Abasia-astasia. 

Definition. — Abasia  (a  privative;  /Sao-w,  a  step)  is  a  term  given  by  'P. 
Blocq,  in  1888,  to  a  difficulty  in  starting  the  act  of  walking  from  a  state 
of  previous  rest.  Astasia  (a  privative;  o-rao-ts,  a  standing)  is  an  inability  to 
stand,  contrasted  wdth  integrity  of  sensation,  muscular  strength,  and 
co-ordination  of  other  movements  of  the  legs. 

Nature. — The  phenomena  are  thus  far  inexplicable  in  the  absence  of  dis- 
coverable lesions,  and  are  usually  regarded  as  hysterical.  It  is  a  condition 
occurring  in  adidts,  equally  frequent  in  men  and  women — as  determined  by 
Knapp's  study  of  50  cases,  of  which  half  were  in  either  sex. 

Symptoms. — These  occur  in  connection  with  a  variety  of  morbid  states, 
and  a  large  majority  of  them  are  doubtless  hysterical. 

In  the  "unconscious"  variety  the  patient  is  without  any  idea  that  he 
cannot  walk  or  stand,  when  he  suddenly  finds  that  he  cannot  do  either. 
i\.nother  variety  of  abasia-astasia  is  the  "hypochondriacal,"  in  which  the 
patient  acts  under  "conscious"  erroneous  impression  that  he  cannot  walk 
or  cannot  stand.  It  is  sometimes  associated  in  the  hypochondriacal  para- 
noiac with  paresthesia,  and  in  the  neurasthenic  with  abnormally  increased 
sense  of  fatigue.  A  third  form  is  associated  with  some  suddeiily  acting 
"shock,"  as  fright,  which  acts  inhibitorily  on  the  motions  of  the  patient. 
Finally  there  is  the ' '  coercion ' '  variety  of  abasia-astasia,  in  which  the  patient , 
while  in  the  act  of  walking  or  standing,  is  suddenly  seized  with  the  idea  that 
he  cannot  walk  or  shall  not  walk.  This  differs  from  the  h^^pochondriacal 
form  in  that  the  patient  is  conscious  of  the  erroneousness  and  absurditj-  of  the 
idea,  but  is  nevertheless  coerced  by  it. 

These  different  forms  are  not  always  sharply  defined.  Suddenness  is 
especially  characteristic  in  the  "unconscious"  form.  In  other  cases  the 
patient  may  walk  a  few  steps  and  then  suddenly  break  down.  Sometimes 
he  stands  rooted  to  the  ground,  as  it  were.  At  other  times  the  development 
is  slow,  requiring  even  years  to  reach  its  acme.  Sometimes  it  is  preceded  by 
trembling  or  staggering,  as  associated  symptoms,  the  residt  of  the  effort  of 
the  patient  to  stand  or  move  forward. 

Closing  the  eyes  usually  increases  the  difficult}-.  On  the  other  hand, 
sometimes,  wdth  the  eyes  closed  the  patient  can  walk  in  the  normal  manner, 
when  it  is  impossible  to  do  so  with  the  eyes  open.  The  latter  is  especially 
true  of  the  hypochondriacal  variety.  In  these  cases,  too,  the  natural  gait 
is  sometimes  restored  after  attempting  an  unusual  method  of  walking,  as 
walking  backward  or  wdth  the  legs  crossed  or  by_ leaping  or  in  miHtary  step. 
So,  also,  abasics  can  walk  on  all-fours.  The  morbid  state  is  also  influenced 
by  certain  surroundings,  as  broad  open  surfaces  or  long  narrow  corridors  or 
standing  without  special  support.     Th.  Ziehen  refers  to  a  case 'in  which 


PERIODICAL  PARALYSIS  1123 

abasia  came  on  when  the  patient  walked  under  a  tree,  the  moving  leaves  of 
which  produced  moving  shadows.  There  is  sometimes  associated  tachy- 
cardia; at  other  times  evident  hysterical  symptoms,  such  as  tender  spots, 
hemianesthesia,  and  the  like.  In  other  cases  there  is  epilepsy,  paralysis 
agitans  or  chorea. 

Diagnosis. — This  is  based  upon  the  retention  of  absolute  integrity  of 
sensation,  of  muscular  strength,  and  of  co-ordination  of  the  legs,  demonstrable 
in  the  recumbent  position.  From  hysterical  paraplegia  it  differs  in  that  the 
power  of  motion  is  intact  in  the  recumbent  position.  From  intermittent 
lameness  it  is  distinguished  by  the  fact  that  in  intermittent  lameness  the 
inability  to  walk  comes  on  after  the  patient  has  been  walking  a  while,  and 
the  power  of  locomotion  is  restored  after  rest.  Abasia-astasia  has  been 
observed  in  tumor  of  the  frontal  lobe  of  the  brain. 

Prognosis. — This  is  regarded  as  favorable,  though  relapses  occur. 

Treatment. — The  evident  hysterical  nature  of  the  affection,  in  the  ma- 
jority of  cases,  suggests  the  treatment  for  such  cases.  The  rest-cure,  mas- 
sage, gymnastics,  electricity,  gradually  increasing  practice  in  walking,  are 
measures  which  are  likely  to  be  useful.  Th.  Ziehen,  to  whose  article  in 
Eulenberg's  "  Real-Encyclopadie  "  we  are  indebted  for  much  of  the  informa- 
tion in  this  section,  recommends  "suggestion  mthout  hypnosis,"  especially 
in  the  hypochondriacal  and  hysterical  forms,  as  a  reliable  means  of  rapid  cure; 
and  in  the  cases  in  which  fear  or  terror  is  conspicuous,  small  doses  of  opium, 

Family  Periodical  Paralysis. 

Definition. — A  rare  form  of  hereditary  or  family  paralysis  of  the  volun- 
tary muscles,  usually  general,  except  those  of  the  face,  recurring  at  intervals 
of  from  one  or  two  weeks  to  three  months,  and  confined  principally  to  chil- 
dren. It  is  attended  with  a  loss  of  reflexes  and  electrical  reaction,  but  no 
mental  or  sensory' disturbance. 

The  disease  is  rare.  It  was  first  described  by  Cavare  in  1853  and  by 
Romberg  in  1857.  Edward  WyUis  Taylor ^  collected  25  cases,  including  two 
of  his  own,  up  to  September,  1898,  to  which  John  K.  Mitchell^  added  a 
twentj^-sixth  in  1899. 

Etiology. — The  disease  is  hereditary  and  is  transmitted  through  the 
mother.  As  many  as  12  members  of  a  single  family  have  been  affected, 
though  it  does  not  usually  affect  all  the  children.  Goldfiam  suggests  that 
the  paratysis  is  due  to  autointoxication,  the  poison  acting  upon  the  nerve 
endings  in  the  muscles,  while  he  also  found  that  the  urine  secreted  during 
the  attacks  was  more  toxic  than  at  other  times.  The  view  of  autointoxica- 
tion is  not  accepted  by  all,  and  J.  J.  Putnam  has  advanced  a  theorjr  of  in- 
hibition. The  recent  studies  of  John  K.  Mitchell  on  the  case  referred  to, 
for  some  time  under  his  observation,  tend  to  confirm  Goldflam's  view,  and 
also  to  show  that  there  are  two  poisons,  one  of  which  predominates  in  one 
case  and  the  other  in  another,  and  according  as  one  or  the  other  predominates 
the  effect  is  greater  on  the  peripheral  nerves  and  muscles  or  the  spinal 


1  "Journal  of  Ne 
but  does  not  include  c: 
not  reported  in  detail. 

2  "Amer.  Jour,  of  the  Med.  Sci.,"  December,  l8 


1124  DISEASES  OF  THE  NERVOUS  SYSTEM 

center.  It  should  not  be  omitted  that  spme  dinicians,  including  C.  L.  Dana, 
consider  the  majority  of  cases  hysterical,  though  he  says  some  may  be  cases 
of  recurring  poliomj'elitis. 

Symptoms. — The  disease  occurs  in  youth  and  in  the  midst  of  health,  even 
during  sleep.  Beginning  as  a  weakness  or  weariness  in  the  arms  and  legs, 
it  is  usually  complete  in  24  hours.  It  is  rarely  confined  to  the  legs,  and  may 
also  involve  the  muscles  of  the  neck,  and  even  those  of  the  tongue  and 
pharynx,  while  those  of  the  head  and  face  remain  intact. 

Sensation  for  the  most  part  is  unaffected,  as  are  also  the  special  senses. 
The  deep  reflexes  are  diminished,  sometimes  abolished,  while  the  superficial 
reflexes  are  feeble.  Faradic  sensibility  of  nerves  and  muscles  is  greatly 
lessened,  sometimes  absent.  There  is  no  fever,  and  sometimes  the  tempera- 
ture is  below  normal,  while  the  pulse  is  slow.  Nothing  abnormal  has  been 
found  in  the  blood  or  urine,  though  the  breath  is  heavy,  the  tongue  is 
coated,  and  the  urine  is  relatively  diminished  during  the  attack  and  in- 
creased after  its  termination,  as  happens  in  migraine. 

The  attack  recurs  at  intervals  of  from  one  to  two  or  more  weeks,  in  some 
instances  daily.  It  begins  to  abate  usually  in  a  few  hours  or  after  a  day  or  two, 
and  ultimately  disappears  completely,  and  the  patient  remains  well  until 
another  attack  sets  in. 

Treatment. — None  is  of  any  service,  though  some  of  the  earlier  cases  seem 
to  have  yielded  to  quinin,  while  it  is  more  than  likely  that  these  were  in  some 
way  complicated  with  malaria. 

AMAUROTIC  FAMILY  IDIOCY. 

Definition. — A  rare  and  generally  fatal  disease  affecting  several  chil- 
dren of  the  same  family,  characterized  by  a  feeble  mental  development, 
by  progressive  weakness  of  all  the  muscles  of  the  body  a'nd  by  failing  vision 
terminating  in  complete  blindness  depending  on  optic  nerve  atrophy  and 
changes  in  the  macula. 

Etiology. — This  is  obscure.  Singurlarly  the  disease  is  apparently  almost 
confined  to  Hebrews,  and  Sachs  tells  us  that  he  knows  of  no  undoubted 
cases  in  other  races.  It  cannot  be  ascribed  to  sjT^hilis  though  the  nerve 
atrophy  resembles  that  due  to  hereditary  syphilis,  with  which  it  may  there- 
fore be  confounded.  Its  duration  is  usually  less  than  two  years.  The 
disease  is  regarded  by  some  as  acquired,  by  others  as  congenital;  the  latter 
is  more  likely. 

Morbid  Anatomy.- — The  morbid  changes  are  essentially  those  first 
described  by  Sachs  who  found  them  similar  to  those  in  brains  of  arrested 
development.  There  was  confluence  of  the  median  and  Sylvian  fissures 
and  complete  exposure  of  the  island  of  ReU.  The  cortex  was  hard  and 
grating  to  the  knife.  Microscopic  examination  found  destruction  of  the 
brain  cells  whose  contour  was  rounded  or  elongated  and  the  cell  protoplasm 
was  variously  degenerated.  The  nucleus  and  nucleolus  were  sometimes 
wanting.  Verj^  few  pyramidal  cells  were  left.  Hirsch  found  these  same 
changes  in  the  gray  matter  of  the  entire  central  nervous  system,  including 
the  spinal  cord  and  spinal  ganglia. 


AMAUROTIC  FAMILY  IDIOCY  1125 

Retinal  changes  are  thus  described  by  Tay:'  "The  optic  disks  were 
apparently  healthy,  but  in  the  region  of  the  yellow  spot  of  each  eye  there  was 
a  conspicuous,  tolerably  diffuse,  large  white  spot  more  or  less  circular 
in  outline,  and  showing  at  its  center  a  brownish-red  fairly  circular  spot 
contrasting  strongly  with  the  white  patch  surrounding  it.  This  central 
spot  did  not  look  at  all  like  a  hemorrhage,  nor  as  if  due  to  a  pigment,  but 
seemed  a  gap  in  the  white  patch  through  which  one  saw  healthy  structures." 

Symptoms. — The  child  is  well  nourished  at  birth  and  the  disease  does 
not  usually  set  in  until  the  third  to  sixth  month  of  life,  when  the  mental 
and  physical  defects  begin  to  be  noticed.  The  child  becomes  quiet,  list- 
less and  apathetic,  and  visual  disturbance  makes  its  appearance.  As 
time  passes  muscular  weakness  occurs,  the  child  is  unable  to  hold  up  its 
head  or  sit  up,  the  muscles  are  soft  and  flabby  though  they  may  be  spastic. 
The  reflexes  may  be  normal,  slightly  subnormal  or  exaggerated.  There 
is  sometimes  hyperacusis  to  sound  and  touch;  on  the  other  hand,  a  loss  of 
hearing  has  been  noted.  Convulsions  may  occur  but  are  not  essential. 
Bodily  functions  and  vitality  are  lowered  resulting  in  susceptibility  to 
bronchial  and  gastro-intestinal  derangement.  Retinal  changes  occur  as 
described  by  Tay.  (See  morbid  anatomy.)  The  symptoms  gradually 
increase  in  severity  and  terminate  in  tdtimate  complete  mental  imbecility, 
marked  palsy  and  total  blindness.  The  child  w&stes  and  dies  usually 
before  the  end  of  the  second  year. 

Treatment. — None  has  ever  proved  of  use.  Proper  and  sufficient 
nourishment  with  wholesome  hygienic  surroundings  naturally  suggest 
themselves. 

VASOMOTOR  AND  TROPHIC  DERANGEMENTS. 

Acute  Angioneurotic  Edema. 

Synonyhs. — Giant    Urticaria;    Acute    Circumscribed   Edema    of   the   Skin; 
Quincke's  Disease. 

Definition. — Ederaatous  swelling  occurring  suddenly  in  various  parts 
of  the  body,  disappearing  in  a  few  hours,  perhaps  to  recur  again. 

Etiology. — Heredity  is  sometimes  observed,  but  any  other  cause  is 
unknown. 

Pathology. — The  condition  is  regarded  by  Quincke  as  a  vasomotor 
neurosis  producing  sudden  dilatation  and  increased  permeability  of  the 
vessels.  It  is,  however,  one  of  the  derangements  which  may  be  said  to  be 
of  mixed  vasomotor  and  trophic  origin. 

Symptoms. — The  face,  especially  the  eyelids  and  nose,  is  the  most  usual 
site,  but  the  swelling  may  affect  any  part  of  the  body,  as  the  hands,  face,  or 
genitalia,  including  the  penis.  It  may  be  painful.  Even  the  mucous  mem- 
branes may  be  invaded,  especially  the  lips,  mouth,  and  pharynx,  while  a 
fatal  edema  of  the  larynx  has  occurred.  The  onset  is  sudden  and  the  patient's 
previous  health  may  have  been  excellent.     Gastro-intestinal  disturbances 

1  For  a  fuUe 
Spiller's  book  o 


1126  DISEASES  OF  THE  NERVOUS  SYSTEM 

manifested  by  vomiting,  colic,  diarrhea,  and  gastralgia,  are  sometimes 
associated  while  they  sometimes  alternate.  They  are  ascribed  to  an  edema 
of  the  mucous  membrane.  This  has  been  demonstrated  from  sections  of 
fragment  of  mucous  membrane  of  the  stomach  removed  by  stomach-tube 
by  Roger  S.  Morris.^  There  are  also  at  times  heat,  redness,  and  itching. 
While  the  symptoms  arise  suddenly,  subsiding  often  as  quickly,  the  disease 
is  likely  to  be  prolonged. 

Treatment. — Remedies  calculated  to  increase  muscular  and  ner\^ous 
tone,  such  as  str^'^chnin,  quinin,  and  iron,  are  indicated.  In  other  respects 
the  treatment  is  sjonptomatic,  and  directed  to  whatever  sj'mptoms  demand 
attention.  Morphin  is  sometimes  necessary  to  relieve  pain.  Tracheotomy 
may  be  necessary  to  escape  death  by  edema  of  the  glottis. 

INTERMITTENT   HYDRARTHROSIS. 

Intermittent  hydrarthrosis  is  an  affection  allied  to  angioneurotic  edema, 
being  characterized  by  periodic  swelling  of  one  or  several  joints,  without 
fever.  The  swelling  may  occur  rapidly,  sometimes,  it  is  said,  so  rapidly  as  to 
be  accompanied  by  a  sensation  as  of  water  rushing  into  the  joint.  There  is 
also  pain  and  stiffness.  The  intermissions  vary  from  i  o  days  to  three  months. 
It  is  sometimes  associated  with  hysteria  in  women.  To  constitute  the  affec- 
tion no  other  local  s^onptom  than  those  mentioned  should  be  present  and 
it  should  not  be  primary  or  secondary  to  any  other  condition.  Nor  should 
it  develop  into  any  other  articular  disease.  It  is  to  be  distinguished  from 
hydrarthrosis,  the  result  of  gout  and  rheumatism  and  traumatism.  The 
prognosis  is  unfavorable  and  the  disease  appears  to  resist  treatment. 

The  condition  was  described  by  Perrin  in  1845  and  70  cases,  according  to 
Garrod,  were  reported  up  to  the  time  of  his  writing. 

Raynaud's  Disease. 
Synonyms. — Local  Asphyxia;  Symmetrical -Gangrene  of  the  Extremities. 

Definition. — A  vasocontractile  disease  characterized  by  three  stages, 
more  or  less  complete — viz. : 

1.  Local  syncope. 

2.  Local  asphjTcia. 

3.  Local  gangrene. 

Symptoms. — The  disease  is  more  frequent  in  women — Raynaud's  cases 
including  20  women  and  5  men.  It  is  also  a  disease  of  early  life ;  the  majority 
of  Raynaud's  patients  were  between  the  ages  of  18  and  30,  while  five  were 
between  three  and  nine.  The  first  phenomenon  noticed  is  an  unusual 
pallor  or  anemia  of  the  part,  resulting  in  marble-like  whiteness  and  lobS  of 
sensation.  This  is  the  local  syncope.  Affecting,  as  it  often  does,  the  fingers 
and  toes,  these  have  been  called  dead  fingers  and  toes.  It  follows  exposure 
to  cold,  and  to  comparatively  slight  degrees  of  cold  in  those  predisposed. 
The  condition  may  disappear  under  warmth,  and  then  only  does  pain  mani- 
fest itself — when  the  parts  are  being  thawed  out,  as  the  saying  is.     Local 


'•Angioneurotic  Edema."  "American  Journal  of  Medical  Sciences."  November,  1904 


RAYNAUD'S  DISEASE  1127 

asphyxia  follows,  consisting  in  engorgement,  the  parts  previously  pale  becom- 
ing purple  and  li\ad.  The  change  is  not  simultaneous  in  all  the  fingers, 
some  being  still  white  while  the  others  are  livid. 

The  local  asphyxia  may  succeed  the  local  syncope,  or  it  may  come  on 
independently  of  it.  The  tip  of  the  nose  and  helices  of  the  ears  are  the 
parts  prone  to  cyanosis,  but  in  addition  to  the  fingers  and  toes  the  hands, 
feet,  and  arms  and  legs  may  be  involved.  A  peculiar  and  striking  mottling 
is  the  result  on  these  large  surfaces,  produced  by  an  alternation  of  various 
shades  of  purple  with  intervening  lighter-hued  spaces.  In  the  darkest 
areas  the  capillary  circulation  is  quite  stagnant.  There  are  also  swelling, 
resulting  stiffness,  and  pain,  the  'after  often  extreme  and  associated  with 
an  intense  itching.  But  in  Raynaud's  disease  there  is  perhaps  more  fre- 
quently anesthesia  than  pain.  These  are  the  phenomena,  too,  of  chilblains, 
with  which  so  many  suffer  in  this  climate  with  the  approach  of  cold  weather. 
In  Raynaud's  disease,  as  in  chilblains,  these  sjTnptoms  may  pass  away  in 
time  under  the  influence  of  warmth;  in  fact,  for  a  long  time  they  occur  onlj' 
during  the  colder  weather.  A  reaction  takes  place,  and  the  parts  assume  a 
bright,  red  color  in  which  the  circulation  is  very  active,  and  the  anemia 
produced  by  pressure  is  rapidly  replaced  by  an  active  hyperemia.  The 
attacks  may  keep  recurring  for  j^ears  without  further  effect,  though  in  extreme 
cases  there  maj^  be  loss  of  substance  in  the  ear-tips  and  fingers'  ends,  which 
in  time  may  become  indurated,  uneven,  and  scarred  from  this  cause. 

The  third  stage  of  local  or  symmetrical  gangrene  is  reached  in  a  few  cases 
only.  In  these  the  parts  affected  remain  asphyxiated,  and  the  phenomena  of 
dry  gangrene  make  their  appearance.  The  fingers  or  toes,  one  or  more, 
become  black,  dry,  and  cold,  while  gangrenous  blebs  appear  in  the  parts 
adjacent  to  the  sound  tissue,  a  line  of  demarcation  occurs,  and  the  dead  part 
sloughs  away  less  extensively  than  at  first  seemed  likely  to  be  the  case. 
Rarely,  and  only  in  cases  of  young  children,  does  a  fatal  termination  occur. 

The  symptoms  that  have  been  described  may  be  said  to  be  essential,  but 
others  also  may  be  added  of  great  clinical  interest.  One  of  these  is  hemo- 
globinuria, which  is,  of  course,  associated  with  a  corresponding  albuminuria. 
There  are,  at  times,  a  few  blood  disks  in  the  urine.  Hemoglobinuria,  when 
present,  generally  occurs  at  the  same  time  with  the  cyanosis,  and  the  attack 
has  frequently  been  preceded  by  a  chill.  Other  associate  symptoms,  less 
common,  are  scleroderma  and  edema,  probably  angioneurotic. 

At  other  times  cerebral  symptoms,  including  torpor  and  partial  loss  of 
consciousness,  are  present;  at  others,  epUepsy,  mania,  delusions,  and  even 
temporary  hemiplegia.  Dimness  of  vision  is  a  symptom  easily  explained  if 
we  suppose  there  is  a  spasm  of  blood-vessels  producing  local  retinal  sj'ncope. 
Other  associated  sjTtiptoms  are  peripheral  neuritis  with  tingling  and  formi- 
cation— neuritis  being  regarded  as  one  of  the  causes  of  the  disease ;  arthritic 
swelling;  urticaria;  erythema;  also  colicky  pains,  nausea,  vomiting,  and 
diarrhea. 

Pathology. — Three  chief  theories  have  been  brought  forward  to  explain 
Raynaud's  disease: 

1.  That  it  is  due  to  endarteritis  obliterans. 

2 .  That  it  is  caused  by  peripheral  neuritis. 

3 .  That  it  is  the  result  of  vascular  spasm. 


1128  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  intermittent  nature  of  the  disease  is  quite  incompatible  with  its 
causation  by  endarteritis,  which  is  progressively  increasing  in  its  effects. 

It  is  true  that  some  of  the  results  of  peripheral  neuritis  are  similar  to 
those  of  Raynaud's  disease,  but  the  frequency  of  the  former  affection  as 
contrasted  with  the  rarity  of  the  latter  militates,  also,  against  this  view. 

The  theory  of  arteriole  spasm,  suggested  by  Raynaud  himself,  best 
explains  the  symptoms.  It  is  possible  that  endarteritis  may  be  associated 
with  spasm  in  advanced  cases.  The  frequency  of  the  disorder  among 
women  and  children,  whose  vasomotor  system  is  so  impressible ;  its  occurrence 
under  the  influence  of  cold,  which  is  one  of  the  most  powerful  exciters  of 
vasomotor  spasm ;  the  frequent  dimness  of  vision,  which  has  been  shown  by 
ophthalmoscopic  examination  to  be  associated  with  contraction  of  the 
central  artery  of  the  retina;  the  occasional  precedence  of  a  chill;  and  the 
phenomena  of  hemoglobinuria,  all  go  to  show  the  probability  of  vasomotor 
spasm.  Since  the  hemoglobinuria  is  likely  to  be  associated  with  hemoglo- 
binemia — which  probably  arises  from  the  solution  of  hemoglobin  liberated 
in  the  asphyxiated  parts — such  an  origin  for  the  hemoglobinuria  must  be 
admitted.  The  relation  of  Raynaud's  disease  to  chilblains  also  affords  an 
interesting  field  of  investigation — in  fact,  has  already  been-  studied  by 
Legroux. 

Diagnosis. — It  is  not  unlikely  that  Raynaud's  disease  and  gangrene 
from  endarteritis  obliterans  have  been  confounded.  Raynaud's  disease 
is  limited  to  smaller  areas,  as  the  ends  of  the  fingers,  the  tip  of  the  nose 
and  the  helices  of  the  ears.  It  is  preceded  by  local  pallor.  Obliterating 
endarteritis  affects  larger  vessels  and  limbs,  especially  the  lower  limbs,  is 
less  apt  to  be  symmetrical,  and  is  more  likely  to  be  fatal  while  Raynaud's 
disease  is  rarely  so. 

Prognosis. — This  is  not  altogether  unfavorable.  Only  delicate  and 
feeble  children,  as  a  rule,  perish,  while  it  is  quite  possible,  under  favorable 
circumstances,  to  outgrow  the  tendency. 

Treatment. — Persons  subject  to  local  syncope  and  local  asphyxia 
should  be  protected  from  cold,  and  when  the  attack  comes  on,  they  should 
be  kept  warm,  if  necessary  in  bed,  the  parts  being  wrapped  in  wool  and 
subjected  to  artificial  heat.  Friction  may  with  advantage  be  associated. 
Galvanism  and  faradism  are  recommended. 

B.  B.  Gates,  of  Knoxville,  Tenn.,  has  reported  the  successful  treat- 
ment of  Raynaud's  disease  by  nitroglycerin  in  doses  of  i/ioo  grain  (0.00065 
gm.)  increased  to  1/50  grain  (0.0013  gm.)  three  times  a  day,  and  Harvey 
Gushing  has  reported  recovery  by  the  application  of  the  tourniquet  or 
rubber  bandage  to  the  affected  limbs  repeated  frequently  during  the  day. 

Progressive  F.\cial  He.miatrophy. 

Synonym — Unilateral  Progressive  Facial  Atrophy. 

Definition. — A  gradual  progressive  wasting  of  the  bony,  muscular, 
integumental,  and  adipose  tissue  of  half  the  face. 

Etiology. — That  it  is  a  trophic  neurosis  can  scarcely  be  doubted.  In 
one  case — that  of  Mendel — which  came  to  autopsy  there  was  the  terminal 
stage  of  a  neuritis  in  all  the  branches  of  the  trifacial.     In  Homen's  case, 


SCLERODERMA  1129 

an  acute  one,  and  perhaps  not  strictly  to  be  regarded  as  an  instance  of 
true  facial  hemiatrophy,  a  tumor  was  found  pressing  on  the  Gasserian 
ganglion  and  trigeminal  nerve,  but  in  similar  cases  of  tumor  of  the  gang- 
lion facial  hemiatrophy  has  not  occurred.  It  has  been  observed  in 
syringomyelia. 

The  disease  usually  begins  in  youth,  but  in  a  few  cases  it  did  not 
make  its  appearance  until  middle  age.  It  is  rather  more  common  in 
the  female  sex.     Sachs  has  collected  97  cases. 

Symptoms. — The  atrophy  is  much  more  frequent  on  the  left  side 
than  on  the  right.  It  may  begin  as  a  circumscribed  spot  on  the  cheek 
or  chin,  or  diffusely,  involving  first  the  subcutaneous  tissue,  the  muscles, 
chiefly  those  of  mastication,  and  finally  the  bones,  especially  of  the  upper 
jaw.  In  the  cases  which  begin  in  early  youth  the  muscles  remain  intact. 
The  tissues  of  the  orbit  take  part  in  the  atrophy,  and  the  eye  appears  sunken. 
The  corresponding  halves  of  the  tongue  and  of  the  soft  palate  are  sometimes 
involved.  The  hair  on  the  same  side  may  fall  out  and  appears  thin.  The 
line  of  demarcation  is  sharp  in  the  median  line.  In  a  few  rare  instances 
the  disease  is  bilateral,  and  in  a  few  cases  also  the  atrophy  involves  the 
corresponding  shoulder  and  arm.     Sensibility  is  intact. 

Diagnosis. — The  disease,  though  very  rare,  can  scarcely  be  confounded 
with  anything  else.  The  facial  asymmetry  associated  with  congenital 
wry-neck  alone  resembles  it.  Striimpell  mentions  a  case  of  facial  hemihy- 
pertrophy  in  a  boy  of  10  under  his  observation.  Hypertrophy  of  one 
side  or  of  one  limb  is  also  a  rare  condition. 

Treatment. — A  suitable  treatment  is  the  application  of  electricity 
to  the  atrophic  side,  alternated  with  massage,  but  it  does  not  promise  much. 


Scleroderma. 

Synonyms. — Cutis  iensa  chronica;  Sclerema;  Dermaiosclerosis;  Glossy  Skin. 

Definition. — A  chronic,  somewhat  diffuse,  indurated,  hide-bound,  and 
pigmented  condition  of  the  skin,  trophoneurotic  in  origin. 

Etiology. — This  is  obscure.  It  is  more  common  in  women  than  in 
men,  and  is  most  frequent  in  early  adult  and  middle  age. 

Pathology. — The  identity  of  scleroderma  and  morphea  is  claimed  by 
some.  We  follow  Louis  A.  Duhring  in  separating  them,  because  both  are 
capable  of  assuming  a  variety  of  forms  which  present  entirely  different 
clinical  features  at  various  stages.  Scleroderma  is  much  rarer  than  mor- 
phea. In  the  matured  forms,  while  the  epidermis  is  unaltered,  there  is 
increase  of  pigment  in  the  lower  layers  of  the  rete,  with  a  distinct  over- 
growth of  connective  tissue  in  the  corium  and  subcutaneous  connective 
tissue.  Contrary  to  what  would  be  expected,  the  sweat  and  sebaceous 
glands  appear  to  be  normal. 

Symptoms. — The  disease  appears  first  in  the  neck,  shoulders,  back, 
chest,  arms,  and  face.  It  begins  usually  as  a  stiffening  of  the  skin  which 
passes  over  into  a  hard,  tense,  unyielding  tissue,  resisting  motion,  and  caus- 
ing fixation  and  flexion.  The  patient  is  literally  "hide-bound."  The 
hand,  with  its  smooth,  glossy  surface,  utterly  without  wrinkles,  is  striking 


1130  DISEASES  OF  THE  NERVOUS  SYSTEM 

and  distinctive.  The  change  may  involve  the  greater  part  of  the  body 
and  even  the  whole  of  it.  When  less  general,  it  is  symmetrical.  The 
condition  passes  insensibly  into  that  of  the  surrounding  healthy  tissue. 
Pigmentation  is  usually  a  later  symptom,  but  may  be  an  early  one. 

There  is  generally  no  constitutional  disturbance  or  other  local  s>Tnp- 
tom,  such  as  pain,  burning,  and  tingling,  but  more  rarely  these  are  present. 
The  evolution  of  the  condition  is  generally  slow,  requiring  weeks  and 
months,  and  when  completed,  it  is  likely  to  remain  unchanged  for  months 
or  years,  or  slowly  passes  away,  leaving  the  skin  normal.  Rarely,  how- 
ever, an  atropic  state  may  succeed,  producing  such  a  shrinking  or  con- 
traction that  the  integument  is  apparently  bound  to  the  bones,  while  over 
the  joints  the  skin  may  become  so  fixed  and  immobile  that  vdcers  and 
excoriations  are  easily  produced. 

Diagnosis. — The  diagnosis  rarely  furnishes  difficulty.  In  some  stages 
it  resembles  morphea,  from  which  it  will  be  distinguished  when  that  subject 
is  considered. 

Prognosis. — This  should  always  be  guarded,  as  the  disease  is  often 
intractable,  though  recovery  sometimes  occurs. 

Treatment. — Treatment  of  a  curative  kind  is  unknown.  The  patient 
should  be  thoroughly  protected  against  cold,  as  he  is  exceedingly  sensitive. 
Friction  with  oil  is  a  rational  means  for  softening  the  skin,  and  may  give 
comfort,  but  does  not  check  the  spread  of  the  disease.  Cod-liver  oil,  iron, 
and  arsenic  are  indicated.  The  constant  electrical  current  has  been  recom- 
mended in  the  local  forms.     X-ray  has  given  sume  benefit  in  one  of  our  cases. 

Morphea. 

Synonym. — Keloid  of  Addison. 

Definition. — A  tropliic,  asymmetrical  neurosis  of  the  skin,  characterized 
by  patches  of  skin  firm  in  texture,  white,  pale  pink,  light  yellow,  or  waxy 
hued,  sometimes  elevated,  at  other  times  depressed. 

Etiology. — More  common  than  scleroderma,  it  is  also  found  more  often 
in  women,  and  at  all  ages.  Its  etiology  is  unknown,  but  its  trophoneurotic 
origin  is  more  than  likely. 

Symptoms. — -The  patches  occur  more  frequently  about  the  breasts  and 
neck  and  sometimes  in  the  course  of  nerves,  such  as  the  intercostal  or 
lumbar,  or  on  the  face  along  the  branches  of  the  fifth  pair.  They  range 
from  2/s  inch  (i  centimeter)  to  four  inches  (10  centimeters)  in  diameter. 
There  may  be  a  preliminary  hyperemia  ■with  itching  of  the  skin  and  in- 
creased pigment  deposit,  or  a  milk-white  leukoderma  from  the  beginning. 
The  spots  are  dry,  without  perspiration,  sometimes  scaly.  Ultimately 
there  may  be  anesthesia,  in  pinkish  or  purplish  hyperemic  spots  or  in  small 
linear  cicatricial-like  areas  which  grow  rapidly.  In  fact,  the  rapidity  of 
spread  of  the  spots  is  one  of  the  most  interesting  clinical  features.  In  the 
later  stages  there  are  often  distinct  atrophy  and  cicatrization  with  pigmen- 
tation. The  spots  may  persist  for  months  or  disappear  in  a  few  weeks, 
and  though  more  frequently  persistent  for  a  long  time,  they  ultimately 
disappear  spontaneously.  Tlie  spots  seem  to  be  the  direct  result  of  a  cutting 
off  of  the  circulation  by  a  narrounng  of  the  blood-vessels .     This  may  be  by 


AINHUM  1131 

compression  by  an  inflammatory  exudate,  but  is  more  likely  to  be  a  vaso- 
motor constriction,  probably  due  to  irritation  of  the  vasoconstrictor  nerves. 

Histologically  there  is  a  condensation  of  the  connective  tissue  of  the 
corium  with  a  shrinkage  of  the  papillary  layer. 

Diagnosis. — Morphea  differs  from  scleroderma  in  that  its  lesions  are 
more  circumscribed,  and  in  an  absence  of  sclerodermic  hardness.  Pig- 
mentation and  cicatrization  usually  appear  only  in  the  later  stages  of 
morphea,  while  they  are  seen  in  the  early  stages  of  scleroderma  before 
there  is  change  in  structure.  Scleroderma  is  symmetrical  in  distribution; 
morphea  is  not.  The  atrophic  striae  seen  in  one  form  of  morphea  closely 
resemble  the  lineae  albicantes  of  pregnancj'  or  other  cause  of  distention. 

Treatment. — That  recommended  in  scleroderma  may  be  expected  to  be 
useful  in  morphea,  especially  arsenic,  which  is  recommended  b}^  Louis 
A.  Duhring.  Here,  too,  the  constant  galvanic  current  is  held  to  be  of 
service,  an  extended  trial  being,  however,  necessary. 

AiNHUM. 

Synonyms. — Ainham;  Quigila;  Suhka  Pakla,   or  Dry  Suppuration;  Pity- 
riasis cethiopius;   Scleroderma  annulare. 

Definition. — A  trophic  disease  resulting  ultimately  in  the  spontaneous 
amputation  of  one  or  more  toes,  especially  the  little  toe,  confined  almost 
exclusively  to  male  negroes. 

Etiology. — It  would  seem  that  a  moist,  sandy  soil  and  warm  climate 
must  have  some  influence  in  its  etiology,  but  nothing  definite  is  known. 
Its  practical  limitation  to  the  colored  race  has  been  referred  to.  The 
operation  of  a  pathogenic  organism  has  been  suggested,  and  the  disease 
as  an  amputating  leprosy.  Traumatism  has  undoubtedly  been  associated 
with  it. 

Symptoms. — Ainhum  begins  as  a  furrow  or  crack  at  the  digitoplantar 
fold,  seen  first  on  the  inner  side.  In  a  few  days  the  toe  will  swell  and 
become  the  seat  of  a  burning,  shooting  pain,  which  may  extend  into  the 
foot  and  leg,  though  pain  is  not  constant.  The  furrow  increases  laterally 
and  in  depth  until  finally  the  toe  is  constricted  and  the  distal  end  becomes 
ovoid.  The  swelling  subsiding,  spontaneous  amputation  ultimately  takes 
place,  a  dry  scab  forms  at  the  furrow,  and  the  case  ends.  It  is  not  always 
confined  to  one  toe,  though  it  is  as  a  rule.  Sensation  is  not  usually  destroyed 
though  it  may  be,  and  the  nail  remains  unchanged.  There  are  no  con- 
stitutional symptoms. 

The  histology  of  the  process  has  been  studied  by  C.  H.  Eyles,  who 
concludes  that  there  is  an  ingrowth  of  epithelium  with  corresponding 
depression  of  surface,  due  to  a  hyperplasia  that,  strangles  the  papillae 
and  cuts  off  the  nourishment  of  the  epithelium  and  causes  it  to  undergo 
horny  change.  The  bone  changes  are  those  of  a  rarefying  osteitis,  pro- 
ceeding from  the  periosteum  inward.  According  to  CoUas,  it  is  an  ampu- 
tating leprosy. 

The  diagnosis  is  easy.     There  is  no  disease  which  resembles  it. 

The  prognosis  is  favorable  as  to  any  danger  to  life.  Its  duration  is 
from  two  to  four  years. 

Treatment  is  unnecessary. 


SECTION  X. 

DISEASES  OF  THE  MUSCULAR  SYSTEM. 

MYOSITIS. 

Infectious  Myositis. 

Definition. — A  rare  form  of  acute  or  subacute  inflammation  of  striated 
muscle,  due  to  unknown  infectious  agencies. 

Morbid  Anatomy. — Several  cases  have  come  to  necropsy.  The  con- 
ditions found  have  been  firmness,  fragility,  and  fatty  degeneration  of  the 
muscle  substance,  with  serous  infiltration  and  hyperplasia  of  the  interfas- 
cicular connective  tissues.  In  another  case  there  was  hyaline  degeneration 
in  varying  degree  without  involvement  of  the  intermuscular  tissue. 

Symptoms. — The  parts  usually  involved  are  the  extremities,  but  the 
disease  may  also  invade  the  trunk -muscles  and  heart.  There  is  swelling 
with  slight  edema,  hardness,  and  stiffness,  making  motion  painful  and  diffi- 
cult. Instead  of  pain  there  is  rarely  paresthesia.  The  s\-mptoms  resemble 
those  of  trichiniasis,  insomuch  that  it  has  been  called  pseudo-trichiniasis. 
In  addition  to  the  symptoms  named  an  erythematous  rash,  irregularly 
scattered  over  the  trunk  and  extremities,  is  regarded  by  Lowenfeld  as 
characteristic.  It  is  sometimes  followed  by  slight  pigmentation.  There 
sometimes  succeeds  an  atrophy  of  groups  of  affected  muscles,  and  Wagner 
suggested  that  some  of  the  cases  may  be  examples  of  acute  progressive 
muscular  atrophy.  Such  cases  are  hardly  fair  examples  of  infectious 
myositis.     The  duration  of  the  disease  is  from  three  months  to  three  years. 

Another  form  of  infectious  myositis  is  acute  purulent  myositis,  some- 
times associated  with  pyemia. 

Progressive  Ossifying  Myositis. 

This  is  a  rare  form  of  myositis,  in  which  the  muscles  undergo  progres- 
sive calcification,  localized  or  extending  over  widespread  areas.  The  dis- 
ease is  more  common  in  males,  and  usually  begins  about  puberty.  It 
occupies  many  years  in  development,  and  consists  in  a  preliminary  inflam- 
matory process,  followed  by  more  or  less  extensive  deposits  of  bony  plates 
throughout  the  muscular  s^'stem,  and  at  times  in  ossification  of  entire 
muscles,  with  fixation  of  joints  and  vertebrffi. 

Treatment. — No  treatment  has  availed  in  any  of  these  forms  of  acute 
inflammation. 

11.32 


*     PROGRESSIVE  MUSCULAR  DYSTROPHIES  1133 

PROGRESSIVE  MUSCULAR  DYSTROPHIES— PRIMARY 
MYOPATHIC  FORMS  OF  MUSCULAR  ATROPHY. 

In  addition  to  the  spinal  or  myelopathic  forms  of  muscular  atrophy 
described  under  nervous  diseases,  there  are  several  varieties  of  muscular 
wasting  which  apparently  reside  in  the  muscles  themselves,  and  which  are 
therefore  strictly  idiopathic.  These  forms  occur  in  the  young,  and  follow 
decidedly  upon  hereditary  disposition.  They  are  all  probably  the  result 
of  a  congenital  tendency  to  defective  development. 

There  are  several  clinical  types  of  primary  muscular  atrophy,  of  which 
the  principal  are : 

1.  Pseudo-hypertrophic  muscvdar  paralysis. 

2.  Erb's  form  of  juvenile  muscular  paralysis  or  the  scapulo-humeral 
form. 

3.  The  facio-scapulo-humeral  type  of  Landouzy  and  Dejerine. 

These  are  all  forms  of  one  disease,  called  by  Erb  progressive  muscular 
dystrophy.  In  very  rare  cases  the  atrophy  has  begun  in  the  distal  portion 
of  the  limbs. 

I.    Pseudo-hypertrophic  Muscular  Paralysis. 

Synonyms. — Pseudo-hypertrophy  of  Muscles;  Lipomatosis  luxurians  niuscu- 
laris  (Heller);  Atrophia  mtisculorium  lipomatosa  (Seidel). 

Definition. — A  state  of  muscular  paresis  associated  -ndth  an  atrophy 
of  the  muscles  involved — an  atrophy  obscured  hy  interstitial  fatty  over- 
growth. 

Etiology. — This  is  especially  an  affection  of  childhood,  and  heredity  is 
an  important  causal  factor,  many  members  of  the  same  familj^  being  some- 
times affected  through  several  generations.  Boys  are  more  frequent  sub- 
jects than  girls,  though  the  disease  is  more  likely  to  be  transmitted  through 
the  mother,  even  though  she  may  not  herself  be  a  subject.  Heredity  is 
not  invariable.  The  disease  usually  begins  before  puberty,  though  some- 
times as  late  as  the  20th  or  25th  year  or  even  later.  Hysteria,  epilepsy, 
feeble  mindedness,  with  an  occasional  anomaly  of  the  skull,  have  been 
observed  in  the  same  families. 

Morbid  Anatomy. — The  nervous  system  is  not  involved  except  in  rare 
cases.  Minutely  examined,  the  muscles  exhibit  marked  differences  in  the 
size  of  the  muscular  fasciculi,  some  being  wider,  many  narrower  than  nor- 
mal, while  there  is  considerable  increase  in  the  adipose  and  connective  tissue 
between  the  fasciculi.     The  fibrillse  themselves  are  not  fatty. 

Symptoms. — The  disease  begins  gradually  with  paretic  symptoms, 
without  the  hypertrophic  appearances  which  are  later  so  pronounced.  A 
child  previously  healthy  exhibits  clumsiness  in  its  movements  and  in- 
security on  its  legs,  being  especially  awkward  in  jumping  and  running 
upstairs.  Then  close  examination  discovers  that  certain  muscles  or  groups 
of  muscles  are  enlarged,  the  calves  of  the  legs  being  especially  conspicuous. 
The  extensors  of  the  leg,  the  glutei,  the  lumbar  muscles,  the  deltoid,  triceps. 
and  infraspinales  next  become  enlarged,  while  the  hands,  arms,  and  neck 
are  rarely  involved,  in  strong  contrast  to  the  spinal  atrophies.     Walking 


1134  DISEASES  OF  THE  MUSCULAR  SYSTEM 

becomes  inore  and  more  difficult,  until  finally  a  diagnosis  may  be  made  from 
the  gait  alone,  which  becomes  waddling,  while  the  shoulders  are  thrown 
back,  the  belly  is  thrown  forward,  the  vertebral  column  being  also  arched 
forward  in  the  lumbar  region,  The  buttocks  stand  out,  and  the  legs  are 
far  apart.  In  walking  the  legs  are  raised  slowly,  the  toes  dropping  from 
paresis  of  the  dorsal  flexors.  Especially  characteristic  is  the  child's  method 
of  rising  from  the  floor.  He  first  gets  on  all-fours,  and  raises  his  trunk  by 
moving  the  arms  along  the  floor.  The  arms  are  then  drawn  toward  the 
legs  until  the  knees  can  be  reached,  when,  with  one  hand  on  the  knee,  he 
pushes  himself  up,  then  grasps  the  other  knee,  and  completes  the  act  of 
raising  himself  to  the  erect  position.  Late  in  the  disease  the  same  paretic 
condition  may  extend  to  the  upper  extremities,  maldng  it  impossible  to 
rise. 

The  enlargement  of  the  muscles  is  due  to  an  interstitial  deposit  of  fat, 
and  as  a  consequence  the  muscles  are  soft  and  flabby  instead  of  hard  and 
firm,  as  in  true  hypertrophy.  Thus  the  hj'pertrophy  is  truly  a  pseudo- 
hypertrophy, the  condition  being  reaUy  one  of  atrophy  of  muscular  sub- 
stance. Along  with  this  may  be  associated  a  genuine  atrophy  of  other 
muscles,  with  loss  of  substance  unassociated  -mth  fatty  infiltration,  espe- 
cially in  the  upper  extremities.  Very  rarely  there  is  a  true  hypertrophy-, 
except  of  individual  muscle-fibers. 

Fibrillar  twitchings  are  rarely  present.  Electrical  excitability  is  dimin- 
ished in  proportion  to  the  destruction  of  muscular  tissue,  but  there  is  never 
a  reaction  of  degeneration  in  a  tj^jical  case.  Sensibility  remains  normal, 
and  the  sphincters  are  intact.  The  patellar  reflex  is  sometimes  absent. 
The  skin,  especially  of  the  legs,  sometimes  presents  a  peculiar  bluish  mot- 
tling. As  a  rule,  the  intelligence  of  the  child  is  preserved,  though  sometimes 
there  is  mental  and  moral  obliquity. 

2.  Erb's  Juvenile  Form  of  Progressive  Muscular  D-vstrophy. 

Synonym. — Scaptdo-hmneral  Form  oj  Muscular  Dystrophy. 

This  type  is  also  commonly  found  before  the  age  of  20,  usually  be- 
tween 15  and  20,  but  its  subjects  are  not  so  young,  as  a  rule,  as  those  of 
the  pseudo-hypertrophic  form.  It  is,  like  all  the  forms  of  muscular  dys- 
trophy, hereditary  in  families  of  which  female  members  are  affected,  while 
the  boys  may  have  pseudo-hypertrophic  paralysis.  It  starts  rather  more 
frequently  in  the  upper  extremities,  the  upper  arms  and  shoulders,  but 
may  begin  also  in  the  back  and  legs.  The  foUo\\ang  are  the  muscles  in- 
volved, according  to  Erb:  In  the  upper  extremities  the  pectoralis  major, 
latissmus  dorsi,  and  later  the  triceps;  while  there  remain  normal,  at  least 
for  some  time,  the  stemomastoid,  the  levator  anguli  scapulse,  the  coraco- 
brachialis,  the  teres  major  and  teres  minor,  the  deltoid,  the  supraspinatus 
and  infraspinatus,  and  the  small  muscles  of  the  hand,  which,  it  will  be  re- 
membered, are  remarkably  wasted  in  myelopathic  atrophy.  The  muscleS 
of  the  forearm,  except  the  supinator  longus,  remain  exempt  for  a  long  time, 
if  not  altogether.  In  the  lower  extremities  the  glutei,  the  quadriceps,  the 
peronei,  and  the  tibialis  anticus  are  aft'ected,  while  the  sartorius  and  calf 
muscles  are  spared  for  a  long  time. 


PROGRESSIVE  MUSCULAR  ATROPHY  1135 

Very  characteristic  is  the  marked  projection  of  the  scapula,  due  to  pa- 
ralysis of  the  serratus.  The  gait  in  this  form  becomes  waddling,  and  walking 
is  ultimately  impossible,  although,  like  its  congeners,  the  progress  of  the 
disease  is  slow,  23  to  28  years  being  the  range  of  duration  of  cases  described 
by  Erb.  Bulbar  symptoms  are  rare,  but  the  diaphragm  may  atrophy  and 
death  be  due  to  respiratory  deficiency. 

The  muscular  changes  are  essentially  atrophic,  though  in  the  beginning 
a  few  of  the  muscular  fibers  may  be  hypertrophied.  The  interstitial  con- 
nective tissue  is  increased,  its  nuclei  proliferated,  and  there  is  no  interstitial 
fat.  The  number  of  muscle  nuclei  is  also  increased,  and  vacuoles  may  be 
seen  in  the  individual  fasciculi. 

3.  The  Facio-scapulo-humeralType. 

This  is  also  a  family  form.  Duchenne  called  attention  to  the  fact  that 
in  certain  children's  palsies  the  muscles  of  the  face  are  involved  in  the 
atrophy,  but  the  fact  was  overlooked  until  Landouzy  and  Dejerine  opened 
the  subject  anew,  and  showed  that  this  event  is  not  infrequent — indeed, 
may  be  the  first  symptom.  This  atrophy  may  begin  later  in  life — say  the 
twentieth  to  thirtieth  year.  In  these  cases  the  eyes  can  no  longer  be  com- 
pletely closed,  and  whistling,  laughing,  and  talking  become  difficult.  An 
appearance  characteristic,  even  diagnostic,  known  as  the  fades  myopathique, 
restdts,  to  which  the  half-closed  eyes,  the  sunken  cheeks,  and  the  tapir 
mouth  contribute.  The  muscles  of  mastication,  the  internal  ocular,  and 
those  of  the  forearm  and  hand  remain  normal.  Fibrillary  contractions  are 
absent,  and  there  is  no  reaction  of  degeneration.  In  other  respects  it  re- 
sembles the  juvenile  form  of  Erb's  palsy,  with  which  it  is  closely  allied. 
From  what  has  been  said  it  is  evident  that  the  three  forms  just  described 
are  modifications  of  one  variety,  a  view  strengthened  by  the  fact  that  two 
or  more  of  the  types  may  be  present  in  the  same  family. 

THE  PERONEAL  TYPE  OF  PROGRESSIVE  MUSCULAR 
ATROPHY. 

Synonym — Progressive  Neural  Muscular  Atrophy. 

This  form  of  atrophy,  described  by  Charcot  and  Marie,  and  indepen- 
dently by  Tooth,  is  met  in  the  second  half  of  childhood,  seldom  after  20.  It 
occurs  also  -in  families,  more  frequently  in  males.  It  begins  in  the  peroneal 
muscles,  involving  also  the  intrinsic  muscles  of  the  foot,  and  may  lead  to 
club-foot,  of  the  variery  pes  equinus  or  pes  equinovarus.  The  upper  ex- 
tremities may  be  affected  after  many  years,  and  rarely  it  begins  in  the  hands. 
It  differs  from  the  other  forms  of  juvenile  atrophy  in  the  presence  of  fibril- 
lary contraction  and  the  occasional  presence  of  the  reaction  of  degenera- 
tion, while  vasomotor  and  sensory  disturbances  may  also  be  present. 

Degeneration  of  the  peripheral  nerves  has  been  found  with  ascending 
degeneration  of  the  posterior  columns,  and  some  change  in  the  lateral 
columns.  Both  the  symptomatology  and  morbid  anatomy  of  this,  so  far  as 
known  from  a  limited  number  of  autopsies,  go  to  show  that  it  is  a  combina- 
tion of  neuritis  and  alteration  in  the  spinal  cord. 

Prognosis  and  Treatment. — These  are  also  essentially  identical  with 
those  of  progressive  muscular  atrophy. 


1136  DISEASES  OF  THE  MUSCULAR  SYSTEM 

AMYOTONIA  CONGENITA. 

GENERAL  OR  LOCALIZED  HYPOTONIA  OF  THE  .MUSCLES  IN  CHILDHOOD. 

Synonyms. — Oppenheim's  disease;  Myatonia  Congenita;  Congenital 
Myohypoto  nia.^ 

Definition. — A  congenital  affection  consisting  in  atrophy  with  corre- 
sponding weakness  of  muscles  (hypotonia  and  atonia),  especially  of  the  ex- 
tremities and  more  of  the  lower;  associated  with  loss  more  or  less  complete 
of  the  tendon  reflexes.  In  advanced  cases  the  weakness  resembles  paralysis, 
but  closer  observation  discovers  feeble  contractions  in  the  muscles  but  not 
sufficient  to  move  the  limbs.  The  muscles  of  the  trunk  and  the  neck  are 
most  rarely  affected,  while  those  of  the  eye,  tongue  and  throat  escape,  as 
does  the  diaphragm,  while  the  intercostal  muscles  may  be  invaded.  The 
electrical  reaction  is  affected  proportionately  to  the  hypotonia.  Intelligence 
and  sensation  are  undisturbed.  Neither  heredity  nor  family  tendency  seems 
to  play  any  part.  Although  always  congenital  the  symptoms  are  not  al- 
ways noticed  immediately  after  birth.  Oppenheim,  who  was  the  first  to  in- 
vestigate it,  believes  the  morbid  change  is  in  the  muscles  which  are  arrested 
in  their  development,  and  thinks  it  has  no  relation  to  muscular  dystrophy. 
He  admits  the  possibility  of  disease  in  the  cells  of  the  anterior  horns  of  the 
cord  whence  it  is,  however,  distinct,  the  latter  developing  acutely  in  a  pre- 
viously normal  child. 

Morbid  Anatomy. — No  case  came  to  necropsy  until  one  described  by 
Spiller"  in  1905  in  which,  however,  no  changes  in  the  nervous  system  were 
found,  but  the  muscles  were  wasted,  in  places  almost  absent,  while  a  large 
amount  of  fatty  connective  tissue  was  present  with  increase  of  its  nuclei. 
The  muscles  presented  also  in  places  a  hyaloid  appearance.  Postmortem 
rigidity  was  delayed.  The  microscopic  examination  showed  arrest  of  devel- 
opment of  the  muscular  fibers,  but  no  change  in  the  central  nervous  sj^stem 
or  peripheral  nerves.  Later  necropsies  have  revealed  alteration  of  the  nerve 
cells  of  the  spinal  cord  but  in  a  few  cases  the  lesions  were  purely  muscular. 

Diagnosis. — Congenital  amyotonia  differs  from  progressive  muscular 
dystrophy  especially  in  the  absence  of  family  tendency,  in  being  congenital, 
and  in  the  absence  of  progressive  increase  in  the  symptoms ;  from  amaurotic 
family  idiocy  in  that  in  the  latter  the  symptoms  increase  and  the  ophthalmo- 
logical  changes  are  pathognomonic.  It  occurs  in  more  than  one  member 
of  a  family. 

Improvement  has  been  obser\-ed  in  some  instances. 

MYOTONIA  CONGENITA. 

Sy'nonym. — Thomsen's  Disease;  Myohypertonia. 

Definition. — A  hereditary  affection,  characterized  by  overdevelopment 
of  muscles  and  by  tonic  cramp  on  attempt  at  voluntary  motion. 

Etiology. — The  disease  is  alwaj's  congenital,  the  symptoms  making 
their  appearance  in  early  childhood  and  in  family  groups,  more  frequently 

1  Oppenheim  suggested  the  name  myatonia.  but  this  word  is  so  like  myotonia  (Thomsen's  disease)  that 
confusion  has  occuried.    Amyotonea  is  used  by  English  authors. 

»  Contributions  from  the  Laboratory  of  Neuropathology,  University  of  Pennsylvania,  for  the  year  1905. 


MYOTONIA  CONGENITA  1137 

in  men.  Cases  of  acquired  myotonia  have  been  observ^ed,  but  these  are 
regarded  as  somewhat  different  from  Thomsen's  disease.  A  few  isolated 
cases  presenting  the  same  symptoms  have  been  described.  It  is  to  be 
regarded  as  a  congenital  anomaly  of  the  muscular  system. 

Morbid  Anatomy. — The  muscles  are  characterized,  especially  in  the 
extremities,  by  voluminous  development  in  strong  contrast  to  their  power. 
In  addition  to  an  obvious  macroscopic  enlargement  there  is  also  found  his- 
tologically an  evident  increase  in  the  volume  of  the  musciilar  fasciciili, 
recognized  by  Erb  and  confirmed  by  Hale  White,  together  with  inter- 
muscular proliferation  of  the  muscle  nuclei  and  moderate  increase  of  the 
connective  tissue  itself.  The  heart  is  exempt,  but  the  diaphragm  may  be 
involved.  There  is  no  lesion  of  the  spinal  cord.  The  only  necropsy  in  a 
case  of  Thomsen's  disease  ever  observed  was  reported  by  Dejerine  and 
Sottas.     The  muscles  were  altered,  but  the  nervous  system  was  normal. 

Symptoms. — The  disease  manifests  itself  at  first  in  childhood  by  a 
stiffness  or  "mild  tetanus,"  in  which  the  relaxation  which  necessarily  pre- 
cedes each  muscular  act  is  delayed.  Voluntary  contraction  takes  place 
slowly  and  with  difficulty.  The  arm  and  leg  muscles  are  involved,  and 
thus  the  child's  play  is  interfered  with.  There  is,  however,  no  paralysis, 
and  after  motion  is  started,  it  proceeds  with  facility.  Prompt,  rapid,  and 
precise  muscular  movements  are,  however,  difficult,  and  miUtary  ser\-ice, 
for  example,  becomes  impossible.  Rarely  facial,  ocular  and  pharyngeal 
muscles  are  involved.  The  condition  is  aggravated  by  cold  and  emotion. 
Sensation  and  the  reflexes  are  normal.     Rarely  there  is  mental  weakness. 

A  peculiar  reaction  of  muscle  and  nerve  to  both  currents  is  developed, 
called  the  myotonic  reaction  of  Erb.  The  motor  nerves  show  quantitatively 
a  normal  faradic  and  galvanic  excitability,  and  all  briefly  acting  stimuli  give 
short  contractions;  but  with  continuous  irritation  by  both  currents  the  con- 
tractions attain  their  maximum  slowly  and  relax  slowly,  while  vermicular 
wave-like  contractions  pass  from  the  kathode  to  the  anode.  The  muscles 
are  also  faradically  easily  excited,  responding  to  a  fairly  strong  current 
always  with  the  above-described  prolonged  contraction.  To  galvanic  irri- 
tation of  muscle  there  is  a  slight  increase  of  excitability,  and  to  somewhat 
strong  currents  the  contractions  are  sluggish,  tonic,  and  continued.  They 
occur  only  with  current  closure  and  not  with  current  opening.  The  mechan- 
ical irritability  of  the  muscles  to  strokes  from  the  percussion  hammer  is 
also  increased. 

Diagnosis.- — If  more  is  needed  than  the  peculiarity  of  the  muscular 
phenomena,  the  electrical  and  mechanical  muscular  reactions  described  are 
characteristic. 

Prognosis. — The  disease  is  incurable,  but  patients  become  accustomed 
to  the  defect  and  conceal  it  as  much  as  possible. 

Treatment. — Nothing  specific  is  known.  Friction  and  massage,  with 
muscular  gymnastics,  are  rational  measures  to  be  recommended. 


SECTION  XI. 

THE  INTOXICATIONS. 

The  intoxications  constitute  a  group  of  diseases  caused  by  the  action  of 
certain  foreign  substances  introduced  from  without,  through  the  digesti\'e 
or  respiratory  tracts  or  through  the  skin.  They  differ  from  the  infections 
in  that  the  toxic  agent  does  not  "increase  after  entering  the  blood. 

ALCOHOLISM. 

Definition. — The  effect  on  the  human  economy  of  the  intemperate  use 
of  alcohol  in  some  of  the  forms  in  which  it  is  used  as  a  beverage.  Such 
effect  is  either  acute  or  chronic. 

Acute  Alcoholism. 

Definition. — This  is  the  condition  known  as  inebriety  or  drunkeness. 
Var^-ing  amounts  of  alcohol  are  required  to  produce  it,  very  small  quantities 
sufficing  to  intoxicate  those  unaccustomed  to  its  use,  while  the  habitual 
drinker  may  consume  large  quantities  wdthout  effect. 

Dipsomania  is  a  term  applied  to  a  state  in  which  there  is  an  inherited 
immoderate  desire  for  alcohol  at  times,  followed  by  long  periods  in  which 
there  is  no  such  desire. 

Morbid  Anatomy. — There  is  no  permanent  anatomical  change  in  acute 
alcoholism,  the  congested  condition  of  the  entire  body  passing  away  with 
the  dnmken  debauch. 

Symptoms. — The  order  of  symptoms  is  not  always  the  same.  More 
frequently  the  primary  effect  is  one  of  excitement,  associated  with  flushed 
face,  bright  eye,  and  loose  tongue.  To  this  succeeds  the  well-known  stag- 
gering gait  of  drunkenness,  which  increases  until  its  subject  is  unable  to 
walk  and  finally  falls  to  the  ground.  The  ready  speech,  at  first  coherent, 
now  wanders  at  random,  and  finally  ceases  altogether.  The  stage  of  nar- 
cosis is  reached,  and  the  drunken  man  breathes  stertorously  in  his  sleep, 
his  face  being  congested  and  his  breath  alcoholic.  He  may,  perhaps,  be 
aroused,  and  may  respond  vaguely  and  incoherently  to  a  question,  but  soon 
drops  off  to  sleep  again. 

Another  subject  in  the  first  stage  is  much  more  excited  and  even  violent, 
and  he  may  cry  out  boisterously,  and  either  spontaneously  or  upon  the 
slightest  provocation  inflict  injury  or  even  commit  murder.  In  other 
subjects,  again,  there  is  no  stage  of  excitement,  and  they  are  morose,  or 
pass  gradually  and  directly  into  stupor.  The  stage  of  inco-ordination 
and  ultimate  stupor  comes,  however,  invariably  if  the  quantity  of  alcohol 
drunk  is  enough  to  bring  it  about.  The  effect  is  upon  the  cortical  nerve 
cells  of  the  brain. 

1138 


ALCOHOLISM  1139 

Other  less  conspicuous  features  are  a  lowered  temperature — 96°  to 
go°  F.  (35.6°  to  32.2°  C).  or  even  lower — involuntary  evacuations  of  the 
bowels  and  bladder,  dilated  pupils,  and  muscular  twitchings.  The  breath- 
ing may  be  slow  and  the  pulse  correspondingly  slow. 

Diagnosis. — The  diagnosis  of  drunkenness  is  usually  easy,  yet  mistakes 
are  not  infrequent ;  it  has  been  mistaken  for  apoplexy  or  apoplexy  with  fracture 
0}  the  skull.  In  the  latter  case  stupor  is  usually  deeper,  and  the  patient 
cannot  be  aroused,  while  the  breathing  is  more  stertorous.  The  subject 
should  always  have  the  benefit  of  the  doubt,  and  resident  physicians  in 
hospitals  will  often  save  themselves  and  the  institution  they  serve  much 
opprobrium  if  they  will  remember  this.  Uremic  coma  developing  with 
convulsions  also  simulates  drunkenness,  and  when  the  existence  of  Bright's 
disease  is  unsuspected,  may  cause  error.  In  such  the  odor  of  alcohol  in 
the  breath  is  wanting,  while  that  of  urine  is  sometimes  present,  although, 
of  course,  a  person  with  nephritis  might  have  an  attack  of  uremic  coma 
after  he  had  been  drinking  alcohol.  In  acute  alcoholism  the  pupil  is 
commonly  dilated.  In  uremia  it  is  variable,  being  sometimes  dilated  and 
sometimes  contracted.  In  all  doubtful  cases  the  urine  should  be  drawn  by 
the  catheter  and  tested  for  albumin  and  the  phthalein  test  used.  In  opium 
posioning,  which  may  also  be  confounded  with  alcoholism,  the  pupils  are 
contracted. 

Chronic  Alcoholism. 

Definition. — This  is  a  condition  of  degenerative  tissue  metamorphosis 
more  or  less  general  which  supervenes  sooner  or  later  in  who  use  alcohol 
habitually  and  intemperately.  Intemperance  does  not  always  imply  the 
consumption  of  the  same  amount  of  alcohol,  smaller  quantities  producing 
harmful  effects  in  some  persons  while  large  quantities  are  apparently  harm- 
less in  others. 

Morbid  Anatomy. — If  we  include  under  this  the  numerous  morbid 
states  which  are  directly  or  indirectly  ascribed  to  the  long-continued  use  of 
alcohol,  such  as  cirrhosis'  of  the  liver,  gastritis,  low  grades  of  meningitis, 
and  the  arterical  changes  so  frequently  ascribed  to  it,  a  large  amount  of  space 
would  be  consumed.  Fortunately,  these  conditions  have  already  been  de- 
scribed as  separate  entities,  and  their  relation  to  alcohol  as  a  cause  has  been 
discussed. 

A  few  words  may,  however,  be  devoted  to  the  consideration  of  the 
effect  of  alcohol  on  the  cellular  elements,  since  it  is  through  such  effect  that 
its  consequences  are  produced.  A  good  while  ago  Lionel  S.  Beale  called 
attention  to  the  destructive  effect  of  alcohol  on  protoplasm.  More  recently, 
in  1894,  Obersohn,  working  in  the  laboratory  of  Gaule,  in  Zurich,  demon- 
strated not  only  that  alcohol,  ether,  and  chloroform  destroy  cellular  proto- 
plasm, but  also  that  the  cells  which  are  the  most  complicated,  so  far  as 
function  is  concerned,  such  as  nerve-cells,  are  the  most  vulnerable.  These 
conclusions  were  confirrned  by  other  experiments,  among  them  Wilkins, 
in  this  country,  in  1895,  and  the  whole  tendency  of  experiment  and  obser- 
vation at  the  present  day  is  to  show  the  degenerative  effect  of  alcohol  on 
elementary  histological  units,  j 


1140  THE  INTOXICATIONS 

Chronic  alcoholism,  like  acute,  predisposes  to  other  diseases.  Its 
direct  effect  is,  as  already  stated,  mainly  on  the  protoplasm  of  cells,  modi- 
fying or  impairing  their  normal  metabolism,  at  times  destro^ang  cells  and 
substituting  them  by  fibroid  material,  at  others  inciting  to  inflammatory 
action;  at  others  still  simply  dcla\'ing  oxidation,  as  in  the  case  of  the  a  dipose 
A'esicle,  whose  fat  remains  unoxidized  because  its  congener,  alcohol,  is  more 
easily  oxidized.  In  some  instances,  as  in  the  case  of  the  liver-cells,  fat  is  de- 
,  posited  in  new  situations  because  it  cannot  be  sufficiently  burnt  up.  Differ- 
ent kinds  of  alcoholic  beverages  also  seem  to  act  differently,  some,  as  gin, 
producing  destruction  of  liver-cells  and  cirrhosis,  while  others,  as  malt 
liquors,  produce  fatty  livers.  Friendwald  in  Welch's  laboratory  caused 
typical  cirrhosis  in  rabbits  by  feeding  them  alcohol  with  degeneration  of 
the  liver  cells.  See  also  section  on  cirrhosis  of  the  liver.  It  is  also  true 
that  persons  addicted  to  intermittent  debauch  are  less  liable  to  inflamma-' 
tory  lesions  than  constant  consumers. 

As  a  consequence  of  irritation  of  the  intima  by  the  alcohol,  arise  endar- 
teritis, sclerosis,  and  thickening  followed  bj'  atheroma  and  fragility.  Irri- 
tation of  nervous  tissues  results  in  meningitis  neuritis  and  cerebritis. 

Thirty  jj-ears  ago  Lancereaux  announced  that  alcoholic  excesses  are 
one  of  the  principal  causes  of  tuberculosis,  affecting  by  preference  the 
back  of  the  right  lung,  while  disease  of  the  left  in  front  is  the  resiolt  of 
insufficient  aeration  or  defective  alimentation;  also  that  such  disease  is 
characterized  by  improvement  and  general  arrest  if  the  patient  leaves  off 
his  habit,  and  by  recurrence  if  he  relapses. 

The  effect  of  alcoholism  on  the  kidney  is  also  two-fold  in  the  direction  of 
contraction  and  enlargement,  the  former  due  to  gradual  destniction  of 
renal  cells  and  tubules  with  substitution  of  interstitial  tissue,  the  latter  to 
fatty  infiltration  and  hypertrophy.  Tyson  has  often  expressed  the  belief 
that  alcohol  is  a  less  frequent  factor  in  causing  interstitial  nephritis  than 
was  formerly  supposed,  because  of  the  facilities  for  its  elimination  in  its 
long  journey  from  the  stomach  through  the  liver  and  lungs  to  the  kidney. 

Symptoms. — These  may  be  classified  to  the  systems  they  invade.  Thus 
we  have  the  effects  of  alcohol  on-  the — 

Nervous  System. — The  most  constant  of  these  is  the  well-known  unsteadi- 
ness— especially  of  the  hands  in  the  performance  of  muscular  actions.  It 
is  also  apparent  in  an  attempt  to  protrude  the  tongue.  Gradual  mental 
deterioration  is  an  inevitable  consequence,  sooner  or  later,  of  chronic  alco- 
holism. It  is  manifested  in  sluggishness  of  intellect,  in  weakness  of  resolu- 
tion, a  loss  of  moral  character,  in  irritability,  restlessness,  and  occasional 
dementia  and  insanity.  Yet  it  is  surprising  how  some  enormous  consumers 
of  alcohol  maintain  tl*ir  mental  acumen  and  ability  to  manage  large  finan- 
cial interests,  while  their  vascular  and  digestive  apparatus  is  e\'idently  the 
seat  of  advanced  degeneration.  When  dementia  and  insanity  are  present, 
they  are  probably  due  to  vascular  degeneration  and  consequent  secondary 
changes  in  the  brain  structure.  The  tendency  of  such  insanity  is  toward 
delusions,  including  suspicion,  distrust,  fear  of  impending  evil,  and,  more 
rarely,  delusions  of  grandeur,  as  in  general  paralysis  of  the  insane. 

Multiple  and  simple  neuritis  is  a  well-recognized  and  almost  character- 
istic symptom  of  chronic  alcoholism,  and  has  already  been  considered. 


ALCOHOLISM  1141 

Pachymeningitis  hemorrhagica  is  sometimes  met.  More  frequent  are 
slight  thickening  and  turbidity  of  the  pia  arachnoid  membrane.  But  this  is 
not  peculiar  to  alcoholism,  being  the  same  as  that  found  in  the  neuroses  of 
insanity. 

A  gradually  deepening  drowsiness  culminating  in  coma,  sometimes  pre- 
sents itself  terminating  fatally  without  the  symptoms  of  kidney  disease.. 
There  may  be  no  changes  in  the  brain  of  one  thus  dying  or  there  may  be  a 
slight  edema  known  as  "wet  brain"  or  in  protractive  cases,  there  may  be 
encephalo-meningitis  with  adhesions  of  the  membranes. 

Digestive  Apparatus.— This  is  a  favorite  point  of  attack  in  alcoholism. 
Chronic  gastric  catarrh  is  one  of  its  most  frequent  consequences,  producing 
loss  of  appetite,  nausea,  constipation,  coated  tongue,  and  foul  breath,  symp- 
toms which  are  always  worse  in  the  morning,  and  are  temporarily  relieved  by 
the  dram  which  the  habitual  drinker  is  apt  to  seek  at  this  time  of  day. 
Autopsy  in  such  cases  may  be  negative  as  to  the  stomach,  or  reveal  the 
changes  described  under  chronic  gastric  catarrh. 

Symptoms  due  to  Liver  Changes.- — -From  these  arise  the  symptoms  due  to 
cirrhosis  and  contraction,  fatty  infiltration,  and  enlargement.  The  inter- 
stitial overgrowth  so  charactertistic  of  cirrhosis  is  probably  secondary  to  a 
primary  poisonous  and  destructive  effect  of  the  alcohol  on  the  cells,  as  con- 
firmed by  the  experiments  of  Weigert,  and  later  by  those  of  Obersohn  and 
Wilkins,  previously  referred  to.  The  compression  of  the  cirrhotic  liver  on 
the  portal  vessels  produces  secondary  effects,  viz.,  hyperemia  of  the  stomach, 
causing  gastric  catarrh;  hyperemia  of  the  rectum,  producing  hemorrhoids; 
and  of  the  esophagus,  pharynx,  and  nasal  mucous  membrane,  resulting  in 
hemorrhage  in  any  one  of  the  localities;  in  dilatation  of  the  venulas  of  the 
face  and  nose,  and  eruptions  on  the  latter,  constituting  the  acne  rosacea  or 
"blossoms,"  by  which  the  toper  is  so  often  marked.  In  many  cases,  on  the 
other  hand,  the  livers  of  hard  drinkers  have  been  found  normal. 

From  vascular  changes  result  cardiac  and  renal  disease,  and  their  symp- 
toms, unequal  distribution  of  the  blood  in  the  brain,  and  consequent  symp- 
toms, viz.,  dizziness,  thrombosis,  apoplexy,  softening. 

Delirium  Tremens,  or  Mania  a  Potu. 

Definition  and  Symptoms. — This  is  a  special  manifestation  of  chronic 
alcoholism,  ascribed  to  the  long-continued  action  of  alcohol  on  the  brain, 
though  its  occurrence  coincides  rather  with  the  sudden  withdrawal  of  the 
drug.  On  the  other  hand,  a  debauch,  however  prolonged,  by  a  person  pre- 
viously temperate,  is  rarely  followed  by  mania  a  potu,  so  that  the  relation  of 
the  illness  to  the  withdrawal  of  alcohol  may  be  more  apparent  than  real. 
Purely  accidental  circumstances  may  determine  the  cessation  from  drinking. 
It  is  very  frequently  an  attack  of  acute  illness,  especially  pneumonia,  to 
which  drunkards  are  especially  predisposed.  The  first  symptom  is  usually 
sleeplessness  associated  with  intense  depression,  or  there  may  be  intense 
restlessness,  during  which  the  patient,  unless  restrained,  will  go  out  of  the 
house  on  some  imaginary  business.  To  this  succeed  hullueinations  of  visions 
as  the  result  of  which  he  imagines  he  is  pursued  by  monsters,  serpents,  rats, 
mice,  and  other  vermin.     The  intense  shivering  terror  of  the  victim  under 


1142  THE  IXTOXICATIOXS 

these  circumstances  is  pitiable,  and  the  "horrors" — a  term  applied  to  the 
disease — is  but  a  feeble  expression  of  the  terrors  of  the  patient.  Frequently 
in  his  attempts  to  escape  these  objects,  he  is  unmanageable,  and  must  be 
confined.  Suicide  is  not  infrequent  with  such  patients.  At  other  times  the 
eager  though  misguided  intelligence  displayed  in  watching  the  imaginary 
objects  is  amusing.  Auditory  hallucinations  may  be  present,  and  unusual 
noises  be  complained  of.  At  the  same  time,  even  though  the  patient  is 
^'iolent,  the  piilse  will  be  found  frequent  feeble,  and  often  irregular.  There 
is  great  muscular  weakness,  as  evidenced  by  the  tremor  which  accompanies 
all  muscular  acts.  There  is  slight  fever,  102°  to  103°  F.  (38.9°  to  39.4°  C), 
which  is  increased  if  there  is  intercurrent  infiammator\-  disease. 

Diagnosis. — This  is  never  difficult.  The  symptoms  somwhat  resemble 
those  of  meningitis,  and  meningitis  is  also  sometimes  present,  but  with  the 
history  of  the  case  and  the  general  appearance  of  the  patient  a  mistake  is  not 
likely  to  be  made.  It  is  most  important,  however,  to  examine  each  case 
thoroughly,  as  pneumonia  is  so  frequently  associated  with  delirium  tremens 
and  constitutes  its  most  serious  danger.  Again  pneumonia  of  the  apex  is 
sometimes  accompanied  by  delirium  similar  to  that  of  deHrium  tremens. 

Prognosis. — If  there  is  pneumonia,  recovery  is  a  rare  event,  but  if  de- 
lirium is  uncompUcated,  recovery  generally  takes  place,  certainly  from  the 
first  attack,  and  generally  even  after  one  or  more  attacks  and  a  duration  of 
from  three  or  four  days  to  a  week.  If  recovery  does  not  take  place,  the 
adynamia  increases,  the  pulse  grows  increasingly  feeble,  the  tongue  dry, 
the  delirium  becomes  muttering,  and  the  patient  dies  with  the  usual  sjTnp- 
toms  of  the  typhoid  state.  The  event  is,  of  course,  more  common  in  hospital 
practice. 

Prophylaxis. — Alcohol  is  a  poison.  It  is  true  that  a  certain  amount  may 
be  burned  as  fuel  when  taken  without  harm  to  the  indi\adual.  There  is  no 
measure  to  that  amount  however  until  mischief  is  done.  The  only  safe  rule 
is  absolute  abstinence.  If  this  were  followed,  the  directions  given  below, 
would  be  unnecessary. 

Treatment  of  Alcoholism. 

Acute  alcoholism  rarely  requires  any  treatment  except  restraint  from  the 
further  use  of  alcohol  and  opportunity  to  sleep  off  the  debauch.  A  full  dose 
of  chloral — from  15  to  30  grains  (i  to  2  gm.) — may  be  necessary  when  there 
is  extreme  excitement.  Morphin  is  indicated,  but  caution  should  be  exer- 
cised in  its  use.  In  cases  where  the  subject  is  not  to  drunk  too  swallow,  a 
dram  (3 . 7  c.c.)  of  aromatic  spirit  of  ammonia  often  acts  happily.  When  there 
is  reason  to  believe  that  alcohol  or  undigested  food  is  in  the  stomach,  the 
stomach  should  be  washed  out,  preferably  with  a  stomach  tube.  Should  it  be 
deemed  desirable  that  an  emetic  be  given  to  one  unconscious,  apomorphin 
hypodermically  administered  is  the  best — from  1/15  to  i/io  grain  (0.0044 
to  0.0066  gm.). 

The  first  step  in  the  treatment  of  chronic  alcoholism  is  the  withdrawal 
of  the  poison.  Except  when  mania  a  potu  is  present,  this  may  be  total. 
Nothing  is  to  be  gained  by  gradual  withdrawal,  while  it  only  prolongs  the 
struggle.  No  drugs  like  morpliin  or  chloral  or  cocain  should  be  used  in 
the  treatment  of  chronic  alcoholism,  as  to  do  so  is  simply  to  substitute  one 


ALCOHOLISM  1143 

evil  for  another  and  to  weaken  the  resohition  of  the  victim.  The  bromids 
may,  however,  be  availed  of,  and  trional,  chloralamid,  and  sulphonal  may 
be  employed  to  procure  sleep.  Not  less  than  15  grains  (i  gm.)  of  any  of 
these  drugs-  should  be  administered  for  an  adult,  while  twice  the  dose 
may  be  necessary.  Hydrobromate  of  hyoscin  is  often  an  admirable 
remedy  to  quite  excitement.  It  may  be  given  in  doses  of  1/96  grain 
(0.0007  gm-)-  Attempts  at  reformation  are  rarely  successful,  but  success 
is  not  impossible.  The  first  and  most  important  element  of  the  treatment 
is  a  comdction  on  the  part  of  the  patient  that  alcohol  in  the  very  smallest 
amount  is  harmful  to  him ;  this  must  be  accompanied  by  a  firm  resolution  to 
resist  the  sometimes  well-nigh,  overwhelming  desire  for  drink,  and  his  will- 
ingness to  be  truthful  and  open  with  his  medical  advisers  and  his  friends ; 
without  this  firm  resolution  almost  any  treatment  is  useless.  Some  means 
of  restraint  is  usually  indispensable,  and  as  a  rule  can  only  be  secured  in  an 
institution.  Unfortunately,  relaxation  of  this  is  apt  to  be  followed  by  a 
relapse.  The  difficulties  increase  in  the  presence  of  hereditary  tendency. 
An  abundance  of  nutritious  food  should  be  insisted  upon,  as  it  is  found  to 
be  the  best  substitute  for  alcohol,  while  tea  and  coffee  may  be  allowed 
freely,  having  the  advantage  of  being  stimulating  without  intoxicating. 
Tonics,  such  as  strychnin  1/30  grain  (0.0022  gm.)  three  or  four  times  a 
day,  or  quinin,  should  be  administered,  none  of  the  specific  treatments. 

As  to  the  remainder  of  treatment,  it  must  be  mainly  sjrmptomatic,  di- 
rected to  the  symptoms  as  they  arise.  Neuritis,  one  of  the  most  important 
of  these,  has  been  elsewhere  considered. 

Still  another  drawback  is  the  intense  depression  which  succeeds  the 
exciting  effect  of  alcohol  and  often  impels  to  a  return  to  its  use. 

Treatment  of  Mania  a  Potu. 

Alcohol  should  as  a  rule  be  immediately  withdrawn.  There  are,  how- 
ever, certain  cases  where  a  weak  pulse  and  dilated  heart  are  improved  by  a 
continuation  of  the  alcohol. 

The  first  indication  after  withdrawal  of  the  alcohol  is  to  secure  sleep. 
For  this  purpose  the  soporifics  previously  named  scarecely  suffice,  though 
they  may  be  tried  in  the  full  doses  specified.  Especially  may  we  hope  to 
obtain  some  results  from  the  hyoscin  in  doses  of  1/96  grain  (0.0007  gm.) 
given  hypodermically.  In  many  cases  of  delirium  tremens  it  is  scarcely 
possible  to  do  without  morphin,  which  may  be  given  hypodermically  in  1/4 
grain  (0.0165  gm-)  doses,  caution  being  observed  not  to  repeat  too  often. 
Chloralose  may  be  given  in  from  5  to  10  grain  (0.33  to  '0.66  gm.)  doses, 
dissolved  in  warm  water;  it  has  the  advantage  of  small  doses,  equal  in  effect 
to  the  largest  of  chloral,  while  in  also  diminishes  tremor  and  has  no  harmful 
secondary  effects.  20  grains  (1.32  gm.)  of  trional,  mixed  in  water,  with 
10  minims  (0.62  c.c.)  of  tincture  of  capsicum,  after  a  calomel  purge  is  useful. 
A  very  hot  bath  is  given,  of  which  the  temperature  is  gradually  lessened. 
If  in  30  minutes  the  delirium  shows  no  signs  of  abatement,  10  grains  of 
trional  (0.65  gm.)  are  again  given.  In  all  cases  forced  feeding  in  small 
quantities  often  repeated  is  practised,  the  diet  consisting  of  milk,  eggs,  and 
soups.  Paraldehyd  in  fluidram  (3.7  c.c.)  doses  is  a  remedy  which  may  be 
expected  to  be  of  service.     A   cold  bath  sometimes  has  a  tranquilizing 


1144  THE  IXTOXICATIOXS 

effect,  especially  if  there  is  fever,  or  sponging  the  body  may  suffice.  .  Many 
things  must  be  done  to  keep  the  patient  occupied,  because,  after  all,  the 
treatment  amounts  for  the  most  part  to  a  conflict  between  the  patient  and 
faithful  attendants  and  the  irrepressible  and,  at  times,  almost  maniacal 
desire  of  the  patient  to  get  away.  In  preventing  this  it  may  sometimes  be 
necessary  to  confine  him  to  bed,  but  all  gentleness  should  be  exercised  in 
carrying  out  this  measure.  It  is  much  better  to  use  a  folded  sheet  than  the 
unsightly  straps  which  are  sometimes  used  in  hospitals. 

With  the  idea  that  the  symptoms  are  due  to  toxic  substances  produced 
within  the  body  by  the  disassimilation  of  alcohol,  purgation  has  assumed 
greater  importance  with  a  view  to  elimination.  For  the  same  reason  diure- 
tics are  advised,  diuresis  as  well. 

As  a  rule  it  is  much  better  to  stimulate  with  the  aromatic  spirit  of  am- 
monium, digitalis,  and  strychnin,  one  dram  (4  gm.)  doses  of  the  first,  10 
minims  (0.62  c.c.)  of  the  second,  and  1/30  grain  (0.00022  gm.)  of  strychnin 
being  given  every  three  hours  to  overcome  such  weakness.  Even  larger 
doses  may  be  demanded  by  emergencies.  Nourishing  food  in  easily  as- 
similable shape,  repeated  at  short  intervals,  shotild  be  insisted  upon  as  the 
best  subsititute  for  alcohol.  With  the  first  sound  sleep  comes,  usually, 
relief  and  the  patient  awakes  convalescent,  unless,  as  already  said,  the 
mania  is  accompanied  by  acute  disease,  like  pneumonia,  when  death  is 
apt  to  be  the  termination,  whatever  our  efforts. 

A  failing  heart  and  insufficient  kidney  secretion  may  be  overcome  by 
hypodermic  injections  of  spartein  and  caffein. 

The  treatment  of  dipsomania  is  most  difficult  because  the  conditions  is 
less  tangible.     It  is  the  previous  condition  that  requires  treatment. 

THE  MORPHIN  HABIT. 
Syono  Y.\is . — Morphinism.     Morphinomania. 

Definition. — An  irresistible  craving  for  morphin,  which  is  commonly 
used  in  gradually  increasing  daily  doses  to  meet  the  demand.  Periodic 
attacks,  or  "morphin  sprees,"  comparable  to  alcohol  sprees,  duiing  which 
large  quantities  are  used  also  occur. 

Etiology. — The  morphin  habit  is  most  frequently-  acquired  as  the 
result  of  long-continued  administration  of  morphin,  to  relieve  some  suffering 
due  to  a  painful  or  incurable  malady  or  for  insomnia.  The  influence  of 
heredity  in  favoring  the  formation  of  the  habit  is  acknowledged.  Neurotic 
persons  are  more  apt  to  become  its  victims.  The  victim  of  alcohol  often 
becomes  a  morphin  fiend,  being  deluded  by  early  experience  with  the  drug 
to  believe  that  he  can  thus  overcome  the  previous  more  disgusting,  if  not 
more  terrible,  habit.  The  same  is  true  of  cocain.  Opium  smoking  such  as 
is  practised  in  the  orient  appears  to  be  less  harmful  than  the  ingestion  of 
opium  by  the  mouth  or  hypodermically. 

The  quantities  consumed  are  often  enormous,  as  much  as  400  grains 
of  opivun  (25.92  gm.)  as  a  daily  dose  being  reported. 

Symptoms. — The  chief  symptom  is,  of  course,  the  craving  jor  mor- 
phin, but  it  brings  with  it  others  which  are  more  or  less  temporarily  re- 
lieved by  a  dose  of  the  drug.     Among  these  are  irresolution  and  loss  oj  self- 


MORPHINISM  1145 

control,  and  a  moral  obliquity  similar  to  that  induced  by  alcohol,  especialh- 
in  women,  who  are  the  most  frequent  subjects.  Untruthfulness ,  especially 
with  regard  to  the  drug  and  the  quantities  used,  is  habitual.  Epigastric 
pain  or  nausea,  or  both,  are  frequently'  complained  of  toward  the  time 
when  another  dose  is  due,  though  whether  this  is  actual  or  feigned  is  not 
always  easily  determined.  Mental  depression  is  a  more  constant  and  char- 
acteristic symptom,  associated  with  intense  anxiety,  restlessness,  and  a  sense 
of  impending  evil,  both  relieved  for  a  time  by  the  dose.  All  of  these  symp- 
toms are  increased  by  a  more  prolonged  withdrawal  of  the  drug,  when 
the  mental  depression  becomes  intense,  sometimes  impeUing  to  suicide 
So  far  from  the  usual  constipating  effort  of  morphin  being  produced  by 
the  drug  thus  used,  diarrhea  is  not  infrequent.  So  too  the  contraction  of  the 
pupil  usually  produced  by  opium  is  substituted  by  dilatation. 

As  the  habit  is  prolonged  tremor,  paresis,  and  more  rarel}'  ataxia  are 
superadded,  while  diffuse  and  neuralgic  pain  is  complained  of.  Sleep  is 
irregular,  digestion  is  bad,  and  appetite  and  nutrition  fail,  the  pulse  becomes 
feeble  and  rapid,  vasomotor  derangements  appear,  as  shown  by  a  tendency 
to  sweating  and  by  dilatation  of  the  pupils.  Except  when  under  the 
direct  influence  of  the  drug  the  patient  grows  weak  and  becomes  a  ready 
victim  to  acute  disease. 

On  the  other  hand  the  opium  eater  sometimes  attains  old  age,  present- 
ing a  wizened,  sallow  appearance  quite  characteristic.  The  pleasurable 
effect  so  often  ascribed  to  opium  is  rarely  reaHzed,  though  it  is  not  un- 
likely that  a  certain  amplification  and  distortion  of  actual  facts  which 
may  arise  in  the  dreamy  state  may  form  the  basis  of  such  weird  and  beau- 
tiful fancies  as  are  pictured  by  DeQuincey. 

Diagnosis  and  Prognosis. — With  an  accurate  history  the  diagnosis  is 
easy,  otherwise  it  is  difficiilt;  but  the  prognosis  is  exceedingly  uncertain 
because  of  the  difficulty  in  carrying  out  treatment. 

Treatment. — Successful  treatment  is  scarcely  possible  outside  of  an 
institution,  and  even  within  one  serious  difficulties  beset  the  way,  the 
chief  of  which  is  the  deception  practiced  by  the  patient.  Patients  should 
be  divested  of  their  o-rti  clothing  and  put  to  bed  in  hospital  garb,  because 
in  this  way  alone  can  we  be  sure  that  morphin  is  not  concealed  about  the 
person.  Whenever  possible,  a  special  nurse  should  be  assigned  to  each  case. 
The  latest  testimony  favors  complete  and  sudden  withdrawal  of  the  drug 
as  ftimishing  a  short  struggle,  though  a  severe  one.  Such  treatment  is 
usually  followed  by  diarrhea,  vomiting,  and  insomnia.  In  most  cases  it  is 
impossible  to  secure  the  consent  of  the  patient  to  sudden  and  complete 
withdrawal,  when  the  gradual  plan  must  be  adopted.  The  success  of  either 
plan  depends  on  securing  effectual  control  of  the  patient,  and  if  this  cannot 
be  obtained,  all  efforts  fail.  Some  counsel  even  that  no  adjuncts  should  be 
employed,  but  certainly  there  can  be  no  harm  in  the  employment  of  general 
tonic  treatment  and  remedies  directed  to  the  irritabiHty  of  the  stomach 
and  torpor  of  the  liver.  A  calomel  purge  is  useful  at  the  start.  It  is  a 
well-established  fact  that,  as  in  alcoholism,  the  patient  should  be  well 
nourished,  given  such  food  as  milk,  cream,  beef-juice,  or  beef  peptonoids, 
rich  broths,  and  beef-tea.  When  there  is  great  asthenia,  aromatic  spirit 
of  ammonium,  strychnin,    and  digitalis  may  be  given  as  directed  under 


1146  THE  INTOXICATIONS 

alcoholism.  If  possible  an  occupation  of  an  absorbing  kind  should  be 
furnished. 

To  promote  sleep,  one  of  the  numerous  hypnotics  in  which  the  present 
day  is  rich  should  be  given.  Chloralamid  is  probably  the  best  of  these. 
It  is  not  easy  of  administration,  because  of  its  pungent  taste  and  diflficidt 
solubility.  Twenty  grains  (1.32  gm.)  or  30  grains  (1.98  gm.)  are  a  moder- 
ate dose,  and  are  easily  soluble  in  a  fluiddram  (3.7  c.c.)  of  a  mixture  of  two 
parts  alcohol  and  one  part  glycerin.  Of  such  solution  two  teaspoonfuls 
should  be  given  in  a  glass  of  sherry  wine  or  four  tablespoonfuls  of  milk  at 
the  ordinary  temperature.  Trional,  sulphonal  or  veronal  may  be  given 
in  from  15  to  20  grain  (0.99  to  1.32  gm.)  doses  dissolved  in  hot  water. 
Hyoscin  in  doses  of  i/ioo  grain  (0.0007  gm.)  may  also  be  tried.  Chloral 
may  be  used  in  doses  of  from  10  to  30  grains  (0.66  to  1.98  gm.).  If 
there  is  cardiac  weakness,  the  dose  should  not  exceed  10  grains  (0.66  gm.). 
Chloralose  may  be  given  in  5  grain  (0.33  gm.)  doses  in  wafers  or  in  hot 
milk. 

Too  much  carelessness  is  practiced  by  physicians  in  placing  morphin 
in  the  hands  of  patients  to  be  used  at  their  pleasure.  The  hypodermic 
syringe  has  wrought  untold  mischief,  and  should  never  be  placed  in  the 
hands  of  patients.  On  the  other  hand,  when  morphin  is  judiciously  ordered 
for  patients  suffering  extreme  pain  only,  it  is  very  rarely  the  case  that  a 
habit  is  established. 

CHLORALISM. 

Definition. — The  chloral  habit  or  the  habitual  use  of  chloral. 

This  habit  is  sometimes  acquired  when  the  drug  is  used  to  obtain  sleep 
or  prescribed  by  the  physician  for  any  purpose. 

Symptoms. — For  symptoms  and  treatment  of  acute  chloral  poisoning 
see  page  11 76. 

The  presence  of  the  chloral  habit  is  characterized  by  nervousness, 
mental  weakness,  and  depression  of  spirits,  even  to  a  degree  of  melancholia. 
There  may  also  be  general  weakness,  characterized  by  muscular  tremor 
and  cardiac  palpitation.  Lowered  temperature  is  characteristic.  These 
symptoms  are  aggravated  by  sudden  •wnthdrawal  of  the  drug.  There  is 
sometimes  dyspnea,  aggravated  at  meals  or  after  exertion.  Mania  and 
dementia  are  reported. 

Various  skin  eruptions  or  a  tendency  toward  them  are  a  symptom. 
Though  there  may  be  no  eruption,  the  slightest  exertion  or  a  glass  of  wine 
will  produce  an  intense  er}i;hematous  redness  on  the  face  and  elsewhere 
on  the  body.  This  erythema,  which  may  also  extend  to  the  mucous  mem- 
branes is  ascribed  to  vasomotor  weakness.  There  may  be  diarrhea  from 
the  same  cause. 

Treatment. — Treatment  requires  the  gradual  -nnthdrawal  of  the  drug 
and  cardiac  stimulation  by  ammonia  and  digitalis,  the  use  of  nutritious 
food,  tonics,  massage,  and  electricity.  For  insomnia  if  needed,  sulphonal 
or  trional,  administered  as  previously  directed,  are  more  suitable  than 
chloralamid.  In  extreme  cases  morphin  maj''  be  used.  It  is  not  usually 
difficult  to  master  the  habit. 


COCAINISM  1147 


COCAINISM. 


Cocainism  has  become  a  comparatively  frequent  modern  habit.  It  is 
especially  common  among  physicians,  some  of  whom  acquire  the  habit  in 
tentative  local  applications  to  their  own  mucous  membranes  in  the  treat- 
ment of  patients.  We  have  known  three  successive  chiefs  of  clinic  in  throat 
and  nose  dispensary  service  to  acquire  the  habit.  Cocain  is  also  taken  as 
a  substitute  for  some  other  drug,  and  its  subjects  are  very  apt  to  be  those 
with  neuropathic  tendencies.  It  is  usually  snuffed,  frequently  in  the  form 
of  one  of  the  powders  on  the  market  for  the  relief  of  coryza. 

Symptoms. — The  effect  is  a  total  demoralization  of  the  individual, 
who  loses  all  moral  responsibility,  delaying  and  neglecting  appointments 
in  the  most  remarkable  manner.  There  is  volubility  of  tongue,  suggesting 
alcoholism,  and  the  presence  of  hallucinations,  which  also  resemble  those 
of  the  alcoholic  effect.  The  eyes  are  bright,  and  the  pupils  are  dilated. 
The  subject  becomes  suspicious,  charging  his  wife  with  infidelity,  and 
his  best  friend  with  persecuting  him.  Hallucinations  of  hearing,  sight, 
and  smell  are  sometimes  present,  including  tinnitus  auriimi.  Mild  epilep- 
toid  seizures,  with  partial  loss  of  consciousness,  may  occur,  limited  to 
muscle  groups,  as  about  the  eyes.  Nystagmus  is  also  a  symptom.  The 
pulse  becomes  weak- and  feeble.  The  symptoms  are  often  associated  with 
those  of  alcoholism  and  opium. 

A  symptom  to  which  a  certain  amount  of  diagnostic  value  has  been 
attached  is  a  sensation  of  foreign  bodies  under  the  skin.  In  one  case 
observed  by  Rybakoff  of  Moscow,  was  a  sensation  as  of  worms  beneath 
the  skin.  The  recognition  of  the  sjTnptom  is  ascribed  to  M.  Magnan  of 
Paris. 

Treatment. — The  sale  of  combinations  of  cocaine  to  the  public  should 
be  prohibited.  If  the  habit  be  uncomplicated,  treatment  is  promising.  It 
mainly  requires  withdrawal  of  the  drug,  which  should  be  total.  The  as- 
sistance of  a  trusty  nurse  or  friend  is  essential,  but  it  is  not  often  necessary 
to  remove  uncomplicated  cases  to  a  sanatorium.  Cases  complicated  with 
alcoholism  or  the  opium  habit  are  more  difficult  to  handle,  and  incarcera- 
tion in  an  institution  becomes  necessary. 

Tonics  of  the  usual  kind — strychnin,  in  full  doses,  and  quinin — should 
be  ordered.  Non-intoxicating  stimulants,  like  ammonia  and  coffee,  should 
be  given  to  counteract  the  depressing  effect,  while  good,  nourishing,  easily 
assimilable  food  is  necessary. 

LEAD-POISONING. 
Synonyms. — Colica  pictonum;  Plumbism;  Saturnism; Devonshire  Colic. 
Definition. — A  disease  of   manifold  symptoms  resulting  from  the   toxic 
effect  of  lead  on  the  system,  having  its   subjects   mainly  among  workers 
in  lead-works,  and  among  painters,  glaziers,  and  plumbers. 

Etiology. — The  lead  enters  the  system  by  inhalation,  through  the 
digestive  tract,  or  by  the  skin.  Almost  without  exception  the  cases  we 
have  had  in  hospital  were  from  the  lead-works  in  the  neighborhood  of 
Philadelphia.     The  Philadelphia  Hospital  is  almost  never  without  one  or 


1148  THE  rxToxrcirioxs 

more  such  cases.  Water  which  has  been  kept  in  lead  tanks,  or  even 
painted  tanks,  or  water  passed  through  lead  pipes,  has  produced  the  dis- 
ease. It  must,  however,  be  very  pure  water,  such  as  rain  water,  and  it 
is  the  very  impurities  of  our  drinking-waters  which  protect  us.  Almost 
all  drinking  waters  contain  sulphate  of  lime,  the  sulphuric  acid  of  which 
combines  with  the  superficial  layer  of  lead  and  forms  an  insoluble  coating 
of  sulphate  of  lead  which  prevents  further  solution. 

Accidental  contamination  has  been  caused  by  the  use  of  cosmetics 
and  hair  dyes.  To  the  use  of  chrome  yellow  as  a  substitute  for  eggs  for 
coloring  were  traced  a  number  of  cases  occurring  in  Philadelphia -in  a 
very  interesting  study  by  D.  D.  Stewart.*  Even  vegetables  canned  in  tin 
vessels  are  held  to  have  produced  lead-poisoning.  But  the  best  manu- 

facturers now  up  safe  canned  goods. 

Among  the  more  rare  cases  of  lead-poisoning  may  be  named  materials 
used  in  making  rag  carpets,^  cooking  in  badlj^  glazed  crockery-ware,  beer 
drawn  through  lead  pipes,  or  beer,  cider,  and  wine  from  bottles  which  have 
been  washed  with  shot  of  which  some  have  been  left  behind,  the  use  of 
snuff  packed  in  spurious  tin-foil  containing  lead,  and  from  sleeping  on 
mattresses  the  hair  in  which  was  dyed  black  by  some  lead-containing  sub- 
stance; and  one,  a  most  incredible  case,  mentioned  b}^  Naunyn,  is  that 
of  a  proof-reader  who  was  poisoned  after  many  years'  reading  of  printed 
proof.  Notwithstanding  the  solubility  of  the  acetate  of  lead  so  much  used 
in  medicine,  it  is  very  rare  that  poisoning  has  resulted  from  its  adminis- 
tration, and  there  need  be  no  fear  of  using  it  for  the  purposes  in  which  it 
is  indicated  until  at  least  2  drams  (7.4  gm.)  have  been  given.  Cases  of 
poisoning  by  lead  administered  as  a  medicine  are  reported  by  Taylor  and 
other  toxicologists.  Osier  tells  of  four  cases  at  Johns  Hopkins  Hospital 
following  the  use  of  lead  and  opium  pills  for  dysenterj'.  To  these  J. 
Milton  Miller  has  added  two  interesting  instances  and  reviewed  others.' 

That  the  lead  itself  lodges  in  the  tissues  is  easy  of  demonstration,  and 
analysts  have  gone  so  far  as  to  determine  the  exact  quantity  in  the  different 
tissues  of  animals  poisoned  by  lead;  which,  by  the  way,  is  surprisingly 
small,  tlfe  largest  amount  found  being  1/4  of  one  per  cent,  in  the  bones, 
while  that  in  the  muscles  was  but  2/1000  to  3/1000  of  one  per  cent.  On  the 
other  hand,  it  would  seem  that  lead  is  contained  in  the  tissues  of  many  per- 
sons who  are  healthy — according  to  J.  J.  Putnam,  in  25  per  cent. 

Most  cases  occur  among  adults,  usually  between  the  ages  of  30  and  40, 
but  in  children  occasionally.  Women  are  said  to  be  more  predisposed  than 
men,  as  four  to  one,  and  to  be  more  readily  brought  under  its  influence.  Yet 
one  seldom  sees  a  case  of  lead-poisoning  in  women,  because  they  are  less 
frequentlj''  exposed  to  the  cause. 

The  period  of  exposure  necessary  to  produce  lead-poisoning  varies 
greatly,  from  a  month  or  less  to  many  years. 

Morbid  Anatomy. — This  is  not  striking.  Tissue  may  contain  a  con- 
siderable amount  of  lead  without  exhibiting  changes.  Fatty  degeneration 
and  fibrosis  are,  however,  characteristic.  Thus,  the  muscles  become 
fatty  and  fibroid.     The  kidneys  gradually  lose  their  parenchymal  cells 

'  "Philadelphia  Med.  News,"  June  l8  and  December  21.  1887. 

'  A  very  interesting  case  thus  caused  is  reported  by  J.  Milton  Miller  and  G.  Oram  Ring  :n  the  "  Amer. 
Jour,  of  the  Med.  Sciences"  for  February,  p.  193,  1896. 

'  Lead-poisoning  from  the  therapeutic  use  of  lead-acetate  in  capsules  with  a  report  of  two  cases.  ' '  Thera- 
peutic Gazette,"  Aug.,  1904. 


LEAD  POISONING  1149 

and  become  fibroid,  wiiile  nerves  exhibit  fatty  degeneration.  In  the 
spinal  cord  are  found  in  chronic  lead-poisoning  the  changes  characteristic 
of  anterior  poliomyelitis — i.  e.,  sclerosis  of  the  anterior  comua,  with 
atrophy  of  the  cells  and  nerve  fibers,  but  the  remainder  of  the  cord  and 
nerve-roots  are  not  altered.  Demonstrable  changes  in  the  central  nervous 
system,  even  when  there  are  symptoms  of  lead  encephalopathy,  are  not 
numerous.  In  32  out  of  71  cases  Tanquerel  found  none.  Von  Monkalow 
discovered  a  high  degree  of  atrophy  of  the  cortex,  especially  marked  over 
the  frontal  region  at  the  vertex,  and  in  the  crura  cerebri.  Small  hemor- 
rhages in  various  parts  of  the  brain  and  atheroma  of  the  arteries  have  been 
noticed;  also  overgrowth  of  connective  tissue.  Severe  enterocolitis  has 
been  found  in  acute  cases.     Arterio  sclerosis  is  common. 

Symptoms. — While  the  sj^mptoms  which  make  known  the  presence  of 
lead-poisoning  are  at  times  rapid  in  their  development  and  at  others  slow 
to  appear,  there  seems  on  this  account  scarcely  sufficient  reason  for  di\'iding 
them  into  two  classes  of  acute  and  chronic. 

The  most  striking  of  the  symptoms,  and  often  the  first  to  which  at- 
tention is  called,  is  colic.  Indeed,  it,  with  constipation,  next  to  be  con- 
sidered, is  often  the  sole  manifestation  of  the  disease,  and  from  these  two 
alone  a  diagnosis  may  be  considered,  after  exposure  to  lead  absorption. 
The  terna  lead  colic  has  long  been  a  recognized  term  in  medical  terminologj-. 
The  pain  is  most  frequent  in  the  region  of  the  iimbilicus,  and  is  often  relieved 
by  pressure.  It  varies  greatly  in  degree,  being  sometimes  a  simple  grumb- 
ling pain,  at  others  of  extreme  severity,  the  patient  writhing  in  the  par- 
oxysm. This,  as  a  rule,  does  not  last  long,  but  is  soon  followed  by  another. 
On  the  other  hand,  it  may  continue  for  hours  or  until  relief  is  afforded 
by  treatment.  It  is  probably  due  to  powerful  contractions  of  the  mus- 
cular wall  of  the  intestine,  by  which  the  nerve  filaments  distributed  through 
it  are  compressed.  As  contrasted  with  flatulent  colic,  the  abdomen  is  not 
distended,  but  flat,  and  may  even  be  contracted,  sometimes  so  much  so 
that  it  is  said  that  the  vertebrae  may  be  discerned  through  the  abdominal 
walls.  Yet  distention  of  the  abdomen  is  occasionally  present.  The  pulse 
during  the  attacks  of  colic  is  often  strikingly  slowed,  having  been  noticed 
as  infrequent  as  30  beats  in  a  minute. 

Groups  of  muscles  anj^where,  and  especially  the  flexor  muscles,  as  of 
the  arms  and  legs,  become  involved  in  cramp,  the  latter  more  frequently. 
There  may  also  be 'cramps  in  the  fingers  and  toes.  In  addition  to  these 
painful  cramps,  which,  like  the  colic,  are  intermittent,  there  is  pain  in  the 
neighborhood  of  the  joints.  The  sum  of  these  painful  joints  and  muscles 
has  received  the  name  arthralgia  saturnina.  They  are  quite  frequent,  oc- 
curring, according  to  statistics  of  Tanquerel,  in  755  out  of  2151  cases. 

Constipation  is  very  common,  even  more  commonly  present  than  the 
colic,  and  yet  it  is  not  invariable,  and  may  even  be  substituted  by  diarrhea. 

A  blue  line  on  the  patient's  gums  is  a  very  characteristic  symptom, 
and  appears  at  the  border  of  contact  of  the  gums  with  the  teeth,  or  just 
above  it.  ■  As  a  rule,  it  is  easily  recognized  when  present.  It  is  caused 
by  the  presence  of  sulphuret  of  lead,  produced  by  the  action  of  sulphureted 
hydrogen  upon  the  lead  in  the  tissue  of  the  gums.  Hence  the  line  is  more 
common  and  distinct  on  the  gums  of  those  who  take  no  care  of  the  mouth, 


1150  THE  LXTOXICATIONS 

and  in  whom  sulphureted  h^-drogen  is  generated  in  the  decomposition  of 
the  food.  This  line  often  remains  after  all  other  symptoms  have  subsided, 
and  although  it  is  not  invariably  present,  its  disappearance  may  be  con- 
sidered as  quite  a  certain  sign  that  the  lead  has  been  practically  eradicated. 

Anemia  is  a  very  constant  symptom  in  lead-poisoning,  and  its  higher  de- 
grees are  attended  by  a  sallowness  which  early  gave  rise  to  the  term  icterus 
saiurninus,  but  which  is  in  no  way  due  to  a  deposit  of  bile  pigment.  In 
more  serious  cases,  too,  the  impaired  nutrition  results  in  an  emaciation 
which  is  sometimes  extreme.  Along  with  the  anemia  there  is  often  loss 
of  appetite,  and  frequently  a  sweetish  taste  and  fetid  breath. 

Degeneration  of  the  Red  Cells. — Comparatively  recent  studies  have  found 
associated  with  lead-poisoning  in  common  with  other  toxic  conditions  a 
granular  degeneration  of  the  erythrocytes.  The  granular  change  which 
responds  to  the  basophilic  stains  was  first  investigated  by  Geelmyden, 
Hansemann,  Von  Noorden  and  others,  but  Grawitz  was  the  first  (1889) 
to  lay  particular  stress  on  the  condition  as  evidence  of  a  special  form  of 
degeneration.  It  would  appear  from  the  recent  studies  of  Alfred  Stengel, 
C.  Y.  White  and  Wm.  Pepper,  sd,^  that  no  poison  thus  far  studied  is  as 
regular  in  its  production  of  degeneration  or  as  prompt  in  its  action  as 
lead.  Cadwallader  has  also  shown  the  occasional  occun-ence  of  nucleated 
red  corpuscles  in  the  blood  of  lead-poisoning. 

Another  symptom  of  great  importance  is  muscular  paralysis,  which 
may  be  localized  or  general.  The  localized  palsies,  in  contrast  with  muscular 
cramp,  are  more  likely  to  involve  extensor  muscles  than  flexors,  and  espe- 
cially those  of  the  wrist,  giving  rise  to  the  very  characteristic  symptoms 
known  as  "wrist-drop,"  which,  in  Tanquerel's  experience,  occurred  in  107 
out  of  2151  cases.  Usually  it  is  not  until  the  colic  and  arthralgia  present 
themselves  that  the  paralysis  appears.  On  the  other  hand,  it  has  been 
the  first  symptom  observed.  It  may  last  but  a  few  days,  or  it  maj^  resist 
all  treatment.  It  may  affect  a  single  muscle  or  groups  of  muscles.  It 
is  further  characterized  by  the  fact  that  the  muscles  affected  are  subject 
to  rapid  and  extreme  atrophy,  so  that  they  seem  almost  to  disappear.  Dis- 
locations of  the  more  movable  joints,  as  the  shoulders  and  phalanges,  may 
occur  in  consequence.  While  sensibility  is  but  slightly  impaired,  electro- 
muscular  contractility  rapidly  disappears.  The  muscles  cease  to  respond 
to  the  faradic  current,  while  the  reaction  to  galvanism  is  unchanged  or 
slightly  increased  at  first. 

The  palsies  of  lead-poisoning  are  due  to  neuritis  which  may  also  be 
acute. 

The  localized  forms  of  lead  palsy  are  divided  by  Madame  Dejerine- 
Klumpke  in  her  masterly  monograph^  into  the  following  groups : 

I.  The  antibrachial  type,  the  most  frequent  of  all  forms,  and  in  which 
the  musculo-spiral  nerve  is  involved,  producing  paralysis  of  the  extensors 
of  the  fingers  and  the  characteristic  wrist-drop,  the  supinator  longus  usually 
escaping.  As  the  result  of  the  prolonged  flexion  of  the  wrist  there  may 
be  slight  displacement  backward  of  the  ends  of  the  bones  with  distention 


'"Further  Studies  of  Granular  Degeneration  of  Erythrocytes,"  "American  Journal  of  the  Medica 
Sciences,"  May,  1902.  t^  .    . 

"  Des  Polyndorites  en  general  et  de  Paralysies  et  Atrophies  Saturnines  en  particuliar  par  MadameDejenne 
Klumpke,  Paris,  1S90. 


LEAD  POISONING  1151 

of  the  synovial  sheaths  'producing  the  so-called  Gruebler's  tumor  over  the 
wrist . 

2.  The  superior  or  brachial  type  involving  the  deltoid,  the  biceps,  the 
brachialis,  the  supinator  lo'ngus  and  rarely  the  pectoralis.  It  is  much 
rarer  than  the  anti-brachial  type.  The  atrophy  is  of  the  scapula-humeral 
type  and  is  commonly  bilateral.  It  may  be  primary  or  secondary  to  the 
first  form. 

3.  The  Aran-Duchenne  type  in  which  the  small  muscles  of  the  hand 
and  the  thenar  and  hypothenar  muscles  are  involved  producing  a  paralysis 
like  that  of  the  early  stage  of  polio-myelitis  anterior.  This  group  seems  to 
be  always  primary  and  may  be  the  first  manifestation  of  lead  intoxication. 

4.  The  peroneal  type  in  the  lower  extremities  producing  foot-drop 
and  steppage  gait,  due  to  paralysis  of  the  peroneal  muscles,  of  the  common 
extensor  of  the  toes  and  of  the  extensor  proprius  of  the  great  toe. 

5.  Laryngeal  form  invading  the  adductor  muscles  of  the  larynx  as 
noted  by  Morell  MacKenzie. 

In  the  generalized  palsies  the  invasion  may  be  gradual,  beginning  in 
the  wrist  and  ankles  and  extending  gradually  over  the  body,  or  it  may 
extend  rapidly  becoming  complete  in  a  few  days. 

The  central  nervous  system  may  also  be  invaded  by  lead-poisoning. 
Occurring  usually  in  those  who  are  peculiarly  exposed.  The  symptoms  come 
on  in  from  eight  days  to  50  years,  the  majority  showing  themselves,  ac- 
cording to  Tanquerel,  within  the  first  nine  months.  The  most  frequent 
mode  of  manifestation  is  in  eclampsia  independent  of  Bright's  disease. 
True  epilepsy  may  follow  these  convulsions.  But  there  may  be  headache 
or  amaurosis,  optic  neuritis,  apathy,  stupor,  or  the  opposite  condition  of 
maniacal  excitement  or  melancholia  and  hallucinations.-  In  a  few  cases 
of  lead-poisoning  the  symptoms  are  limited  to'  the  central  nervous  system — 
in  72  out  of  1390  cases  observed  by  Tanquerel.  Tremor  of  the  paralyzed 
muscles  is  a  frequent  nervous  system. 

A  frequent  complication,  more  especially  when  it  has  been  present 
for  some  time,  is  interstitial  nephritis,  and  its  resulting  morbid  product,  the 
contracted  kidney,  as  shown  by  the  presence  of  a  small  degree  of  albu- 
minuria and  hyaline  tube-casts;  and  as  this  is  the  form  of  kidney  disease 
in  which  uremic  convulsions  are  most  frequent,  it  is  evident  that  these 
must  be  distinguished  from  the  convulsions  just  referred  to  as  part  of 
saturnine  encephalopathy.  Hence  an  examination  of  the  urine  in  every 
case  should  be  early  made  in  the  study  of  the  case.  Arteriosclerosis  is  often 
a  direct  result  as  weU  as  hypertrophy  of  the  heart. 

Prognosis. — As  to  prognosis,  it  depends  largely  upon  the  degree  of 
saturation  of  the  system  with  lead.  Ordinary  lead  colic  is  commonly 
followed  by  recovery.  As  a  rule,  therefore,  persons  who  respond  most 
quickly  to  the  action  of  the  poison  are  those  who  most  promptly  recover, 
provided,  of  course,  they  are  removed  from  the  influence  of  the  lead, 
for  such  persons,  too,  being  most  suspectible,  are  in  great  danger  from 
prolonged  exposure.  We  are  enabled  to  infer  something  of  the  prognosis 
from  the  symptoms  which  are  present.  If  the  attack  be  ushered  in  by  a 
colic,  and  there  be  no  other  symptoms  except  constipation,  and  a  lead  line 
on  the  gums  we  may  confidently  expect  our  patient  to  recover  completely. 


1152  THE  INTOXICATIONS 

If  there  be  arthralgia  and  palsy,  the  prospect  is  less  certain,  still  less  so  if 
there  be  atrophy,  and  least  of  all  if  there  be  encephalopathy,  though  even 
here  recovery  may  take  place.  Contracted  kidney  due  to  lead-poisoning  is 
also  usually  incurable.  No  favorable  prognosis  should  be  given  when  the 
patient  is  unable  to  remove  himself  from  the  cause.  It  must  be  remem- 
bered, too,  that  relapses  occur,  often  at  long  intervals,  even  when  the 
patient  is  removed  from  exposure,  and  that  the  primary  disease  has  been 
known  to  make  its  appearance  a  long  time  after  exposure.  As  a  matter  of 
fact  Wiclcham  Legge  collected  264  cases  of  persons  who  died  with  symptoms 
of  plumbism  in  32  of  whom  the  cause  of  death  was  some  excephalopathy, 
in  43  Bright's  disease,  in  47  cerebral  hemorrhage,  in  43  paralysis,  44  lead- 
poisoning,  38  phthisis  and  40  pneumonia,  heart  disease,  aneurysm  also  oc- 
curred. There  is  an  absence  of  precision  in  the  above  as  where  deaths  are 
said  to  have  been  due  to  encephalopathy,  cerebral  hemorrhage  and  paraly- 
sis, but  the  data  help  us  to  a  conception  of  the  prognosis. 

Treatment. — Much  may  be  done  to  guard  against  the  occurrence  of 
lead-poisoning  by  proper  precautions  on  the  part  of  those  exposed  to  it, 
and  those  employed  in  lead-works  may  do  much  to  protect  themselves, 
or  rather  their  employers  may  do  it  for  them.  Such  persons  should  keep 
themselves  scrupulously  clean  by  frequent  hot  baths  and  frequent  changes 
of  clothing,  which  should  never  be  allowed  to  become  saturated  with 
lead.  Mehu  recommends  that  hypochlorite  of  sodium  be  added  to  the 
hot  baths.  It  is  made  by  mixing  in  2  1/2  gallons  (10  liters)  of  water 
13  ounces  (400  gm.)  of  chlorinated  lime  mth  11  drams  (43  gm.)  of  sodium 
carbonate.  Sulphur  baths  were  recommended  by  Todd,  it  being  thought 
that  sulphur  has  the  power  of  neutralizing  lead  by  forming  insoluble 
compounds  with  it.  From  2  to  4  ounces  (62.5  to  124.5  g"^-)  oi  sulphuret 
of  potassium  are  mixed  in  from  20  to  30  gallons  of  water  (75.5  to  113. 4 
liters).  Above  all,  the  employees  in  lead-works  should  not  be  allowed  to 
eat  meals  in  the  lead  factory,  as  the  metal  is  often  introduced  with  food. 
Finally,  the  ventilation  of  the  factory  should  be  of  the  best.  Experience 
has  shown  that  much  may  be  done  to  arrest  the  dangers  of  lead-works 
by  such  precautions.  The  same  remarks  as  to  cleanliness,  bathing,  and 
change  of  clothing  apply  to  painters,  and  indeed  to  aU  who  have  to  do  with 
lead  in  any  .shape  or  degree.  It  is  evident  that  lead-lined  and  painted 
cisterns  should  never  be  used  in  houses,  that  cosmetics  and  hair-dyes  are 
dangerous,  and  that  care  should  be  taken  in  the  selection  of  canned  foods 
not  to  use  those  which  have  been  too  long  canned. 

The  curative  measures  may  be  divided  into  those  for  the  immediate 
relief  of  urgent  symptoms  and  the  removal  of  the  lead  from  the  system. 
It  is  scarcely  necessary  to  say  that  the  patient  should  be  promptly  removed 
from  the  influence  of  the  lead.  The  extreme  pain  of  the  lead  colic  re- 
quires to  be  relieved  by  the  hot  bath  or  poultice,  and  an  opiate,  of  which 
the  best  mode  of  administration  is  by  the  hypodermic  syringe,  1/4  to  1/3 
grain  (0.016  or  0.02  gm.)  of  sulphate  of  morphin  being  required  for  the 
purpose.  Identical  treatment  is  required  for  the  arthralgia.  The  ac- 
companying constipation  is  best  relieved  by  sulphate  of  magnesium, 
the  sulphuric  acid  of  which,  on  theoretical  grounds,  at  least,  aids  in  render- 


ARSENICAL  POISONING  1153 

ing  inoperative  the  lead  which  entered  the  system  by  forming  an  insoluble 
sxilphate. 

These  more  urgent  symptoms  being  relieved,  measures  directed  to 
the  elimination  of  the  lead  should  be  taken.  The  hot  baths  already  referred 
to  fulful  this  purpose  as  well  as  prophylaxis,  while  purgatives  and  diuretics 
may  aid  elimination.  The  iodid  of  potassium  is  the  remedy  most  relied 
upon  to  eliminate  lead.  It  is  believed  that  after  its  absorption  the  lead 
becomes  intimately  united  with  the  albumin  of  the  tissues,  forming  an 
insoluble  compound;  that  the  iodid  of  potassium,  after  its  absorption, 
combines  with  the  lead  and  forms  a  soluble  iodid  of  lead,  which  is  dissolved 
out,  re-enters  the  circxilation,  and  is  passed  out  with  the  urine  and  feces.  It 
is  evident  that  elimination  by  these  channels  will  be  encouraged  by  purga- 
tives and  diuretics.  Iodid  of  potassium  should  be  given  in  ten  grain  doses 
three  times  a  day  is  the  proper  dose  and  this  dose  should  be  kept  up  until 
the  patient  is  relieved.  Iodid  of  potassium  is  more  efficient  when  given 
fasting  and  freely  diluted.     The  use  of  Fel  Bovis  in  3  grain  doses  is  valuable. 

For  the  paralyzed  muscles  faradic  electricity  is  indicated  and  should 
be  daily  applied,  both  to  resist  the  tendency  to  atrophy  and  to  overcome  it. 

That  restorative  and  blood-making  remedies,  in  the  shape  of  nutri- 
tious, easily  assimilable  food,  together  with  iron,  should  also  be  given  to 
antagonize  the  cachexia  which  is  always  a  part  of  plumbism  is  evident. 
In  view  of  the  nervous  and  muscular  symptoms  which  enter  so  largely  into 
the  disease  strychnin  may  be  expected  to  be  a  useful  adjunct  or  our  treat- 
ment, and  it  is  generally  so  considered.  It  should  be  given  in  full  doses, 
1/30  grain  (0.0022  gm.)  three  times  a  day,  and  increased  to  1/20  grain 
(0.0033  gm-)  >  which  should  be  kept  up.  Ergot  is  said  to  have  been  usefiil  in 
restoring  the  power  of  muscles  involved  in  the  palsy. 

ARSENICAL  POISONING. 

Acute  Arsenical  Poisoning. — Acute  arsenical  poisoning  is  usually 
the  result  of  accidental  or  intentional  ingestion  some  commercial  form  of 
arsenic  such  as  Paris  green  or  "Rough  on  Rats,"  prepared  and  sold  for  the 
destruction  of  rats,  raice,  vermin,  and  insects.  Occasionally  also  it  is 
taken  with  suicidal  intent. 

Symptoms. — These  are  intense  abdominal  pain,  at  first  gastric,  with 
vomiting;  later  intestinal,  twith  diarrhea  and  tenesmus,  which  may  be  fol- 
lowed by  collapse  and  death.  The  symptoms  are  not  unlike  those  of 
cholera,  including  rice-water  stools,  cardiac  weakness,  and  cyanosis.  Some- 
times a  skin  eruption  makes  its  appearance,  and  sometimes  blood  and 
albumin  appear  in  the  urine.     Fatal  cases  terminate  in  one  or  two  days. 

Recovery  from  these  acute  symptoms  may  be  followed  by  paralysis. 

Treatment.- — The  ingestion  of  a  poisonous  dose  of  arsenic  is  apt  to  be 
followed  by  free  vomiting.  But  even  in  the  event  of  emesis,  the  stomach 
washed  out  with  draughts  of  warm  water.  The  best  antidote  is  freshly 
precipitated  sesquioxid  of  iron,  which  forms,  with  arsenic,  an  insoluble 
compound.  It  must  be  freshly  prepared,  taking  any  of  the  sesqui  solutions 
of  iron,  preferably  the  chlorid,  and  neutralizing  it  with  sodium  carbonate  or 
magnesia.     The  precipitate,  being  hastily  washed  by  emptying  it  on  muslin 


1154  THE  INTOXICATIONS 

or  a  filter,  pouring  water  on  it  and  allowing  it  to  drain,  should  be  freely 
administered.  Dialyzed  iron  may  be  used,  but  it  is  best  also  precipitated 
with  ammonia  or  other  alkali  before  using.  In  extreme  cases  the  tincture 
of  the  chlorid  of  iron,  Monsel's  solution,  or  any  of  the  sesqui  preparations 
may  be  substituted  for  the  precipitated  sesquioxid. 

After  the  emetic  has  acted,  and  while  the  antidote  is  being  given, 
castor  oil  should  be  administered  to  carry  off  the  poison  from  the  bowels. 

Chronic  Arsenical  Poisoning. — This  is  ascribed  to  wall-papers 
covering  occupied  apartments,  tc  artificial  flowers,  to  carpets  and  clothing 
fabrics  colored  or  dj^ed  with  arsenic.  The  glazed  green  and  red  papers  are  those 
especially  dangerous.  The  arsenic  emanations  may  be  in  the  shape  of  small 
particles  or  gaseous  volatile  bodies.  Occasionally,  arsenic  medicinally  admin- 
istered may  produce  the  symptoms  of  slow  arsenical  poisoning,  Fowler's 
solution  being  the  drug  usually  responsible.  A  widespread  epidemic 
occurred  in  Manchester,  England,  due  to  contaminated  glucose  used  in 
making  beer. 

Symptoms. — Chronic  arsenical  poisoning  may  be  suspected  in  the 
presence  of  unexplained  anemia  and  debility,  irritation  of  the  conjunctiva, 
mouth,  pharynx,  and  stomach  producing  gastralgia;  and  of  the  lower 
digestive  tract.  From  neuritis  there  may  result  numbness,  tingling,  and 
pain  in  the  fingers  succeeded  by  paralysis  and  localized  wasting.  All  these 
symptoms  may,  however,  be  produced  by  other  causes.  The  paralysis 
resembles  that  of  lead  palsy,  but  affects  rather  the  lower  extremities,  es- 
pecially the  extensors  and  peroneal  group,  whence  may  arise  the  character- 
istic steppage  gait  of  peripheral  neuritis.  These  symptoms  have  been 
ascribed  by  some  authorities,  as  in  the  case  of  lead-poisoning,  to  central 
lesions  rather  than  to  alterations  of  the  nerves.  Deranged  electrical  reaction 
may  be  present  before  any  loss  of  power,  but  on  differential  examination  a 
weakened  power  of  wrist  extension  and  feeble  power  to  spread  the  fingers 
may  be  detected.  Pigmentations,  flushing  and  redness  of  the  skin  are  com- 
mon, even  keratosis  and  rarely  epithehoma. 

Treatment. — The  patient  should  be  removed  from  the  exposure  and 
the  symptoms  be  treated  as  they  arise.  The  iodid  of  potassium  may  be 
used. 

BISULPHID  OF  CARBON  POISONING. 

Symptoms. — The  acute  symptoms  are  those  of  exhilaration  followed 
by  depression,  excitement  or  taciturnity,  loss  of  appetite  and  headache. 
Overwhelming  doses  cause  great  weakness.  Mania  and  hysteria  have  been 
reported.  The  chronic  symptoms  are  those  of  peripheral  neuritis  resem- 
bling those  caused  by  alcohol,  great  muscular  weakness,  followed  by 
wasting,  sluggish  reflexes,  tremor.  Absence  of  sexual  desire  is  a  characteristic 
sjTnptom.  There  may  be  foot-drop,  wrist-drop  and  finger  extension,  or 
the  fingers  may  become  stiff  and  numb.  There  may  be  scotoma  and 
limitation  of  the  field  of  vision  %\dth  hyperemia  of  retinal  vessels.  These 
symptoms  may  occur  after  short  exposure  or  only  after  long  periods.  The 
urine  has  been  affected  in  some  cases,  shown  by  the  presence  of  hema- 
turia, albumin,  indican,  and  hydrobilirubin.  Blood  changes  are  not  marked 
or  niimerous  but  the  hemoglobin  may  be  reduced. 


FOOD  POISONING  1155 

Prognosis. — Death  never  occurs  from  the  poisoning  alone,  though 
it  may  be  caused  by  resulting  cachexia.  Recovery  is  more  or  less  incom- 
plete, some  claiming  that  it  is  never  complete.  Muscular  weakness  is 
often  permanent  in  mild  degree. 

Treatment. — Prophylaxis  should  be  observed  to  protect  the  work- 
men. The  work-room  should  be  on  the  ground  floor  with  vents  next 
to  the  floor  to  carry  ofE  the  gas  which  is  heavier  than  air.  Such  removal 
can  be  facilitated  by  the  air-pump.  The  muscular  weakness  is  best  treated 
by  electricity  and  massage;  general  weakness  by  strychnin  and  noiirishing 
food. 

FOOD  POISONING. 

Ptomain  and  Leukomain  Poisoning. 

Ptomain,  from  Greek  irr<o/ua,  a  cadaver,  is  a  word  suggested  by  the 
Italian  toxicologist,  F.  Selini,  for  substances  generated  in  the  decomposi- 
tion of  organic  matter,  which  more  recent  studies  have  shown  to  be  the 
result  of  bacterial  action.  Ptomains  are  basic,  uniting  with  acids  to 
form  salts.  Leukomains  are  similar  basic  substances  formed  in  the  living 
body.  Ptomains  differ  greatly  in  their  character  and  properties,  certain 
ones  being  intensely  poisonous,  others  harmless.  For  the  former  L.  Brieger 
suggested  the  name  toxins,  retaining  that  of  ptomains  for  the  non-poison- 
ous basic  products;  but,  as  Victor  C.  Vaughan  suggests,  there  are  diflS- 
culties  in  the  way  of  such  classification,  because  a  ptomain  may  be  poison- 
ous under  certain  conditions  and  harmless  under  others. 

Meat  Poisoning. 

This  succeeds  the  eating  of  various  kinds  of  meat  in  which  poisons 
have  developed  either  through  bacterial  agency  or  chemical  change. 
Of  the  cases  due  to  bacteria  several  groups  may  be  made : 

1.  Poisoning  due  to  the  colon  bacillus  or  the  typho-coli  group  intermediate 
between  the  typhoid  grjup  and  colon  baciUus  group.  The  symptoms  of 
this  group  exhibit  a  wide  range  of  symptoms,  being  limited  in  certain  mild 
cases  to  headache  and  moderate  fever,  while  certain  severe  cases  begin 
suddenly  with  vomiting,  purging  and  severe  pain,  terminating  in  coUapse 
and  death.  Some  cases  resemble  in  their  sj^mptoms  the  paratyphoid 
infection,  while  others  are  discoverable  only  by  the  presence  of  the  typhoid 
(Widal)  reaction.  Very  interesting  and  important  is  the  fact  that  in  this 
type  the  appearance  of  the  meat  is  unaltered.  Beef  and  veal  are  most 
liable  when  the  animals  are  the  subject  of  some  diarrheal  or  septic  state. 
The  last  has  been  noted  in  Germany.  In  England  pork  is  a  frequent  seat 
of  the  poison  served  in  the  favorite  pork  pie. 

2.  Poison  Due  to  Putrefaction.  Both  smell  and  taste  proclaim  the  danger 
from  this  source.  The  poisonous  products  are  the  result  of  protein  hydrolysis 
and  include  putrescin,  cadaverin  and  sepsin.  There  are,  however,  also 
found  associated  organisms,  especially  proteus  and  colon  bacilli,  which 
are  held  responsible  by  some,  so  that  it  cannot  be  regarded  as  settled  whether 
they  or  the  aromatic  compounds  named  are  responsible. 


1156  THE  INTOXICATIONS 

3.  Poisoning  Due  to  Bacillus  Botulinus.  This  is  a  rare  form  of  bacillus 
discovered  by  von  Ermengem  in  ham  which  was  held  responsible  for  an 
outbreak  involving  50  cases.  The  symptoms  are  like  those  of  atropin 
poisoning,  dryness  of  the  throat,  dilated  pupils  and  cardiorespiratory 
paralysis. 

Ham  poisoning  not  due  to  trichina  has  ocurred  in  England,  Germany, 
and  Switzerland,  while  poisoning  has  also  been  traced  to  beef,  mutton,  less 
frequently  veal,  turkey,  and  goose,  and  in  America  to  canned  meats. 
Some  of  these  last  must  be  ascribed  to  muriate  of  zinc  and  tin,  but  others 
are  doubtless  due  to  the  meats.  Poultry,  especially  if  kept  too  long,  and 
game  birds  also  prove  poisonous  at  times. 

Symptoms. — The  symptoms  of  various  epidemics  of  meat  poisoning  vary, 
but  the  following  are  more  constant,  after  a  period  of  incubation  of  from 
one  to  48  hours:  nausea,  vomiting,  cramps,  and  diarrhea — in  a  word,  acute 
gastro-intestinal  irritation.  To  these  may  be  added  dryness  of  the  mouth, 
constriction  of  the  throat,  difficulty  in  swallowing,  vertigo,  indistinctness  of  vision, 
dilatation  of  pupils,  while  sometimes  constipation  substitutes  diarrhea. 
Thirst,  headache,  and  muscular  weakness  may  also  be  present. 

The  symptoms  may  begin  at  once  without  incubation  in  a  feeUng  of  lan- 
guor and  general  malaise,  loss  of  appetite,  nausea,  and  griping  pain  in  the 
belly. 

In  fatal  cases  the  symptoms  of  cholera  are  simulated,  such  as  cramps 
in  the  legs  or  arms,  or  both,  muscular  twitchings,  stiffness  of  the  joints, 
drowsiness,  coldness  of  surface,  pinched  features,  blueness  of  fingers  and  toes 
and  around  the  sunken  eyes — in  a  word,  the  symptoms  of  collapse.  On  the 
other  hand,  the  temperature  sometimes  rises  to  101°  to  103°  F.  (38.3°  to 
39.4°  C),  wnth  a  pulse  of  from  100  to  128. 

Poisoning  by  Milk  and  its  Products. 

The  causes  of  poisoning  by  cheese  claimed  attention  as  far  back  as  1827 
when  analyses  of  poisonous  cheese  were  made  by  Hunnefeld.  The  older 
view  that  the  poisons  are  fatty  acids  has  been  refuted,  and  Vaughan  isolated 
aptomainin  1884  which  he  has  called  tjTotoxicon  (Tvpds,  cheese,  and  to^mov, 
poison).  Tyrotoxicon  was  not,  however,  always  found  by  Vaughan  in 
cheeses  of  acknowledged  poisonous  properties;  nor  was  it  the  most  virulent. 
In  1885  he  found  it  in  mUk  which  had  stood  in  well-stoppered  bottles  for 
about  six  months,  and  in  1886  Newton  and  Wallace  obtained  it  from  milk 
which  had  poisoned  a  number  of  persons  in  a  hotel  at  Long  Branch,  N.  J. 
Since  then  tyrotoxicon  has  been  isolated  many  times  from  poisonous  milk. 
Finally,  in  1886,  Vaughan  obtained  tyrotoxicon  from  ice-cream  which  had 
proved  poisonous,  and  since  then  it  has  been  frequently  found  in  such  cream. 
A  number  of  cases  of  poisoning  after  eating  "cream  puffs"  have  been  re- 
ported in  Philadelphia  and  elsewhere,  in  which  doubtless  the  same  ptomain  is 
responsible.  A  family  under  Tyson's  observation  was  poisoned  by  hlanc 
mange,  of  which  all  had  eaten  freely,  and  which  had  been  made  for  several 
days. 

Symptoms. — The  symptoms  of  milk  and  cheese  poisoning  are  those  of 
gastro-intestinal  irritation,  comparable  in  various  degrees  to  those  described 
as  due  to  meat  poisoning,  etc. 


FOOD  POISONING  1157 

Poisoning  by  Shell-fish  and  Fish    (Ichthysmus). 

The  mussel  furnishes  the  most  frequent  source  of  poisoning  from  this 
cause,  instances  of  which  were  reported  as  early  as  1827  by  Combe.  A 
ptomain  was  isolated  by  L.  Brieger  in  1885,  from  poisonous  mussels,  at 
Wilhelmshaven,  where  numerous  instances  occur.  Brieger  has  called  it 
from  mytilis,  a  mussel.  It  is  found  chiefly  in  the  liver  of  the  mussel, 
but  whether  in  a  special  poisonous  mussel  or  a  mussel  which  becomes 
poisonous  under  certain  circumstances  is  not  settled,  though  the  latter 
would  seem  to  be  true,  since  Schmidtmann  found  that  non-poisonous 
mussels  placed  in  the  waters  of  Wilhelmshaven  Bay  became  poisonous,  and 
poisonous  mussels  from  the  latter  became  harmless  after  being  placed  in  the 
open  sea. 

Symptoms. — Both  cooked  and  raw  mussels  may  produce  the  poison- 
ous symptoms.     Three  sets  are  described: 

First,  those  of  gastro-intestinal  irritation,  similar  to  those  described  as 
due  to  meat  poisoning,  and  which  may  terminate  fatally  ■nithin  two  daj'S, 
the  autopsy  revealing  inflamed  stomach  and  intestines. 

In  a  second  set  of  symptoms  the  nervous  system  seems  to  bear  the 
brunt  of  the  poison,  and  these  cases  are  said  to  be  the  most  frequent.  The 
symptoms  include  a  sense  of  heat  and  itching,  usually  beginning  in  the  eye- 
lids, but  soon  extending  over  the  whole  face  and  sometimes  over  a  large 
portion  of  the  body.  An  eruption,  vesicular  and  papular,  makes  its  appear- 
ance and  intensifies  the  itching.  The  eruption  is  often  followed  by  asth- 
matic breathing.  Sometimes  the  dyspnea  precedes  the  eruption,  the  face 
becomes  livid,  the  patient  unconscious,  and  there  are  convulsive  movements 
of  the  extremities.  In  other  cases  there  are  delirium,  con^odsions,  coma, 
and  death  within  three  days.  In  other  ner\'Ous  cases  there  are  numbness 
and  coldness,  frequent  pulse  but  no  fever,  the  pupils  are  dilated,  and  death 
takes  place  in  a  couple  of  hours  with  s^^mptoms  of  coUapse. 

In  a  third  set  of  cases  a  symptom  like  intoxication  b}^  alcohol  is  pres- 
ent, followed,  by  paralysis,  coma,  and  death. 

Treatment  of  Ptomain  and  Allied  Poisoning. 

This  is  mainly  sj'mptomatic — the  purgative  and  emetic  effect  of  the 
poison  generally  promptly  gets  rid  of  any  residue  which  may  be  in  the 
stomach  or  intestinal  canal.  But  if  there  is  any  reason  to  believe  that  these 
are  not  emptied,  purgatives  should  be  administered,  and  of  these  calomel  is 
probably  the  best  because  it  is  less  apt  to  be  rejected.  The  stomach  should 
be  washed  with  a  tube. 

In  addition  counterirritation  by  mustard,  hypodermic  injection  of  1/3 
grain  (0.0165  gn:-)  morphin,  repeated  if  necessary,  to  relieve  pain,  digitalis 
from  10  to  30  minims  (0.66  to  2  gm.),  and  strychnin  1/30  grain  (0.0022 
gm.)  administered  in  the  same  manner  to  counteract  collapse  may  be 
given.  Stimulants  by  the  mouth  should  be  given  if  retained,  and  to  this 
end  champagne  becomes  very  suitable,  or  milk  mixed  with  carbonated 
water  may  be  given  in  small  quantities.  Hexamethylenamine,  salol  and 
sodium  sulphocarbolate  should  be  used  as  intestinal  antiseptics  to  com- 
plete the  detoxication. 


1158  '  THE  INTOXICATIONS 

GRAIN  POISONING. 

For  a  century  or  more  districts  have  been  subject  to  ailments  which 
have  been  traced  to  the  use  of  certain  grains  as  food,  some  of  which  have 
been  found  to  be  spoiled  or  diseased.  Residents  in  some  parts  of  France, 
Germany,  Switzerland,  Italy,  Spain  and  India  and  the  United  States  have 
been  thus  affected. 

I.  Ergotism. — Ergotism  is  one  of  these  ailments.  It  is  a  disease  found 
to  succeed  upon  the  use  of  meal  contaminated  with  the  sclerotium,  an  in- 
termediate stage  of  development  of  the  daviceps  purpura,  a  fungus  which 
infests  the  r>'e  grain.  Ergot  is  a  sclerotium,  which  appears  at  the  base 
of  the  grain  as  a  hard,  dark-hued  "spur,"  which,  as  it  grows,  lifts  up  the 
diseased  and  withered  mass  of  the  original  grain.  Wheat,  barley,  and  rice 
may  also  become  spurred.  The  growth  of  the  fungus  is  favored  by  wet 
seasons.  The  disease  prevailed  in  France,  Switzerland,  and  Germany  much 
more  commonly  from  the  loth  to  the  i8th  century  than  at  present.  The 
cause  of  ergotism  was  discovered  in  1830  by  Thuillier. 

Two  forms  of  chronic  ergotism  are  recognized,  one  convulsive  or  spas- 
modic, the  other  gangrenous. 

Spasmodic  Ergotism. — This  is  beUeved  to  be  due  to  cornutin.  In  this  form 
there  is  a  prodromal  period  of  from  10  to  15  days,  during  which  there  are 
a  peculiar  sense  of  weariness  and  anxiety,  a  tingling  and  sense  of  formication 
in  the  skin,  especially  of  the  fingers  and  toes,  gastro-intestinal  irritation 
manifested  by  vomiting,  purging,  and  colicky  pains,  accompanied  some- 
times with  slight  fever.  Then  spasmodic  symptoms  set  in.  These  consist  at 
first  in  involuntary  twitchings,  which  soon  pass  into  painful  continuous  con- 
tractions, the  arms  being  fiexed  and  the  legs  and  toes  extended.  The  cramp 
lasts  for  an  hour  or  more,  followed  by  a  period  of  exhaustion,  which  may  be 
succeeded  by  another  painful  convulsion.  There  may  be  delirium,  melan- 
cholia, or  dementia.  The  urine  may  be  suppressed  or  violent  dysuria 
may  be  present  from  spasm  of  the  bladder.  Pustules,  boUs,  whitlows, 
and  other  evidence  of  deranged  nutrition  may  appear.  Cardiac  contrac- 
tions are  slow  and  feeble,  the  arteries  are  constricted  and  contain  little 
blood.  Death  may  occur  from  cardiac  paralysis,  and  is  often  preceded 
by  convulsions  or  paraljrtic  symptoms.  The  duration  of  the  illness  is  from 
four  to  eight  weeks  or  longer. 

Sclerosis  of  the  posterior  columns  of  the  cord  was  found  in  some  of  the 
cases  which  came  to  necropsy.  Thus,  Tuczek  and  Siemens  found  it  four 
times  in  nine  autopsies,  which  represented,  also,  the  deaths  in  a  group  of 
29  cases. 

Gangrenous  Ergotism. — This  is  believed  to  be  due  to  sphacelinic  acid. 
It  is  ushered  in  by  the  same  prodrome  as  that  described  for  the  spasmodic. 
On  this  succeeds,  from  the  third  day  to  the  fourth  week,  an  erysipelatous 
redness  in  some  peripheral  locality,  as  in  the  toes  and  fingers,  ears,  and  nose. 
This  is  followed  usually  by  dry  gangrene,  but  the  moist  form,'  which  may  be 
confined  to  a  finger  or  toe  or  may  involve  the  whole  hand  or  foot,  may 
also  appear.     The  disease  may  not  go  beyond  the  erysipelatous  redness. 

For  acute  ergot  poisoning  see  concluding  section. 


BERI  BERI  1159 

2.  Lathyrism,  or  Lupinosis. — This  is  a  condition  resulting  from  the 
use  of  meal  made  from  the  chick-pea,  or  grain  of  a  variety  of  vetches, 
more  particularly  the  lathyrus  sativus  and  lathyrus  cicera.  It  is  used  in 
admixture  with  barley  and  wheat  in  India,  Italj^  and  Algiers.  According 
to  James  Irvine,  the  symptoms  supervene  in  India  when  the  proportion 
exceeds  1/12. 

The  symptoms  are,  first,  gastro-intestinal  irritation,  then  a  condition 
of  spastic  paralysis,  which  may  pass  on  to  complete  paraplegia.  The  arms 
are  rarely,  if  ever,  affected. 

No  associated  morbid  change  has  been  discovered. 

Treatment  of  Grain  Poisoning. 

This  consists,  primaril}',  in  the  removal  of  the  cause  and  the  substitu- 
tion of  wholesome  food;  in  removal,  also  from  the  district,  if  possible,  and 
suitable  treatment  of  symptoms. 

BERI-BERI. 

Definition. — Beri-beri  is  a  disease  of  the  Malay  Peninsula,  Phihppine 
Islands,  South  America,  Japan,  China,  and  some  parts  of  Africa,  character- 
ized in  its  end-results  at  least,  by  edema,  wasting  of  the  muscles,  and  of 
polyneuritis.     It  is  a  disease  of  great  antiquity. 

Morbid  Anatomy. — In  the  acute  cases,  there  is  general  edema;  there 
is  postmortem  ecchymosis;  the  mucous  membrane  as  the  pharjmx  is  red; 
there  is  excessive  liquid  in  the  abdominal,  pleural,  and  peritoneal  cavities. 
The  gastro-intestinal  mucous  membrane  may  be  congested  or  actively  in- 
flamed with  hemorrhagic  erosions;  there  may  be  hemorrhagic  extravasa- 
tions. Microscopic  examination  of  the  mucous  membrane  of  the  gastro- 
intestinal tract  shows  active,  congested,  smaJl-ceUed  infiltration  necrosis  of 
the  epitheUum. 

There  is  a  bacillus  which  Wright  considers  pathognomic,  found  be- 
tween the  epithelial  cells.  The  muscle  of  the  heart  shows  fatty  degenera- 
tion.    The  Iddneys  are  usually  congested. 

According  to  Wright,  the  changes  of  the  nervous  system  are  as  follows: 
In  the  earhest  stages  the  neurons  are  found  to  be  "spotted  with  black 
altered  myelin.  Nissl's  bodies  of  the  process  have  disappeared.  Later 
in  the  nerve  cells  the  nuclei  are  swollen;  the  peripheral  cells  are  rarified. 
It  is  not  the  degree  of  neuro-atrophy  in  the  acute  pernicious  beri-beri 
which  causes  death,  but  it  is  its  extent.  The  second  stage  is  seen  in  the 
more  subacute  stage  of  beri-beri.  The  cells  are  rarefied.  Nissl's  bodies  have 
disappeared  or  broken  down;  the  termination  of  the  dependent  fibers  are 
in  an  early  and  distinct  stage  of  atrophy.  In  the  third  stage  there  is  vacuo- 
lation  of  the  cells ;  rupture  of  its  membrane  and  that  of  its  nucleus ;  sometimes 
exclusion,  either  wholly  or  partially  of  the  nucleolus."  The  last  stages 
are  accompanied  by  complete  degeneration  of  the  peripheral  nerve  fibers. 

Etiology. — The  disease  certainly  has  a  direct  relation  to  the  kind  of 
rice  used  as  a  diet.  Taldki  banished  beri-beri  from  the  Japan  navy  in  1884 
by  the  correction  of  diet  and  the  substitution  of  other  foods  for  rice.  Brat- 
ton,  Fraser,  Stanton  and  others  have  established  beyond  question  that  in- 


1160  THE  INTOXICATIONS 

dividuals  fed  upon  polished  rice  develop  beri-beri,  while  those  fed  upon  par- 
boiled rice  do  not  develop  beri-beri.  Two  hundred  and  twenty  persons 
were  fed  upon  polished  rice;  of  those,  twenty  developed  beri-beri.  Of  223 
persons  under  exactly  the  same  conditions,  except  they  were  fed  parboiled 
rice,  none  developed  beri-beri. 

Later  the  same  observers  made  some  experiments  upon  fowls,  and  found 
they  could  develop  beri-beri  at  will  by  feeding  them  upon  polished  rice. 

Beri-beri  patients  were  in  contact  with  persons  fed  upon  parboiled  rice,  but 
did  not  contract  the  disease.  No  organisms  were  found  in  the  blood  or 
urine  of  beri-beri  patients. 

The  Philippine  statistics  go  to  show  certainly  that  a  diet  without 
polished  rice  does  not  cause  beri-beri,  while  one  with  polished  rice  does 
cause  it.  On  the  other  hand  Wright  believes  the  disease  is  an  acute  in- 
fectious disease  due  to  a  specific  organism,  the  paralysis  so  characteristic 
of  the  disease  being  simply  the  result  of  a  toxin. 

Symptoms.' — Wright  divides  the  disease  into 

1.  Acute  pernicious  beri-beri,  where  there  is  more  or  less  sudden  onset 
with  gastro-intestinal  symptoms,  cardiac  failure,  with  varying  degrees  of 
sensory  motor  paresis  and  pulmonary  failure.     These  cases  end  fatally. 

2.  Acute  Beri-beri. — Here  the  onset  is  sudden  but  not  so  fulminating 
as  in  the  pernicious  cases.  Here  too  there  is  weakness  of  the  heart  and 
signs  of  peripheral  nerve  involvement,  but  the  cases  are  not  so  surely  fatal, 
some  of  them  recovering  and  passing  over  into  the  terminal  stage. 

3.  Subacute  Beri-beri. — Here  the  onset  is  more  gradual;  the  gastro- 
intestinal SA'mptoms  majr  escape  notice.  Clinically  the  heart  does  not  show 
any  involvement,  and  there  is  but  slight  paresis  of  the  sensory  motor  nerves. 

4.  Beri-beri  Residual  Paralysis  or  Neuritis. — This  is  the  state  usually 
recognized  and  long  described  as  endemic  neuritis.  This  includes  the  cases 
of  acute  and  subacute  beri-beri,  which  have  recovered  from  the  first  effects 
of  the  poison  leaving  behind  a  peripheral  neuritis. 

Here  the  sjrmptoms  are  those  of  chronic  peripheral  neuritis.  This  is 
weakness,  lassitude,  followed  by  languor.  There  is  formication  of  the  legs 
and  thighs.  The  body  then  becomes  edematous,  there  is  dyspnea,  cardiac 
distress.  This  stage  is  followed  more  or  less  suddenly  with  great  muscular 
atrophy,  the  patient  becomes  much  emaciated  and  entirely  helpless,  all 
these  symptoms  being  the  result  of  the  general  multiple  neuritis.  Some  of 
the  cases  are  chronic  and  relapsing  in  character. 

Prognosis. — The  disease  is  a  serious  one;  the  acute  pernicious  cases  all 
die  after  a  few  days.  Those  of  the  acute  cases  which  drift  over  into  the 
other  stages,  have  a  mortaUty  of  about  20  per  cent. 

Prophylaxis  and  Treatment. — From  the  more  recent  studies,  especially 
those  of  Fraser  and  Stanton,  attention  to  the  diet  is  the  all  important 
prophylactic  agent.  Polished  rice  should  not  be  used.  Barley  or  beans 
or  parboiled  rice  may  be  substituted  for  this  universal  diet  of  the  East. 
Chamberlain's  experiences  in  the  Philippines  bears  out  this  statement. 
All  the  well-known  sanitary-  regulations  shovild  be  carried  out.  In  the  early 
stages  of  the  disease  parboiled  rice,  the  hulls  from  the  rice,  barley  or  beans 
may  be  used  and  some  of  the  cases  recover. 

■Studies  from  the  Institute  for  Medical  Research,  Federated  Malay  States,  1902 — 1904. 


PELLAGRA  1161 

In  the  stage  of  paralysis,  rest  in  bed,  purgation  for  the  edema,  massage 
and  electricity  for  the  atrophy,  with  strychnine  as  a  tonic,  is  of  value.  Iron 
also  in  the  form  of  Blaud's  pihs  for  the  anemia  is  useful. 

PELLAGRA. 

By  Edward  Jenner  Wood,  M.  D. 

Definition. — Pellagra  is  a  disease  of  unknown  cause,  occurring  usually 
in  the  temperate  and  subtropical  sections,  characterized  by  s\Tnmetrical 
skin  lesions  largely  confined  to  the  uncovered  portions  of  the  body,  by 
gastro-intestinal  disturbances,  by  changes  in  the  nervous  system  of  a  hetero- 
geneous nature,  and  by  definite  seasonal  variation. 

Historical — It  has  been  suggested  that  Hippocrates  was  referring  to  pellagra  when  he 
described  solsido.  This  idea  was  warmly  opposed  bj'  Strombio  who  considered  it  a  new 
disease  never  known  until  after  the  introduction  of  Indian  corn  from  America.  The 
first  definite  description  was  given  by  Caspar  Casal,  a  physician  of  the  Asturias  in  1735. 
It  is  not  improbable  that  pellagra  had  existed  for  many  years  before  in  an  unclassified 
state.  It  is  not  improbable  further  that  it  was  confused  with  syphilis,  leprosy,  scurv^y, 
and  even  such  conditions  as  some  of  the  purpuras.  It  is  a  matter  of  more  than  passing 
interest  to  fix  the  time  of  the  first  appearance  of  this  disease  in  Europe  as  it  would  be  of 
great  aid  in  a  study  of  the  etiology. 

The  first  known  appearance  of  pellagra  was  in  Spain.  In  1755  Strombio  recorded  its 
appearance  in  Italy  and  from  that  time  to  now  that  country  has  been  considered  the 
natural  home  of  the  disease.  It  was  known  as  alpine  scuri-y  when  it  first  appeared  in 
Lombardy  and  about  the  year  1755  this  section  was  ravaged  by  it.  Somewhat  later 
France  became  a  victim  and  in  recent  years  Roumania  has  been  one  of  the  chief  scenes 
of  its  activity.  In  the  last  decade  Egypt  has  furnished  many  cases  which  have  been 
carefully  observed  by  a  number  of  English  physicians.  Sporadic  cases  have  been  reported 
from  Tyrol,  Servia,  Bulgaria,  Greece,  Asia  Minor,  and  a  few  from  Great  Britain. 

It  seems  probable  that  pellagra  has  existed  in  the  United  States  in  sporadic  form  for 
many  years.  Babcock  recently  found  among  the  case  records  of  the  South  Carolina 
hospital  for  the  insane  an  account  by  Dr.  James  Davis  of  a  definite  case  occurring  in 
1834.  It  was  not  until  1907  that  the  first  account  of  a  definite  outbreak  was  reported. 
For  this  report  we  are  indebted  to  George  H.  Searcy  of  Alabama. 

At  this  time  pellagra  has  been  reported  either  in  endemic  or  sporadic  form  in  all  but 
nine  states  of  the  Union.  It  is  more  prevalent  in  the  south  Atlantic  states.  Layinder 
claims  that  30,000  cases  have  occurred  with  a  fatality  of  over  39  per  cent.  This  is  a 
low  estimate.  As  pellagra  is  a  disease  of  rural  sections  and  occurs  chiefly  in  states  out- 
side the  registration  area  no  definite  idea  of  its  extent  can  be  secured  at  this  time. 

Etiology. — Since  the  time  of  Casal,  pellagra  has  been  connected  with  the 
consumption  of  Indian  com.  In  every  period,  however,  there  have  arisen 
zealous  opponents  to  this  theory  and  recently  this  number  has  materially 
increased.  The  difficulty  in  the  way  of  the  solution  of  the  problem  is  that 
the  disease  cannot  be  reproduced  in  any  of  the  laboratory  animals. 

Among  the  zeists  or  advocates  of  the  com  theory  were  two  schools.  One 
taught  that  com  was  injurious  through  a  deficiency  in  food  value.  The  other 
school  considered  it  a  toxic  process  due  to  verderame  or  verdet  which  had 
resulted  from  the  action  of  a  mold,  sporisorium  maidis.  Chickens  were  fed 
on  this  mold  and  developed  a  number  of  sjTnptoms  which  at  the  time  were 
thought  to  be  pellagrous.  Lombroso,  after  many  jeaxs  of  study,  concluded 
that  the  disease  was  an  intoxication  process  produced  by  the  action  of  certain 
micro-organisms  on  Indian  com.  In  themselves  these  organisms  were 
thought  to  be  harmless  but  to  have  the  property  of  producing  a  poisonous 
ptomaine. 

Tizzoni  claimed  to  have  isolated  a  " strepto-bacillus  pellagras"  from  the 
blood,  the  feces,  the  cerebro-spinal  fluid,  and  the  organs  at  autopsy.     This  or- 


1162  THE  INTOXICATIONS 

ganism,  while  not  a  spore-bearer,  was  supposed  to  resist  very  high  temper- 
atures accounting  for  the  fact  that  it  was  not  killed  by  cooking.  It  has  been 
shown  that  this  organism  is  not  the  specific  etiological  factor. 

Recently  L.  W.  Sambon  of  London  has  advanced  the  hypothesis  that 
pellagra  is  due  to  an  animal  parasite  yet  undiscovered  which  is  transmitted 
by  a  biting  fly  of  the  Simulium  group.  The  chief  ground  for  this  view  is  the 
geographical  distribution.  Pellagra  usually  occurs  in  the  foothills  or  the 
so-called  sub-alpine  regions.  It  does  not  usually  occur  on  the  sea  coast 
nor  in  the  high  mountains.  The  Simulium  lays  its  eggs  in  rapidly  running 
water  and  without  this  aeration  the  eggs  die  in  a  few  hours.  Wherever 
Sambon  found  pellagra  he  found  the  stream  and  the  fly.  The  geographical 
findings  in  Italy  conform  exactly  to  those  in  North  Carolina  and  it  seems 
more  than  coincidental  that  the  disease  should  so  often  select  the  very  banks 
of  the  streams.  The  seasonal  variation  and  the  pathologic  changes  further 
suggest  a  disease  of  ^animal  parasitic  origin,  but  until  the  animal  is  found  that 
can  be  successfully  experimentally  inoculated  all  views  are  speculative. 

Pathology. — Some  observers  find  an  analogy  between  pellagra  and  ergo- 
tism, while  others  find  it  between  pellagra  and  such  diseases  as  kala-azar  and 
syphilis.  Like  the  latter  pellagra  is  characterized  by  a  perivascular  infiltra- 
tion of  the  tissues  and  by  a  mononuclear  increase  in  the  elements  of  the  blood. 
It  may  be  argued  that  syphUis  as  well  as  ergotism  produces  tract  degenera- 
tions in  the  cord  but  it  cannot  be  denied  that  there  are  many  points  of  sim- 
ilarity between  the  nervous  changes  in  pellagra  and  ergotism. 

Increase  of  pigment  and  atrophy  of  the  visceral  organs  have  been  often 
mentioned  in  connection  with  pellagra,  but  cannot  be  counted  distinctive. 

Atrophy  of  the  muscular  coat  ofJthe  intestinal  tract  and  ulceration  as  low 
down  as  the  rectum  occur.  Chronic  enteritis  with  cicatricial  constrictions, 
thickening  of  Peyer's  patches  and  cystic  degeneration  of  the  submucous 
glands  have  been  found  at  autopsy. 

In  the  nervous  system  pigmentation  is  especially  marked  and  suggests 
a  senile  state.  Hyperemia,  anemia,  and  edema  of  the  nervous  system  occur 
but  are  not  distinctive.  Obliteration  of  the  central  canal  of  the  cord  with 
general  deformity  of  the  various  elements  frequently  occurs,  but  cannot  be 
counted  as  distinctive.  It  is  commonly  acknowledged  that  the  brunt  of  the 
affection  falls  on  the  lateral  tracts  of  the  cord  in  the  form  of  definite  tract 
degeneration.  The  crossed  pyramidal  tracts  are  usually  affected  but  the 
direct  cerebellar  tracts  always  escape.  The  writer  has  had  a  preponderance 
among  his  cases  of  degeneration  of  the  posterior  tracts.  Muscular  atrophy 
has  been  noted  but  does  not  select  definite  groups  of  muscles.  Lesions  of 
the  posterior  columns  are  more  frequent  in  the  cervical  and  upper  dorsal 
regions. 

The  skin  changes  in  pellagra  are  not  distinctive.  They  follow  either 
the  changes  of  erythema  or  dermatitis.  Atrophy  is  always  the  end-result. 
Hyperkeratosis  and  parakeratosis  are  both  mentioned  and  the  former  is 
counted  of  considerable  importance. 

Symptoms. — Pellagra  affects  all  ages  with  almost  perfect  impartiality. 
The  writer's  youngest  case  was  twenty-two  months  and  his  oldest  seventy- 
five  years. 

All  observers  are  agreed  that  the  female  sex  is  more  often  affected.     In 


PELLAGRA  1163 

Tennessee  the  proportion  was  214  females  and  102  males.  In  both  Tennes- 
see and  North  Carolina  the  negro  was  much  less  frequently  affected  than  the 
white  race.  A  part  of  this  may  be  due  to  the  comparative  infrequency  of 
uncinariasis  in  the  negro,  while  in  the  poor  white  of  the  South  it  forms  the 
chief  source  of  general  lowered  resistance  to  all  infections. 

The  symptoms  of  pellagra  arrange  themselves  into  three  definite  groups : 
the  gastro-intestinal,  the  skin,  and  the  nervous.  The  gastro-intestinal  symp- 
toms usually  appear  about  Christmas  time  and  are  followed  by  the  outbreak 
of  erythema  with  the  first  warm  weather  of  late  spring  or  early  summer. 
The  gastro-intestinal  symptoms  are  at  first  indefinite  partaking  of  the  nature 
of  a  neurosis.  The  mouth  symptoms  are  present  in  a  large  majority  of  all 
cases.  General  redness  of  the  whole  mucous  membrane  of  the  mouth  is  usu- 
ally seen.  The  epithelium  of  the  tongue  is  often  denuded  and  small  ulcers 
and  vesicles  may  be  found.  Congestion  of  the  fungiform  papilla  especially 
about  the  tip  and  edges  is  recorded  by  Manson.  Babcock  found  small  black 
or  bluish  spots  on  the  dorsum  which  was  called  by  Lavinder  ' '  stipple  tongue. " 
Salivation  often  occurs.  The  pain  in  the  mouth  and  sesophagus  is  often  so 
great  as  to  interfere  with  the  taking  of,  food. 

The  gastric  symptoms  are  indefinite.  Nausea  frequently  is  a  distressing 
sjnnptom.  Diminution  of  hydrochloric  acid,  the  presence  of  lactic  acid  and 
mucus  are  found  in  some  cases  and  it  is  not  remarkable  that  the  cachexia  of 
pellagra  added  to  the  gastric  findings  should  have  caused  the  erroneous  diag- 
nosis of  gastric  carcinoma. 

One  of  the  most  constant  symptoms  is  a  diarrhea  which  is  distressing 
in  the  extreme.  The  number  of  stools  daily  is  often  very  great  and  the 
consequent  weakness  adds  greatly  to  the  suffering.  This  symptom  is 
rarely  absent  and  a  careful  history-taking  will  almost  certainly  disclose 
its  past  occurrence.  It  is  no  unusual  thing  to  learn  that  for  a  ntunber  of 
consecutive  seasons  this  symptom  without  other  pellagrous  manifestations 
had  occurred  and  for  this  reason  it  is  often  left  out  by  the  patient  in  re- 
counting the  symptoms.  It  is  a  common  sight  to  find  a  wasted  pellagrin 
wearing  a  diaper,  but  incontinence  will  sometimes  occur  when  there  is  no 
diarrhea.  Occasionally  there  is  an  alternation  with  constipation.  Fatal 
intestinal  hemorrhage  has  occurred. 

The  most  important  symptom  of  pellagra  is  the  symmetrical  erythema 
or  dermatitis  occurring  on  those  parts  which  are  exposed  to  light  and  air. 
This  symmetry  is  most  definite  and  includes  symmetry  of  shape,  size,  and 
location.  Without  this  appearance  or  a  definite  history  of  it  a  diagnosis  is 
never  justified.  The  atypical  locations  of  skin  lesions  are  numerous  and  may 
occur  on  any  portion  of  the  skin  surface,  but  shoidd  never  be  counted  pella- 
grous without  coexisting  symmetrical  lesions  of  the  exposed  portions.  The 
most  usual  location  of  the  skin  lesion  is  the  backs  of  the  hands  and  the  fore- 
arms. The  next  most  frequent  is  the  neck  above  the  collar  and  to  this  is 
given  the  name  Casal's  collar.  The  feet  in  children  and  in  negroes  who  go 
barefooted  are  commonly  affected.  In  the  beginning  it  is  extremely  difficult 
to  distinguish  the  erythema  of  pellagra  from  simple  sunburn.  Later  the 
lesion  assumes  a  brown  or  chocolate  color  before  exfoliation.  After  ex- 
foliation a  soft  smooth  skin  is  left.  Just  about  one-fourth  of  an  inch  within 
the  line  of  demarcation  of  the  skin  lesion  is  to  be  found  a  brown  line  which  is 


1164  THE  INTOXICATIOXS 

known  as  the  hyperkcratotic  border  and  is  imjjortant  because  it  persists  lonj^ 
after  the  disappearance  of  the  erythema  and  is  often  the  means  of  making  a 
diagnosis.  There  are  two  types  of  skin  lesion  commonly  recognized.  The 
dry  type  is  a  simple  dry  erythema  which  undergoes  changes  of  color,  and 
final  exfoliation.  The  moist  variety  is  characterized  either  by  bleb  formation 
or  by  weeping  surfaces  caused  by  crevices  in  the  skin.  The  final  result  of 
both  is  crust  formation.  In  the  moist  variety  the  condition  is  often  loath- 
some in  the  extreme.  It  would  suggest  the  appearance  produced  by  ex- 
tensive bums.  The  skin  lesions  of  pellagra  recur  year  after  year  always  at 
the  same  season.  It  should  be  borne  in  mind  that  the  skin  lesions  are  similar 
to  skin  lesions  in  syphilis  in  that  they  are  present  only  during  a  short  period  of 
the  affection  and  that  the  disease  is  not  eradicated  because  of  the  disappearance 
of  these  symptoms. 

The  nervous  and  mental  manifestations  of  pellagra  are  almost  as  varied 
as  in  syphilis  and  occur  with  almost  as  much  certainty  as  in  this  disease  when 
it  goes  untreated.  Tract  degenerations  are  usual.  As  a  rule  pellagra  must 
exist  for  at  least  three  years  before  the  impression  on  the  nervous  system 
becomes  sufficiently  indelible  to  produce  these  tract  degenerations.  It  is 
usually  stated  that  the  lateral  tracts  are  more  frequently  affected.  In 
the  writer's  experience  the  columns  of  Goll  and  Burdach  have  suffered  of- 
tener.  In  the  event  of  degeneration  of  the  posterior  tracts  the  root  zones  and 
the  posterior  roots  of  the  spinal  nerves  are  not  affected.  There  is  more  hope 
of  restitution  when  there  is  marked  exaggeration  of  the  reflexes  and  a  spastic 
tendency.  In  an  absence  of  reflexes  resulting  from  posterior  column  affec- 
tions the  outlook  is  less  favorable  for  a  return  to  normal.  Amyotrophic 
lateral  sclerosis  of  pellagrous  origin  has  been  reported.  S\Tnptoms  corre- 
sponding with  the  description  of  Landry's  paralysis  have  occurred  in  a  case 
of  the  writer's  and  death  resulted  from  glosso-labio-laryngeal  paralysis. 
Neuritis  especially  invohnng  the  nerves  of  the  hands  and  feet  is  frequent  and 
is  a  most  difficult  condition  to  relieve. 

The  time  of  appearance  of  mental  symptoms  of  pellagra  is  most  variable. 
It  has  been  reported  that  even  in  the  first  outbreak  of  the  disease  insanity 
occurred  before  the  erj'thema  or  digestive  disturbances.  This  insanitj'  is 
usually  of  the  depressive  type  and  melancholia  is  frequently  diagnosed.  De- 
lusions of  persecution  are  frequent,  but  delusions  of  grandeur  unknown.  Sui- 
cidal tendencies  are  often  manifested  and  death  from  suicide  is  a  considerable 
factor  in  increasing  the  death  rate. 

Diagnosis. — In  typical  cases  diagnosis  offers  no  difficulties.  With  the 
triad  of  symptoms — stomatitis  and  diarrhea,  s\Tnmetrical  erj^hema  of  the 
exposed  portions  of  the  skin,  and  nervous  and  mental  changes — there  can 
be  no  error.  The  diagnosis  is  never  justified  in  the  absence  of  skin  s>Tnp- 
toms  or  a  definite  history  of  such.  The  diagnosis  may  be  made  in  the  absence 
of  nervous  or  mental  changes,  having  in  mind  the  fact  that  the  disease  may 
exist  for  many  years  without  the  development  of  either.  Either  one  or  the 
other  group  of  sjTnptoms  of  the  mouth  or  intestinal  tract  may  be  wanting 
but  practically  never  both.  The  only  malady  %vith  which  the  disease  may  be 
reasonably  confused  is  sprue  in  the  South.  This  disease  is  identical  with 
pellagra  without  skin  s^-mptoms,  i.  e.,  the  so-called  "pellagra  sine  pellagra." 

Prognosis. — The  prognosis  is  more  encouraging  than  in    1907.     The 


PELLAGRA  1165 

fulminating  type  is  seldom  seen  at  this  time  and  it  was  this  class  of  cases 
which  produced  the  high  death  rate  in  the  first  years  of  its  observation  in 
this  country.  However,  Lavinder  places  the  death  rate  at  above  39  per 
cent.,  but  this  is  certainly  too  high  for  private  practice.  The  prognosis  is 
materially  affected  by  the  time  of  diagnosis  for  neglected  cases  just  as  in 
syphilis  aro  discouraging.  The  means  of  the  patient  are  important,  for  in  no 
disease  is  change  of  climate  and  envirormient  of  greater  importance.  A 
death  rate  of  10  per  cent,  at  this  time  would  be  conservative  estimation. 

Treatment. — In  the  absence  of  a  known  cause  treatment  must  of  neces- 
sity be  empirical.  In  spite  of  this  fact  much  progress  has  been  recently  made 
along  this  line.  The  only  group  of  drugs  worthy  of  mention  are  the  arylar- 
sonates.  Atoxyl  is  probably  the  best,  but  owing  to  its  toxicity  and  the  fact 
that  it  is  not  dispensed  in  tablet  form  it  has  been  superseded  in  the  hands 
of  the  writer  by  soamin,  which  is  less  toxic  and  can  be  had  in  i-grain  or  5- 
grain  tablets.  In  either  instance  the  drug  is  given  in  dose  of  from  5  to  7  1/2 
grains  (0.3  to  0.5  grams)  by  hypodermic  injection  deep  into  the  gluteal 
muscles.  The  dose  is  repeated  about  every  fourth  day.  This  plan  of 
treatment  is  especially  effective  when  begun  one  month  before  the  time  of  the 
expected  outbreak  in  the  spring.  This  anticipatory  plan  is  of  the  greatest 
importance.  Rest  in  bed  during  the  acute  symptoms  is  as  important  as  rest 
in  tuberculosis  during  the  stage  of  fever.  The  best  diet  is  milk  and  it  should 
be  persisted  in  until  all  diarrhea  ceases.  To  the  milk  may  be  added  a  raw 
egg.  It  is  useless  to  give  drugs  to  control  the  diarrhea.  The  mouth  is  best 
treated  with  simple  cleanliness  and  such  deodorant  preparations  as  Dobell's 
solution. 

Removal  from  unhj^gienic  surroundings  and  correction  of  such  resistance- 
lowering  conditions  as  uncinariasis  cannot  be  too  strongly  emphasized. 


SECTION  XII. 

EFFECTS  OF  EXPOSURE  TO  HIGH  THOUGH  BEARABLE 
TEMPERATURE. 

Such  effects  are  easily  separable  into  two  groups,  covered  by  the  terms 
heat  exhaustion  and  thermic  fever. 

HEAT  EXHAUSTION. 

Definition. — A  condition  of  syncopal  exhaustion  with  vasomotor  paraly- 
sis and  lowering  of  body-temperature,  caused  by  exertion  under  high  temper- 
ature. Such  condition  may  arise  quite  independently  of  the  direct  rays  of 
the  sun.     The  heat  may  be  that  of  confined  rooms  and  may  be  artificial  heat. 

Symptoms. — The  sense  of  great  weakness,  often  experienced  in  hot  weather 
after  some  unusual  exertion,  exhibits  the  mildest  degree  of  this  condition. 
In  the  more  severe  forms  a  sense  of  faintness,  associated  with  pallor,  dizzi- 
ness, at  times  blindness,  and  the  starting  of  cold  perspiration  are  the  first 
symptoms.  Sometimes  the  victim  can  get  to  a  place  where  he  may  sit  or 
lie  down;  at  other  times  he  faints  away  before  assistance  can  reach  him. 
Then  follows  a  condition  of  unconsciousness  or  semi-consciousness,  whence, 
under  favorable  circumstances,  he  may  respond  to  simple  stimulus  by 
ammonia  or  wine  and  then  fall  into  a  sleep,  from  which  he  will  awake  in  an 
hour  revived. 

In  more  severe  cases  the  collapse  is  more  permanent,  the  pulse  is  ex- 
tremely feeble  and  frequent,  the  skin  continues  leaky,  while  there  may  be 
great  restlessness  and  muttering  delirium.  It  is  characteristic  of  this  form  of 
heat  affection  that  there  is  extreme  adynamia  with  lowered  body-temperature. 
H.  C.  Wood,  whose  name  is  inseparably  associated  with  the  subjects  of  heat 
exhaustion  and  thermic  fever,  reports  a  case  T,\dth  a  temperature  as  low  as 
95°  F-  (35°  C-),  with  complete  collapse. 

Diagnosis. — Heat  exhaustion  is  characterized  by  lowered  temperature 
and  feeble  pulse,  as  contrasted  with  the  opposite  in  thermic  fever.  It  is 
important  that  the  two  conditions  should  not  be  confounded,  because  of 
the  widely  different  treatment  required.  The  syncopal  attack  from  cardiac 
failure  or  from  concealed  hemorrhage  much  more  closely  resembles  heat  ex- 
haustion, being  associated  also  with  feeble  pulse  and  lowered  temperature, 
but  as  the  treatment  is  identical,  the  distinction  is  less  important.  The  fall 
in  temperature  is,  however,  less  decided  in  synco/pe. 

Treatment. — The  patient  should  be  put  to  bed  at  once  with  his  head 
horizontal  or  slightly  raised.  When  possible,  stimtdants  should  be  ad- 
ministered moderately  by  the  mouth — brandy,  whisky,  or  ammonia  with 
digitalis.  If  this  is  not  possible,  digitalis  and  strychnin  should  be  given 
hypodermically  from  10  to  30  minims  (0.66  to  2  gm.)  of  tincture  of  the 
former  and  1/30  grain  (0.0022  gm.)  of  the  latter.  Friction  should  be 
applied,  and  dry  heat  by  hot-water  bags  or  cans. 

1166 


THERMIC  FEVER  1167 

THERMIC  FEVER. 

Synonyms. — Heat  Fever;  Sunstroke;  Coup  de  soleil. 

Definition. — A  state  of  high  fever  induced  by  exposure  to  heat,  natural 
or  artificial. 

Etiology  and  Pathology. — In  this  country  the  majority  of  cases  occur 
in  the  summer  season  in  those  exposed  to  the  direct  rays  of  the  sun,  though 
they  occur  also  among  those  exposed  to  high  temperature  within  doors, 
as  in  sugar  refineries,  fire-rooms  of  ocean  steamers,  laundries,  and  the  like. 
A  heated  atmosphere  charged  with  moisture,  impeding,  therefore,  evapora- 
tion, produces  fever  much  more  rapidly  than  a  dry  heat,  which  is  in  fact 
slow  to  produce  it.  The  habitual  use  of  alcohol  is  found  to  be  a  potent  pre- 
disposing cause — at  least  alcoholics  succumb  very  much  sooner  to  the  influ- 
ence of  overheat  than  temperate  persons. 

The  pathology  of  the  two  conditions  of  heat  exhaustion  and  thermic 
fever  is  thus  explained  by  H.  C.  Wood:  "There  is  in  the  pons  or  higher 
portion  of  the  nervous  system  a  center  whose  function  it  is  to  inhibit  the 
production  of  animal  heat,  and  in  the  medulla  oblongata  a  center  (probably 
the  vasomotor  center)  which  regulates  the  dissipation  of  bodily  heat. 
Fever  is  due  to  a  disturbance  of  these  centers,  so  that  more  heat  is  pro- 
duced than  normal  and  proportionately  less  thrown  off.  Let  it  be  supposed 
that  a  man  is  placed  in  such  an  atmosphere,  that  he  is  unable  to  get  rid  of 
the  heat  which  he  is  forming.  The  temperature  of  the  body  wiU  slowly  rise, 
and  he  may  suffer  from  a  general  thermic  fever.  If  early  or  late  in  this  con- 
dition the  inhibitory  heat  center  becomes  exhausted  by  the  effort  which  it 
is  making  to  control  the  formation  of  heat,  or  becomes  paralyzed  by  the 
direct  action  of  the  excessive  temperature  already  reached,  then  suddenly 
all  tissues  wiU  begin  to  form  heat  with  the  utmost  rapidity,  the  bodily 
temperature  rises  with  a  bound,  and  the  man  drops  over  with  one  of  the 
forms  of  coup  de  soleil. 

"Heat  exhaustion,"  on  the  other  hand,  "with  lowered  temperature, 
represents  a  vasomotor  palsy — i.  e.,  a  condition  in  which  the  existence  of 
the  heat  paralyzes  the  center  in  the  medulla  oblongata,  and  the  heat  is 
dissipated  more  rapidly  than  it  is  produced."  It  must  be  admitted  that  the 
explanation  of  heat  exhaustion  is  less  satisfactory  than  that  of  thermic  fever. 

Morbid  Anatomy. — The  high  temperature  characteristic  of  heat  fever 
remains  a  long  time  after  death.  Hence  putrefaction  sets  in  early.  Rigor 
mortis  also  occurs  promptly.  The  blood  remains  liquid.  There  is  general 
venous  engorgement,  especially  of  the  lungs  and  cerebrum.  In  early 
autopsies  the  left  ventricle  is  found  contracted,  the  right  dilated. 

Symptoms. — A  sense  of  uncomfortable  burning  heat  and  feeling  of 
oppression  may  precede  the  "stroke"  which  fells  its  victim,  who  quickly 
becomes  unconscious  and  comatose,  perishing  sometimes  instantly,  at 
other  times  in  a  few  hours.  In  other  cases  there  are  intense  headache, 
dizziness,  oppression,  nausea,  and  vomiting,  occasionally  diarrhea.  Chronia- 
topia,  or  colored  vision,  may  be  present.  Sooner  or  later  unconsciousness 
sets  in,  and  may  be  associated  with  muttering  delirium  and  intense  restless- 
ness. In  this  condition  the  patient  is  commonly  admitted  to  hospital  with 
face  flushed,  eye  suffused,  skin  hot  and  dry,  temperatxire  from  107°  to  112° 


11G8        EFFECTS  OF  EXPOSURE  TO  HIGH  TEMPERATURE 

F.  (41.6°  to  44.4°  C),  the  breathing  labored,  and  sometimes  stertorous,  the 
pulse  frequent  and  full.  The  pupils  at  this  stage  are  usually  contracted, 
though  at  first  dilated.  The  urine  is  scanty,  sometimes  albuminous.  Usu- 
ally there  is  relaxation  of  the  muscles,  but  at  times  there  is  a  convulsive 
tendency,  shown  by  twitching  and  jactitation,  and  occasionally  by  epilepti- 
form convulsions.  The  skin,  usually  dry,  may  become  moist  and  bathed 
with  perspiration,  which  does  not,  however,  reduce  the  temperature.  Wood 
speaks  of  a  peculiar  odor  exhaled  by  the  entire  body  as  characteristic. 

Attention  has  been  called  by  C.  F.  Close'  to  cardiac  dilatation  as  a 
symptom  of  thermic  fever. 

In  fatal  cases  the  stupor  deepens,  the  pulse  becomes  more  frequent 
and  loses  even  its  seeming  strength,  then  becomes  irregular;  the  breathing 
is  labored  and  irregular,  and  toward  the  last,  shallow,  or  assumes  the  Cheyne- 
Stokes  type  previous  to  death.  Death  does  not  usually  take  place  for  several 
hours.  In  favorable  cases  improvement  is  indicated  by  a  falling  temperature 
and  a  return  to  consciousness. 

Iron  and  steel  workers,  ships'  stokers,  and  a  variety  of  other  persons, 
whose  occupation  exposes  them  to  very  intense  heat,  frequently  develop 
attacks  of  muscular  spasm,  which  have  been  studied  by  David  L.  Edsall. 
The  spasms  may  be  mild  or  violent  and  intenseh^  painful  and  in  rare 
cases  even  fatal.  The  spasms  especially  affect  the  flexors  of  the  forearms, 
legs,  hands  and  feet,  and  at  times  have  a  superficial  resemblance  to  tetany; 
but  any  or  all  the  muscles  of  the  trunk  and  extremities  may  be  affected  and 
Chvostek's  and  Trousseau's  phenomena  are  absent.  Signs  of  involvement 
of  the  cerebrum,  spinal  cord  and  nerve-trunks  are  usually  absent  also, 
and  the  disorder  seems  to  be  resident  chiefly  in  the  muscles  themselves. 
The  temperature  may  be  somewhat  elevated,  normal  or,  especiail}^  in  the 
severe  cases,  subnormal.  There  is  likely  to  be  marked  and  at  times  danger- 
ous general  coUapse  in  the  very  bad  cases.  In  the  cases  studied  by  Edsall 
there  were  very  remarkable  disturbances  of  metabolism,  showing  severe 
tissue  destruction,  probably  chiefly  in  the  muscles.  Elliott  has  reported 
practically  negative  postmortem  findings. 

Recovery  may  be  complete,  but  more  rarel}^  a  permanent  condition 
results  in  which  there  may  be  more  or  less  constant  mental  weakness,  as 
evidenced  by  incapacity  for  sustained  mental  efTort,  while  exposure  to 
moderate  degrees  of  temperature  produces  great  excitement  or  headache 
or  pain  in  the  upper  cervical  region.  Epileptic  convulsions  sometimes 
occur.     In  these  cases  there  is  probably  a  certain  degree  of  meningitis. 

Mention  has  already  been  made,  when  treating  of  fevers,  of  the  form 
of  continued  fever  occurring  in  the  south  of  the  United  States,  where  it  is 
known  as  "Florida  fever"  and  "country  fever,"  and  in  India  and  the  West 
Indies  as  fievere  inflammatoire,  for  which  John  Guit^ras  proposes  the  name 
continued  thermic  fever,  but  which  more  recently  he  is  inclined  to  ascribe  to  a 
septic  origin. 

Diagnosis. — The  diagnosis  of  heat  fever  presents  no  difficulties.  The 
distinction  between  it  and  heat  exhaustion  has  been  alluded  to. 

Prognosis. — The  prognosis  depends  partly  upon  the  severity  of  the 
case  and  the  promptness  and  thoroughness  of  treatment.     A  few  cases 

*  "Journal  of  the  Am.  Med.  Assoc,"  March  i,  xgoi. 


THERMIC  FEVER 


1169 


are  almost  instantly  fatal.  If  the  cooling  treatment  can  be  applied  properly, 
a  decided  majority — fully  60  per  cent. — recover.  A  temperature  of  110° 
P.  (43.3°  C),  though  indicating  gravity,  should  not  discourage. 


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Treatment. — By  many  the  success  of  treatment  of  thermic  fever  is 
thought  to  depend  altogether  upon  our  ability  to  lower  the  temperature  of 
the  victim.  To  this  end  it  is  directed  the  patient  be  placed  in'  a  bath  of 
water  to  which  ice  is  freely  added  to  keep  the  temperature  down  as  low  as 


1170        EFFECTS  OF  EXPOSURE  TO  UIGU  TEMPERATURE 

possible,  which  in  summer  is  not  likely  to  be  below  60°  F.  (15.54°  C.)- 
It  is  also  directed  that  the  surface  of  the  body  be  vigorously  rubbed  ivith  ice. 
In  the  absence  of  bathing  facilities  the  patient  was  placed  on  a  mattress 
covered  with  a  mackintosh  and  rubbed  with  pieces  of  ice.  The  refrigerat- 
ing effect  is  further  increased  by  ice-water  enemas.  This  treatment  is 
regulated  by  the  temperature  taken  in  the  rectum,  abated  as  the  temperature 
approaches  the  normal,  and  renewed  as  it  again  rose.  Care  must  be  taken 
to  cease  the  baths  when  the  temperature  has  reached  100°. 

Simon  Baruch  holds  that  the  dogma  so  emphatically  insisted  upon  by 
text-book  authors  is  entirely  erroneous.  While  he  contends  that  hyper- 
pyrexia is  not  to  be  regarded  with  indifference,  ner\^e-stimulating  procedures 
are  the  chief  indication.  "In  sunstroke  the  ner\'e  centers  are  so  over- 
whelmed by  the  temperature  acting  on  predisposed  indi\'iduals  that  they 
render  the  patient  incapable  of  responding  to  the  simultaneous  impact  of 
very  cold  water  over  the  entire  body.  Hence  douches  and  affusions  are 
superior  to  ice  baths  and  packs.  The  correct  treatment  is  a  judicious  adap- 
tation of  the  temperature  of  the  water,  the  mechanical  impact  and  the 
duration,  to  the  indications  existing  in  each  case."  Baruch  gives  the 
following  outline  as  a  guide  to  the  management  of  a  case  of  thermic  fever: 

"If  the  ptilse  is  feeble  or  rapid,  skin  pale,  and  the  patient  conscious, 
temperature  above  103°,  treatment  may  be  begun  by  ablution.  The 
patient  lying  upon  a  rubber  sheet  which  is  covered  with  a  blanket  is  rapidly 
bathed  and  rubbed  for  ten  minutes  with  a  wash  cloth  or  large  crumpled 
piece  of  surgical  gauze  saturated  with  water  at  75°.  If  the  skin  shows 
reaction  this  ablution  may  be  repeated  in  half  an  hour  mth  water  at  70°, 
again  in  half  an  hour  with  water  at  65°,  and  so  on  until  the  rectal  temperature 
falls  two  or  three  degrees.  It  is  a  serious  error  to  continue  bathing  until 
the  rectal  temperature  approximates  the  normal  point;  the  record  shows 
that  many  succumb  with  a  normal  temperature,  and  that  others  rapidly 
and  fatally  fall  to  a  subnormal  temperature.  It  is  far  more  prudent  and 
effective  to  repeat  the  treatment  after  the  system  has  had  time  and  oppor- 
tunity to  react  somewhat  and  to  decrease  the  temperature  of  the  water  and 
increase  the  force  of  its  im.pingement  by  slowly  pouring  it  from  a  greater 
height  or  using  a  jet  or  needle  douche  over  successive  parts  of  the  body, 
never  continuing  the  application  upon  any  part  which  is  already  cooled. 

' '  The  sheet  bath  affords  an  excellent  procedure  in  cases  wath  high  temper- 
ature. In  comatose  cases  water  at  50°  F.  to  40°  F.,  delivered  by  a  douche 
or  by  a  forcible  affusion  from  basins  at  short  intervals  over  successive  parts 
of  the  body,  wdll  afford  the  best  results.  Here,  too,  care  shovild  be  exercised 
not  to  depress  the  nerve  centers  by  long-continued  application  of  very  cold  mater. 
Reaction  must  be  induced." 

Baruch  claims  that  the  mortality  in  thermic  fever,  where  this  plan  has 
been  carried  out,  has  been  reduced  from  40  per  cent,  to  60  per  cent.  He 
deprecates  the  erroneous  conception  of  the  authors  of  text-books  of  the 
present  day  that  reduction  of  temperature  is  the  chief  therapeutic  aim 
and  that  the  coldest  bath  is  the  most  efficient  antithennic  bath. 

The  experience  of  one  of  the  authors  in  three  of  the  hospitals  of  Phila- 
delphia during  an  extremely  hot  summer  would  go  to  show  that  criticisms 


CAISSON  DISEASE  1171 

of  Baruch  are  not  justified.  The  number  of  heat  cases  was  large.  The 
treatment  was  by  ice  baths  or  rubbing  with  ice.  The  mortality  was  almost 
zero. 

After  this,  or  in  addition  to  this,  treatment  should  be  symptomatic.  For 
convulsions,  chloral  or  chloroform;  for  heart  failure,  digitalis  and  strychnin 
hypodermically ;  for  asphyxia,  bleeding.  Mild  cases  or  recurrent  fever  may 
be  treated  with  the  antipyretics  represented  by  antifebrin,  phenacetin,  and 
antipyrin. 

In  the  cases  associated  with  muscular  spasm,  treatment  consists  of  the 
use  of  laxatives  and  sedatives,  though  in  the  bad  cases  the  effects  of  even 
morphin  are  unsatisfactory.  Normal  salt  solution  by  enema  or  subcu- 
taneously,  and  freely  used,  may  prove  valuable,  since  chlorids  are  absent 
from  the  urine ;  and  some  cases  seem  to  have  been  benefited  by  this. 

CAISSON  DISEASE. 

(The  Bends,  Diver's  Disease.) 

Definition. — Caisson  disease  is  a  condition  occurring  in  divers  and 
caisson  workers  who  are  compelled  to  spend  some  time  under  high  degrees 
of  atmospheric  pressure.  It  is  the  result  of  the  saturation  of  the  tissues  with 
nitrogen,  followed  by  too  rapid  decompression.  Bubbles  of  nitrogen  are  lib- 
erated in  the  blood,  causing  emboli  and  the  symptoms  of  the  disease. 

History. — The  first  important  observations  upon  the  disease  were  made 
in  1820  by  Howth  of  Dublin.  Dr.  Jaminet  made  important  observations 
upon  the  condition  during  the  building  of  the  St.  Louis  bridge  over  the  Mis- 
sissippi. Dr.  A.  H.  Smith  of  New  York  in  1886  made  important  observa- 
tions during  the  building  of  the  Brooklyn  Bridge.  In  1912  Leonard  Hill 
published  a  monograph  upon  Caisson  Sickness,  which  brings  up  to  date  all 
of  the  experiments  which  have  thus  far  been  made,  and  places  upon  a  sure 
foundation  the  actual  cause  of  the  condition.  From  this  monograph  we 
have  made  many  quotations. 

Etiology. — The  cases  occur  exclusively  in  caisson  workers  and  in  divers. 
It  is  the  direct  result  of  high  pressure  followed  by  too  rapid  decompression. 
According  to  P.  Bert,  who  proves  his  contention  by  many  animal  experi- 
ments, aU  the  effects  consequent  upon  high  pressure  are  due  to  liberation 
of  bubbles  of  nitrogen  in  the  blood.  It  is  neither  CO^  or  O^,  but  nitrogen 
dissolved,  which  once  set  free  upon  decompression  may  in  one  case  block 
the  pulmonary  circulation,  in  another  cause  embolism  of  the  spinal  cord 
and  so  produce  softening  and  paralysis  there,  and  in  another  produce  swell- 
ing and  emphysema  in  the  tissues.  It  has  been  discovered  both  by  animal 
experimentation  and  with  workers,  that  if  the  decompression  is  done  slowly, 
the  disease  does  not  appear.  The  more  rapidly  decompression  occurs, 
the  more  certainly  the  disease  appears,  and  the  more  serious  the  symptoms. 
It  has  been  discovered  by  actual  experiments  made  by  Hill  and  his  co-work- 
ers that  fat  increases  the  susceptibility  to  caisson  disease.  This  is  due  to 
the  fact  that  fat  individuals  take  longer  to  saturate  and  desaturate  the 
nitrogen  than  more  spare  individuals.  Both  Smith  and  Jaminet  noticed 
this  fact  clinically.     "Compression  up  to  4  1/4  atmospheres  is  not  in  itself 


1172        EFFECTS  OF  EXPOSURE  TO  HIGH  TEMPERATURE 

to  be  dreaded.  It  is  endured  without  any  trouble  and  infinitely  better,  to 
rarification  in  a  far  less  proportion  or  degree.  The  return  to  the  normal 
]Dressure  is  alone  to  be  dreaded.  The  risk  of  this  is  proportionate  to  the 
period  and  degree  of  compression,  and  the  rapidity  of  decompression.  It 
is  necessary  to  make  the  last  much  slower."  (Pol  &  WateUe.)  Coolness 
and  fatigue  are  predisposing  causes  of  the  attacks. 

Morbid  Anatomy. — In  postmortem,  lesions  are  found  in  the  central  nerv- 
ous system,  which  consist  of  bubbles  which  are  more  or  less  abundant  in  the 
white  matter  than  in  the  gray  matter,  the  bubbles  which  occur  in  the  gray 
matter  are  nearer  the  edges.  The  bubbles  are  more  frequent  in  the  dorsal 
and  upper  lumbar  cord  than  in  the  lumbar  enlargement.  This  is  probably 
due  to  better  circulation  in  the  lumbar  and  cervical  region  than  in  the 
dorsal  region.  Following  the  gas  embolism  in  the  vessels,  necrosis  of  the 
cord  constantly  follows,  which  is  the  cause  of  the  paraljrtic  symptoms. 
Massive  embolism  both  in  the  lungs  and  liver  occurs.  Thecases  of  sudden 
death  are  probably  due  to  air  embolism  in  the  lungs. 

Symptoms. — The  symptoms  of  the  disease  are  varied.  Pains  in  the 
various  portions  of  the  body ;  myalgia  and  arthralgia  occurred  in  1 8  per  cent, 
and  32  per  cent,  of  the  cases  observed  and  quoted  by  HiU.  Paraplegia 
occurred  in  8.1  per  cent.,  monoplegia  5.3  per  cent.  Paralysis  of  the  bladder 
occurs  usually  accompanying  paraplegia.  Paraplegia  may  last  a  few  min- 
utes, hours,  or  even  days.  It  may  disappear  or  may  persist,  and  is  a  spastic 
condition.  Often  marked  itching  and  formication  of  the  sldn  occurs, 
probably  due  to  formation  of  bubbles  underneath  the  skin. 

In  no  of  Smith's  cases  there  were  three  deaths. 

Prophylaxis  and  Treatment. — Apparently  the  disease  can  be  practically 
prevented  by  careful  decompression.  There  are  two  methods  of  doing  this, 
the  interrupted  adopted  by  Haldane  and  one  supported  by  Hill,  called  the 
continuous  method.  According  to  Hill  the  latter  method  is  preferable 
and  much  less  trying  to  the  workers.  This  is  practically  done  by  allomng 
the  workers  to  pass  through  air  locks,  of  which  the  presstue  in  the  East 
River  Tunnel  was  as  follows:  the  inner  chamber  was  forty  pounds  pressure; 
the  intermediate  29  pounds;  the  outer  was  12  1/2  pounds.  The  men  were 
ordered  to  take  five  minutes  in  the  first  lock,  eight  minutes  in  the  second, 
ten  minutes  in  the  third  lock,  there  being  an  appro.ximate  distance  of  1,000 
feet  between  each  pair  of  locks,  so  that  in  aU  forty-eight  minutes  were  taken 
to  decompress  from  40  pounds  to  atmosphere.  No  serious  or  fatal  cases 
resulted,  and  but  little  time  was  lost  by  the  men  through  caisson  disease. 
Hill  believes  that  if  a  single  lock  had  been  used  at  12  1/2  pounds,  and  very 
active  exercise  been  carried  out,  fifteen  minutes  would  have  sufficed  for 
decompression. 

For  the  painful  condition — friction,  massage,  hot  baths  may  be  tried. 
Oxygen  may  be  given  in  severe  cases,  but  the  most  effecacious  method  is 
recompression.  As  soon  as  the  symptoms  appear,  the  individual  may  be 
sent  cither  back  into  the  locks,  or  into  a  special  recompression  apparatus. 
According  to  Keays,  recompression  relieved  90  per  cent,  of  3,967  cases  of 
pain.  When  treatment  is  delayed  more  than  si.\  hours,  medical  means  are 
as  valuable  as  recompression.  Hot  fomentations,  massage,  hypodermics 
of  morphine  may  be  used  to  relieve  pain. 


POISONS  ■    1173 

Mountain  Sickness. 

Definition. — This  is  a  condition  due  to  low  atmospheric  pressure  en- 
countered at  high  altitudes. 

Symptoms. — The  symptoms  are  vertigo,  palpitation  of  the  heart, 
dyspnea,  and  faintness.  The  symptoms  are  due,  according  to  Holdane, 
Douglass  and  Higgison,  to  want  of  oxygen,  produced  by  the  diminished 
pressure  of  the  atmosphere.  There  is  also  an  increase  in  the  hemoglobin. 
The  red  cells  in  persons  residing  in  high  altitude  are  increased.  In  persons 
with  weak  hearts  there  may  be  syncope  and  intermittent  heart.  These 
symptoms  disappear  when  the  patient  remains  at  these  heights  after  a  long 
time,  provided  there  is  no  organic  disease  of  the  organs.  The  treatment 
is  obvious.  If  the  symptoms  are  severe,  the  patient  should  go  to  a  lower 
altitude. 


SECTION  XIII. 

SUMMARY  OF  SYMPTOMS  FOLLOWING  OVERDOSES  OF 
POISONS. 

(Alffiabetically  Arranged.) 

Aconite  {Monkshood;  Wolfsbane;  Blue  Rocket). — All  parts  poisonous. 
The  tincture  may  be  mistaken  for  sherry  or  whisky;  it  has  an  exceedingly 
acrid  taste. 

Symptoms. — These  appear  quickly,  and  consist  of  an  acrid  taste  in  the 
mouth,  a  feeling  of  warmth  in  the  stomach,  followed  by  a  tingling  sensation 
throughout  the  body;  muscular  weakness,  pulse  weak  and  slow  at  first, 
later  rapid  and  running;  respirations  slow  and  shallow;  vomiting  may  be 
present,  but  is  rare;  the  sldn  is  cold  and  clammy  and  exceedingly  pale; 
death  may  be  gradual,  from  respiratory  failure,  or  it  may  be  sudden  as  a 
result  of  any  movement  of  the  body  which  throws  any  strain  upon  the  heart. 
The  mind  is  clear  to  the  last. 

Treatment. — Stomach- tube  or  emetics  if  seen  early;  recumbent  posttire, 
with  feet  elevated,  not  allowing  the  patient  to  arise  for  any  cause.  Stimu- 
lants freely,  such  as  ammonia,  ether,  digitalis,  atropin,  and  strj^chnin. 
External  heat  about  the  body,  and  artificial  respiration  for  two  hours. 

Alcohol. — Taken  in  the  form  of  spirituous  beverages.  Acute  alcohoUc 
poisoning.  A  brief  period  of  excitement,  with  flushing  of  the  face,  followed 
by  unconsciousness,  stertorous  breathing,  rapid  and,  finally,  weak  pulse, 
vomiting,  a  subnormal  temperature,  delirium,  complete  muscular  relaxation, 
at  times  convulsions;  the  pupils  are  usually  dilated.  Recovery  commonly 
takes  place  in  a  day  or  two,  but  remissions  may  occur.  Odor  of  alcohol 
on  the  breath. 

Treatment. — Evacuation  of  stomach  by  pump ;  emetics,  like  apomorphin, 
i/io  grain  (0.0064  gm.) ;  washing  out  the  stomach.  If  coma  and  total  relax- 
ation are  present,  use  external  heat  and  stimulation  by  ammonia,  atropin, 
cafi:ein,  digitalis,  strychnin,  or  faradic  current  to  muscles  of  respiration 
applied  by  passing  an  electric  brush  rapidly  over  the  surface. 

Delirium  Tremens. — DeUrivun,  with  hallucinations;  great  restlessness 
and  insomnia;  slight  fever,  pulse  rapid  and  soft. 

Treatment.^ — Withdrawal  of  alcohol;  hyoscin  hydrobromid  i/ioo  grain 
(0.00064  gm.)  hypoderniically  ever}'  two  hours  until  patient  is  fully  under 
its  influence;  bromids  in  full  doses,  or  chloral,  provided  that  the  heart  is  not 
weak;  aided  by  a  cold  bath  to  induce  sleep;  nourishing  food  and  stimulation 
if  the  condition  demands  it,  even  by  alcohol. 

Ammonia — Taken  by  mistake  or  wath  suicidal  intent  in  the  form  of 
"household  ammonia,"  water  of  ammonia,  spirit  of  hartshorn,  and  in 
liniments. 

Symptoms. — At  once,  burning  pain  in  the  mouth,  throat,  esophagus,  and 
stomach;  the  lips  and  tongue  are  intensely  swollen  and  inflamed;  vomiting 
of  blood-tinged  mucus,  suffocative  cough,  with  rapidly  increasing  dyspnea. 

1174 


POISONS  1175 

The  face  is  pale,  pulse  is  rapid  and  thready,  and  coUapse  soon  develops. 
Death  may  follow  at  once  as  the  resvilt  of  spasm  or  edema  of  the  glottis, 
or  some  days  later,  from  the  violent  gastro-enteritis  and  stricture  of  the 
esophagus. 

Diagnosis. — Odor  of  ammonia  on  the  breath,  vapors  of  the  corresponding 
salt  when  a  rod  dipped  in  hydrochloric  acid  is  held  before  the  mouth,  to- 
gether with  the  sudden  onset  of  the  symptoms. 

Treatment. — Neutralization  with  vinegar,  orange- juice,  lemon- juice, 
or  some  other  dilute  acid,  as  soon  as  possible.  If  the  patient  hves,  admin- 
ister milk  and  bland  oils  to  soothe  the  inflamed  mucous  membrane.  Give 
morphin  to  relieve  pain,  stimulants  to  overcome  depression,  and  apply 
external  heat  to  maintain  bodily  temperature.  Tracheotomy  should  be 
performed  if  there  is  danger  of  death  from  edema  of  the  glottis. 

Antimony. — Taken  as  a  tartar  emetic,  the  tartrate  of  antimony  and 
potassium.  A  heavy,  white,  odorless,  slowly  soluble  powder  ha\'ing  a 
sweetish,  metallic  taste ;  charring  to  redness  upon  heating. 

Symptoms. — Metallic  taste  in  the  mouth,  muscular  relaxation,  skin 
moist  and  relaxed,  severe  nausea  and  gastric  distress  followed  by  violent 
vomiting,  and  purging  of,  first,  the  normal  contents  of  the  bowel  and  later 
of  serous  material  containing  small  shreds  of  mucous  membrane.  Cramps 
in  the  abdomen  and  in  the  muscles  of  the  arms  and  legs  occur  as  the  result 
of  the  abstraction  of  water  from  the  tissues  by  the  violent  purging.  At 
the  same  time,  symptoms  of  coUapse  appear — cold,  clammy  sldn,  feeble, 
shallow  respirations,  weak,  thready  pulse,  subnormal  temperature,  coma 
and  death. 

Treatment. — Tannic  acid  as  the  chemical  antidote,  followed  by  washing 
out  the  stomach;  recumbent  posture  with  the  head  low,  not  allowing  the 
patient  to  raise  the  head;  external  heat,  stimulants,  opium  for  the  pain 
and  demulcent  drinks,  such  as  bland  oils,  mucilages  and  albumin  water,  to 
soothe  the  inflamed  mucous  membrane. 

Arsenic. — Used  in  the  form  of  arsenic  trioxide  in  rat-poisons,  in  fly- 
paper, and  to  preserve  stuffed  birds  and  animals.  Paris  green,  used  as 
potato-bug  poison,  is  an  arsenite  of  copper,  hence  the  symptoms  are  similar. 
Arsenous  acid,  or  white  arsenic,  is  an  odorless,  tasteless,  white  powder, 
quite  heavy,  and  but  slowly  soluble  in  water. 

Symptoms. — ^These  appear  usually  in  the  course  of  an  hour,  and  are 
those  of  violent  gastro-enteritis,  so  severe  as  to  suggest  Asiatic  cholera. 
Burning  pain  in  the  throat  and  stomach,  persistent  vomiting  of  brown 
matter  streaked  with  blood,  though  the  vomited  matter  may  be  green 
from  bile.  Purging  is  very  severe;  the  stools,  after  the  passage  of  the 
normal  contents  of  the  bowel,  are  serous  as  in  antimonial  poisoning,  but 
contain  larger  flakes  of  mucous  membrane  and  blood.  The  urine  is  scanty, 
concentrated,  and  contains  albumin.  Great  prostration  accompanies 
these  symptoms  and  the  patient  dies  in  coUapse  in  one  or  two  days.  If  the 
patient  survives  so  long,  there  is  usually  an  intermission  in  the  symptoms 
about  the  third  day  which  in  a  few  hours  is  followed  by  a  return  of  the 
symptoms.  Nervous  symptoms  may  appear.  The  poisoning  resembles 
cholera  morbus  and  Asiatic  cholera. 

Treatment. — An  emetic  if  seen  early,  wash  out  the  stomach,  external 


1176  POISONS 

heat  and  stimulants.  The  best  antidote  is  the  official  ferri  hydroxidum  cum 
magnesii  oxido,  or  ferri  hydroxidum.  These  should  be  freshly  prepared. 
In  the  absence  of  these  official  preparations,  any  liquid  preparation  of  iron 
may  be  used  by  diluting  ^ith  water,  then  adding  a  dilute  solution  of  am- 
monia, strain  out  the  precipitate,  wash  it  free  of  ammonia  while  on  the 
strainer,  then  dilute  with  fresh  water  and  administer  freely. 

Atropin  (Belladonna)  .■ — The  deadly  nightshade.  Used  as  a  mydriatic 
and  in  liniments.  The  leaves  impart  a  narcotic  odor  to  the  tincture,  but 
recognition  depends  upon  the  physiological  effect. 

Symptoms. — Face  flushed,  skin  hot  and  dry,  throat  dry,  pupils  widely 
dilated,  pulse  rapid  and  bounding,  respirations  quickened  and  deepened; 
if  the  dose  has  been  large  there  ma}^  be  active,  talkative  delirium.  An 
erythematous  or  scarlatiniform  rash  is  sometimes  present.  The  urine 
contains  the  alkaloid,  hence  it  wall  cause  dilatation  of  the  pupil  if  dropped 
into  the  eye  of  an  animal. 

Treatment. — Tannic  acid  as  a  chemical  antidote,  followed  by  the  stom- 
ach-tube or  emetics.  Morphin,  physostigmin  or  pilocarpin  as  physiological 
antagonists.     External  heat  and  stimulants  if  the  patient  goes  into  collapse. 

Belladonna. — See  Atropin. 

Bromin. — A  dark  red,  very  heavy  liquid,  emitting  reddish  vapors  re- 
sembling chlorin. 

The  fumes,  when  inhaled,  cause  convulsive  cough,  bloody  expectoration, 
dyspnea,  and  spasm  of  the  glottis. 

Treatment. — Fresh,  moist  air  and  cautious  inhalations  of  ammonia. 

Bromism. — -The  symptoms  of  chronic  gastro-intestinal  disturbance, 
such  as  fetor  of  the  breath,  anorexia,  diarrhea;  great  depression  of  all  the 
functions,  especially  the  sexual  function,  with  languor  and  mental  apathy. 
A  general  eruption  of  acne  is  an  early  sign. 

Treatment. — Stop  the  administration  and  aid  elimination. 

Carbonic  Acid  Gas. — The  choke  damp  or  after-damp  of  miners.  May 
be  accidently  inhaled  in  overcrowded  rooms,  in  fermenting  vats,  over  lime- 
kilns,- or  wherever  the  products  of  complete  combustion  cannot  escape. 

Symptoms. — Headache,  dizziness,  noises  in  the  ears,  a  sense  of  tightness 
across  the  chest,  great  drowsiness,  loss  of  muscular  power,  followed  by 
symptoms  of  asphyxia;  coma,  tumultuous  heart  action,  stertorous  breathing, 
cyanosis,  possibly  convulsions  and  sometimes  delirium. 

Treatment. — Fresh  air,  if  need  be  artificial  respiration,  kept  up  steadily 
and  unceasingly;  ammonia  by  inhalation;  oxj'gen,  if  obtainable;  cold  douche 
to  the  head  and  chest,  with  external  heat  and  stimulation  as  occasion  requires. 
Use  of  pulmotor. 

Carbonic  Oxid  [Carbon  Monoxid)  is  formed  during  the  incomplete 
combustion  of  carbon,  and  is  a  direct  poison,  while  carbonic  acid  gas,  the 
product  of  complete  combustion,  kills  merelj^  by  exclusion  of  oxygen. 

Symptoms. — The  same  as  in  carbonic  acid  poisoning. 

Treatment  as  for  carbonic  acid  gas. 


POISONS  1177 

Caustic  Potash  or  Soda. — Taken  in  the  form  of  "lye." 

Symptoms. — An  acrid,  burning  taste,  the  burning  extending  down  to 
the  stomach,  followed  by  vomiting,  purging,  and  collapse.  The  mucous 
membrane  of  the  mouth  shows  evidence  of  corrosion.  Convulsions  may 
occur.  Stricture  of  the  esophagus  may  follow  recovery  from  the  acute 
symptoms. 

Treatment. — Dilute  vegetable  acids,  such  as  vinegar,  lemon-juice,  or 
orange-juice,  to  neutralize.  Demulcent  drinks,  such  as  bland  oils,  mucilages, 
milk,  or  white  of  egg.  Opium  or  morphin  for  the  pain.  External  heat  and 
stimulants.  The  stomach-tube  should  not  be  used.  If  the  patient  lives, 
the  resulting  stricture  of  the  esophagus  may  require  dilatation. 

Cheese  Poisoning. — Decayed  cheese  owes  its  poisonous  properties 
probably  to  tyrotoxicon. 

Symptoms. — Violent  vomiting  and  purging;  pain  in  abdomen;  tongue 
first  coated  white,  later  red  and  dry;  pulse  weak  and  irregular;  face  is  first 
pale,  later  cyanotic.     The  poisoning,  while  severe,  rarely  causes  death. 

Treatment. — -The  stomach-tube  may  be  used  if  vomiting  has  not  been 
free ;  subsequent  lavage ;  opium  and  demulcent  drinks  to  relieve  pain  and 
irritation;  stimulants. 

Chloral. — A  popular  somnifacient  and  sedative.  Occurs  in  deliques- 
cent crystals  with  characteristic  odor  and  acrid,  burning  taste. 

Symptoms. — Shortly  after  swallowing  a  poisonous  dose  of  chloral, 
the  'patient  becomes  drowsy  and  gradually  passes  into  a  state  of  coma,  from 
which  he  cannot  be  aroused.  Respirations  are  slow  and  labored  at  first, 
later  shallow  and  feeble;  the  pulse  is  feeble  and  shallow;  the  face  may  be 
white,  livid,  or  cyanotic;  the  skin  is  relaxed,  cold,  and  clammy;  the  pupils, 
at  first  contracted,  later  become  widely  dilated ;  there  is  complete  muscular 
relaxation  and  abolition  of  reflexes;  the  temperature  is  lowered  more  than 
by  any  other  toxic  agent. 

Treatment. — An  emetic,  if  seen  early,  or  use  the  stomach-pump.  The 
maintenance  of  bodily  temperature  is  of  the  utmost  importance.  Rouse 
the  patient,  and  employ  artificial  respiration  with  the  faradic  current  and 
by  other  methods  usually  employed.  The  head  should  be  kept  lower  than 
the  feet,  and  the  patient  should  not  be  allowed  to  raise  the  head  or  body 
for  any  reason.     Stimulants  should  be  given  in  full  doses. 

Chloroform. — Identified  by  its  peculiar  ethereal  odor  and  sweet, 
pungent  taste;  a  heavy,  volatile,  non-inflammable  liquid,  not  miscible  with 
water. 

Symptoms. — First  stage  of  narcosis,  excitement,  struggling,  a  flushed 
face,  contracted  pupils,  lessened  sensibility  to  pain.  Second  stage,  muscular 
relaxation,  loss  of  sensibihty,  unconsciousness,  reflexes  abolished,  tempera- 
ture subnormal,  respiration  slow,  pupils  dilated,  pulse  slow.  Third  stage, 
that  of  paralysis,  in  which  the  pulse  is  irregular  and  weak,  respiration  fails, 
skin  becomes  cyanotic.  Death,  which  results  primarily  from  vasomotor 
paralysis  with  secondary  respiratory  paralysis  and  cardiac  failure,  may  occur 
in  any  stage. 

If  the  drug  has  been  swallowed,   the  patient  experiences  an  intense 


1178  POISONS 

burning  pain  in  the  mouth,  throat,  and  stomach,  vomiting  and  purging, 
followed  by  the  symptoms  of  narcosis  enumerated  above. 

Treatment. — In  case  of  accident  during  anesthesia,  the  patient  should 
be  held  head  downward;  employ  artificial  respiration;  rhythmical  traction 
of  the  tongue  by  grasping  it  with  forceps  and  pulling  it  out  of  the  mouth 
and  upward  about  14  times  a  minute;  bandages  to  the  extremities,  and 
compression  of  the  abdomen  by  means  of  a  compress  and  bandage  to  confine 
the  blood  to  vital  centers;  external  heat;  strychnin  and  other  stimulants 
hypodermically ;  adrenalin  chlorid  intravenously  or  by  hypodermoclysis. 
The  faradic  current  may  be  used  by  sweeping  the  electrode  over  the  chest 
to  promote  respiration.  When  swallowed,  the  stomach-tube  or  emetics 
should  be  used  prior  to  the  treatment  above. 

CocAiN. — Solution  used  as  a  local  anesthetic,  particularly  in  eye  surgery. 

Symptoms. — ^ Vertigo,  headache,  paroxysmal  dj^spnea,  rapid  weak  pulse, 
elevated  temperature,  mental  excitement,  blindness,  delirium,  coma,  and 
convulsions.  Some  of  these  may  be  caused  by  the  local  application  of 
solutions  to  mucous  membranes.  The  pupil  is  dilated,  but  the  power  of 
accommodation  remains  in  part. 

Treatment. — Nitrite  of  amyl,  stimulants,  atropin,  caffein,  and  ammonia. 
Wash  out  the  stomach  or  administer  an  emetic  if  the  drug  has  been  swallowed. 
Death  is  unusual. 

CoNiUM  {Poison  Hemlock;  Common  or  Spotted  Hemlock). — Not  a  native 
of  this  country,  hence  cases  of  poisoning  must  be  restricted  to  the  use  of  the 
preparations.  The  plant  and  some  of  the  preparations  have  a  peculiar 
odor,  resembling  the  urine  of  mice. 

Symptoms. — Loss  of  muscular  power,  first  felt  in  the  legs,  going  on  to 
complete  paralysis  which  creeps  up  toward  the  trunk,  the  arms  being  less 
rapidly  affected.  The  muscles  of  respiration  become  involved  eventually, 
the  patient  becomes  cyanotic,  and  death  results  from  asphj^xia.  The  pupils 
are  dilated,  the  skin  is  relaxed  and  clammy  and  ptosis  is  a  prominent  symp- 
tom. Sometimes  delirium,  coma  and  convulsions  are  prominent  from  the 
first. 

Treatment. — Stomach-pump  or  emetics;  tannic  acid;  stimulants, 
particularly  strychnin;  external  heat;  artificial  respiration. 

Copper. — The  sulphate,  blue  stone  or  blue  vitriol,  is  used  in  the  arts. 
Recognized  by  its  crystalline  shape,  blue  color,  and  acrid,  metallic  taste. 
Articles  of  food  are  frequently  prepared  in  imperfectly  cleansed  copper  ket- 
tles; a  bright  piece  of  steel,  such  as  a  knife,  will  show  a  deposit  of  metallic 
copper  a  few  minutes  after  immersion  in  a  liquid  containing  copper.  Verdi- 
gris (subacetate)  is  another  source. 

Symptoms. — -An  astringent,  metallic  taste  in  the  mouth;  pain  in  the 
stomach  and  abdomen;  violent  vomiting  of  a  greenish  or  bluish  liquid; 
profuse  purging  of  the  normal  contents  of  the  bowel,  later  mucus  and  blood, 
accompanied  by  tenesmus;  jaundice,  respiratory  failure,  collapse,  coma, 
and  death. 

Treatment. — Stomach-pump  and  emetics  if  vomiting  has  not  already 
emptied  the  stomach;  yellow  prussiate  of  potassium  (potassium  ferrocya- 


POISONS  1179 

nid)  as  the  chemical  antidote;  demulcents,  such  as  bland  oils,  white  of  egg, 
and  milk;  opium  for  the  pain;  external  heat  and  stimulants. 

Digitalis  (Foxglove). — A  native  of  Europe.  The  tincture  has  a  dis- 
tinct odor  of  tea,  the  drug  itself  lacking  a  narcotic  odor. 

Symptoms. — Nausea,  vomiting,  pain,  with  or  without  diarrhea;  head- 
ache, often  severe,  occasionally  delirium  and  convulsions;  the  skin  is  cold 
and  clammy;  the  pupils  are  dilated;  the  pulse  at  first  slow  and  full,  later 
becomes  dicrotic  or  shuttle-like  and  difficult  to  count,  while  the  heart-beat 
is  irregular  and  tumultuous ;  the  patient  may  show  an  inclination  to  somno- 
lence, which  may  deepen  into  coma;  death  may  not  result  for  several  days 
or  it  may  occur  suddenly  following  a  muscular  exertion. 

Treatment. — Emetics  or  the  stomach-pump  may  be  used  early;  tannic 
acid  as  the  chemical  antidote ;  aconite  may  be  used  early  as  the  physiological 
antagonist;  external  heat;  horizontal  position  for  several  days  after  active 
symptoms  have  subsided;  stimulants,  such  as  ammonia,  ether,  atropin 
and  strychnin,  may  be  used  in  the  later  stages  to  combat  collapse. 

Ergot. — Used  to  produce  abortion. 

Symptoms  of  Acute  Poisoning. — Giddiness ;  pain  in  the  stomach ;  thirst ; 
nausea;  vomiting;  cardiac  oppression;  numbness  and  tingling  of  fingers 
and  toes,  extending  along  the  limbs;  cramp;  dyspnea;  coldness  of  the  body, 
especially  the  limbs;  great  anxiety;  delirium;  coma  and  convulsions  are 
among  the  symptoms  which  may  be  produced. 

Treatment. — Emetics  or  stomach-tube.  Stimulants  and  external  heat 
as  necessary.     Nitroglycerin  may  be  administered  by  the  mouth. 

Chronic  ergotism  occurs  as  a  result  of  eating  bread  made  from  grain  con- 
taminated with  the  fungus.  Early  symptoms  are  gastric  pain,  general  de- 
pression, nausea,  occasionally  vomiting;  sometimes  diarrhea,  at  others 
constipation,  dizziness,  insomnia,  and  lack  of  energy.  Subsequent  symp- 
toms may  take  one  or  both  of  two  courses:  (i)  Gangrenous  ergotism  char- 
acterized by  patches  of  anesthesia,  with  a  sensation  of  coldness  of  the  parts 
affected,  or  by  a  burning  sensation  with  redness  of  the  skin.  This  usually 
occurs  in  the  fingers  and  toes,  and  is  followed  by  dry  gangrene  which  may 
advance  as  far  as  the  elbows  or  knees,  but  rarely  affects  the  trunk.  (2) 
Spasmodic  ergotism  characterized  by  paresthesias  of  various  kinds ;  some- 
times there  is  complete  anesthesia.  Motor  disturbances  follow:  twitchings, 
spastic  muscular  contractions  attended  with  great  pain,  paralyses,  and 
disturbance  of  the  special  senses. 

FiSH-POisoNiNG. — Tainted  fish  probably  contains  ptomains,  while 
several  kinds  of  fish  are  constantly  poisonous. 

Symptoms. — Vomiting,  profuse  purging,  thirst,  great  pain  in  the  abdo- 
men and  in  the  head,  with  subsequent  collapse  and  death  in  some  instances. 

Treatment. — Emetic  or  stomach-pump  if  vomiting  has  not  occurred, 
stimulants,  external  heat,  and  artificial  respiration  if  required. 

Hydrochloric  Acid. — See  Mineral  Acids. 

Hydrocyanic  Acid  (Prussic  Acid). — The  pure  acid  is  an  exceedingly 
poisonous  gas.     In  medicine  it  is  employed  as  a  2  per  cent,  aqueous  solution. 


1180  POISONS 

Contained  in  oil  of  bitter  almonds  distilled  from  the  seed ;  not  found  in  the 
artificial  or  the  purified  natural  product.  Its  salt,  the  cyanid  of  potassium, 
is  employed  as  a  quickly  acting  poison  for  the  destruction  of  animals. 
Contained  also  in  cherry-laurel  water. 

Symptoms. — The  patient  may  drop  dead  almost  immediately  after  a 
large  dose  of  the  poison  has  been  swallowed.  When  smaller  doses  have  been 
taken  there  is  first  difficult  respiration,  slow  pulse,  dizziness,  impeded 
locomotion,  a  sense  of  constriction  and  heaviness  in  the  head,  progressive 
intellectual  confusion,  followed  by  tetanic  convulsions,  involuntarj'  evacua- 
tions of  urine  and  feces,  with  ejaculations  of  semen,  dilated  pupils,  in  turn 
succeeded  by  asphyxia,  collapse,  general  paralysis,  and  death. 

The  odor  of  hydrocyanic  acid  about  the  body,  the  wide-staring  eyes, 
the  clinched  teeth  covered  with  froth,  and  the  cj'anotic  face  are  diagnostic 
of  death  by  this  poison. 

Treatment. — Stomach-pump  or  emetics,  stimulants,  artificial  respira- 
tion, rapidly  interrupted  current  applied  by  means  of  an  electric  brush 
swept  quickly  over  the  chest,  alternate  hot  and  cold  douche.  If  the  patient 
survives  for  2  o  minutes  or  half  an  hour,  the  chances  are  in  favor  of  his  recovery. 

lODiN. — May  be  taken  by  mistake;  the  tincture  has  the  odor  of  iodin, 
which  somewhat  resembles  chlorin. 

Symptoms. — Metallic  taste  in  the  mouth,  salivation,  great  pain  in 
esophagus,  stomach,  and  abdomen,  followed  by  violent  vomiting  and  purging. 
Face  pale,  pulse  rapid,  running,  and  feeble;  urine  suppressed;  death  occurs 
from  respiratory  paralysis.  The  presence  of  iodin  is  detected  by  the  blue 
color  of  the  ypmited  material  if  starch  has  been  present. 

Treatment. — Boiled  starch  (arrowroot  or  flour),  as  a  chemical  antidote; 
emetics  and  stomach-pump ;  opium  or  morphin  for  the  pain ;  external  heat, 
stimiilants,  and  demulcent  drinks. 

Iodoform. — Rarely  taken  internally,  but  toxic  sjTnptoms  may  appear 
when  used  freely  as  an  antiseptic  dressing. 

Symptoms. — In  mild  cases,  malaise,  nausea,  vomiting,  headache, 
anorexia,  followed  by  cerebral  excitement,  insomnia,  fever,  erythematous 
rashes  on  the  skin;  small,  rapid  pidse;  hematuria,  or  retention  of  urine,  and 
in  severe  cases  maniacal  delirium,  coma,  and  at  times  death. 

Treatment. — SouUier  advocates  sodium  bicarbonate  to  unite  with  the 
iodin  and  so  aid  in  its  elimination.  External  heat,  stimulants.  Emetics 
may  be  used  if  the  drug  has  been  swallowed. 

Lead. — Taken  most  frequently  as  sugar  of  lead  (acetate),  or  in  the  form 
of  Goulard's  solution  (subacetate) ,  lead  water  (subacetate),  white  lead 
(carbonate) . 

Symptoms  of  Acute  Poisoning. — After  the  acetate  has  been  swallowed, 
the  patient  complains  of  a  sweet,  metalUc  taste  in  the  mouth,  a  feeling  of 
constriction  in  the  esophagus,  followed  by  vomiting  of  white,  opaque 
masses;  great  thirst;  cramps  in  the  calves  of  the  legs,  occasionally  paralysis; 
constipation  or  diarrhea,  the  feces  being  black,  due  to  the  formation  of 
lead  sulphid;  great  prostration,  coma,  and  death. 


POISONS  1181 

Treatment. — Emetics  and  the  stomach-pump.  Magnesium  or  sodium 
sulphate  in  large  quantities  as  chemical  antidotes.  Opium  or  morphin  for 
the  pain.     External  heat.     Stimulants.     Demulcent  drinks. 

Chronic  Poisoning. — Obstinate  constipation,  with  colicky  pains  center- 
ing around  the  umbilicus;  abdominal  walls  retracted  and  hard;  a  blue  line 
on  the  gums,  due  to  a  deposit  of  lead  sulphid;  the  tongue  is  coated;  the  appe- 
tite diminished;  pulse  hard  and  tense;  bilateral  wristdrop,  due  to  peripheral 
neuritis,  with  paralysis  of  the  extensor  muscles  of  the  forearm;  arthralgia, 
especially  of  the  knee-joints,  less  frequently  involving  the  elbows  and 
shoulders;  cerebral  disturbances — headache,  vertigo,  insomnia,  delirium, 
epileptiform  convulsions. 

Treatment. — Remove  the  cause;  promote  elimination  by  the  administra- 
tion of  potassium  iodid  in  full  doses,  and  by  the  use  of  hot  baths;  opium  or 
morphin  for  the  pain  and  to  relax  the  spasm  of  the  intestine  caused  by  the 
lead;  strychnin  in  full  doses  with  electricity,  massage,  fresh  air,  and  good 
food  to  overcome  paralysis  and  increase  general  nutrition. 

Meat  Poisoning. — Vide  Ptomain  Poisoning. 

Mercury  (Corrosive  Sublimate;  Bichlorid  of  Mercury;  Mercuric  Chlorid, 
or  the  Perchlorid) . — Used  in  aqueous  solution  as  bed-bug  poison,  as  an  insecti- 
cide, to  preserve  specimens,  and  as  an  antiseptic  surgical  dressing. 

Symptoms  of  Acute  Poisoning. — Acrid,  metallic  taste  in  the  mouth, 
followed  by  burning  pain  in  the  esophagus,  stomach  and  abdomen;  the 
mucous  membrane  of  mouth  and  pharynx  is  white  and  swollen;  severe 
vomiting  of  the  stomach  contents  mixed  with  shreds  of  mucous  membrane 
and  blood;  violent  purging  accompanied  by  severe  tenesmus,  the  stools 
being  watery  and  blood-streaked;  urine  scanty  or  suppressed;  profound 
prostration,  collapse,  and  death. 

Treatment. — White  of  egg  as  the  chemical'  antidote ;  wash  out  the  stom- 
ach or  give  emetics  if  vomiting  is  not  profuse ;  external  heat ;  opium  for  the 
pain;  demulcent  drinks;  stimulants. 

Chronic  Poisoning. — Symptoms. — Increased  salivation;  swelling  and 
tenderness  of  the  gums  when  the  jaws  are  snapped  together;  fetid  breath; 
nausea,  vomiting  and  diarrhea  may  be  present  at  intervals;  loss  of  flesh  and 
strength;  anemia;  skin  eruptions;  nervous  disorders — tremors,  psychical 
disturbances,  choreic  movements,  hallucinations,  mania,  and  paralyses  as 
a  resvdt  of  peripheral  neuritis. 

Treatment. — Remove -the  cause;  aid  elimination;  administer  stimulants, 
good  food  and  tonics;  combat  other  symptoms  as  necessity  arises. 

Mineral  Acids. 

Hydrochloric  Acid  (Muriatic  Acid;  Spirit  of  Salt). 

Symptoms. — -Similar  to  those  mentioned  under  sulphuric  acid,  though 
the  acid  is  not  so  powerful  and  leaves  no  distinctive  stain.  It  may  be 
recognized  by  its  odor  and  by  the  white  fumes  formed  when  the  gaseous 
acid  comes  into  contact  with  ammonia.  Medicinally  and  in  the  arts  hydro- 
chloric acid  is  used  in  aqueous  solution,  the  commercial  variety  tinted  yellow 
from  a  trace  of  iron. 

Treatment. — Same  as  for  sulphuric  acid. 


1182  POISONS 

Nitric  Acid  {Aqua  fortis). — A  colorless,  moderately  heavy  liquid  of 
peculiar  and  characteristic  odor,  staining  organic  tissues  yellow. 

Symptoms. — The  same  as  those  mentioned  under  sulphuric  acid, 
though  the  characteristic  yellow  stain  ma^^  be  found  on  the  lips. 

Treatment. — As  for  sulphuric  acid. 

Sulphuric  Acid  {Vitriol;  Oil  of  Vitriol). — A  very  heavj'-,  colorless, 
odorless  liquid,  having  a  very  acid  taste  and  mixing  with  water  with  the 
production  of  great  heat.  Used  largely  in  the  arts.  Turns  organic  matter 
black. 

Symptoms. — Intense  burning  pain  in  m.outh,  stomach,  and  abdomen; 
mucous  membrane  of  mouth  is  swollen,  corroded  or  excoriated,  sometimes 
white;  lips  swollen  and  excoriated;  vomiting  of  a  blackish  fluid,  containing 
shreds  of  mvicous  membrane  and  coagulated  mucus;  intense  thirst  with 
great  dysphagia;  bowels  usually  constipated,  occasionally  diarrhea,  the 
stools  containing  altered  blood  and  shreds  of  mucous  membrane;  urine 
scanty  or  suppressed;  great  feebleness  and  collapse. 

Death  may  occur  in  the  stage  of  collapse.  It  often  occurs  suddenly 
either  from  edema  of  the  glottis,  from  pulmonary  embolism  or  thrombosis, 
from  perforation  of  the  stomach,  or  later  by  the  secondary  efl^ects  resulting 
from  esophageal  stricture  and  destruction  of  the  gastric  mucous  membrane. 

Treatment. — Neutralize  by  giving  oxide  of  magnesia,  chalk,  lime-water, 
soap  and  water,  and  water  in  large  quantity ;  demulcent  drinks ;  opium  or 
morphin  for  the  pain;  external  heat;  stimulants.  The  stomach-pump 
should  not  be  used  in  sulphuric-acid  poisoning. 

Morphin  Poisoning. — See  Opium  Poisoning. 

Mushroom  Poisoning. — Harmless  varieties  may  prove  poisonous  to 
some  individuals.  Agarictis  muscarius  is  the  most  poisonous  variety, 
containing  the  active  principle  muscarin.  The  fungus  is  bright  red,  with 
yellow  spots.  As  a  rule,  highly  colored  fungi,  with  an  astringent,  styptic 
taste  and  a  pungent  odor  should  be  avoided;  they  frequent  especially  dark 
and  shady  places. 

Symptoms. — These  may  be  divided  into  gastro-intestinal  and  nervous. 

Gastro-intestinal  symptoms  appear  six  to  ten  hoiirs  after  the  fungi  have 
been  swallowed.  Pain  in  the  stomach  and  abdomen,  nausea,  vomiting, 
and  diarrhea.  Great  thirst;  small,  weak  ptilse;  sldn  cold,  clammy  and 
livid ;  great  prostration  which  may  restdt  in  death. 

Nervous  symptoms  consist  of  muscular  twitchings ;  con\-ulsions ;  delirium ; 
disorders  of  special  senses,  especially  of  vision;  stupor  or  profound  coma. 

Treatment. — Emetic;  castor  oil  to  evacuate  the.  bowels;  atropin  as  the 
physiological  antidote;  external  heat;  stimulants. 

NicoTiN.— The  Uquid,  volatile  alkaloid  of  tobacco.  An  acrid,  oily 
liquid  of  amber  color,  smelling  of  tobacco.  A  very  deadly  and  quickly 
acting  poison. 

Symptoms. — Burning  in  throat;  dizziness;  muscular  weakness;  nausea; 
vomiting;  skin  cold,  clammy;  pulse  rapid  and  feeble;  pupils  at  first  con- 


POISONS  1183 

tracted,  later  dilated;  mental  confusion,  delirium,  and  convulsions.     Death 
may  occur  within  a  short  time  after  the  poison  has  been  taken. 

Treatment. — Emetics  or  the  stomach-tube,  followed  by  tannic  acid  as 
an  antidote;  stimulants;  external  heat;  artificial  respiration,  if  necessary; 
strychnin. 

NiTROBENzOL  {Nitrobenzene;  Oil  of  Mirbane;  Artificial  Oil  of  Bitter 
Almonds). — Used  in  the  preparation  of  amlin  dyes  and  in  the  arts  on 
account  of  its  flavor  (soaps,  etc.).  Recognized  by  its  highly  characteristic 
odor. 

Symptoms. — Characteristic  intense  cyanosis  extending  over  the  whole 
body;  headache;  dizziness;  muscular  weakness;  breathing  irregular  and 
stertorous;  vomiting  may  occur,  the  vomited  matter  having  the  odor  of  the 
poison,  as  does  the  breath;  mental  confusion,  stupor  and  coma;  pulse  weak; 
temperature  lowered;  skin  relaxed;  the  pupiLs  may  be  dilated  or  contracted, 
usually  dilated. 

Treatment. — Evacuate  and  wash  out  the  stomach  thoroughly;  external 
heat  wath  friction;  artificial  respiration  and  faradism,  if  necessarv-;  stimulants 
as  required;  alcoholic  stimulants  shovild  not  be  given  until  after  evacuation 
of  the  stomach  because  alcohol  renders  the  poison  more  soluble. 

Opium  Poisoning  (Acute)  .-^Taken  accidentally  or  with  suicidal  intent 
in  the  shape  of  morphin  or  laudanum. 

Symptoms. — The  first  stage,  which  is  of  short  duration,  is  marked  bj- 
restlessness;  increased  mental  activity  with  a  feeling  of  exhilaration;  cardiac 
stimulation  and  flushed  face.  This  is  succeeded  by  a  second  stage  of  stupor, 
ushered  in  by  drowsiness,  followed  by  deep  sleep;  slow,  iu\l  pulse;  respira- 
tions slow  and  fuU;  contracted  pupils;  warm,  drj^  skin.  During  this  stage, 
the  patient  can  be  aroused,  but  goes  to  sleep  again  when  he  is  not  disturbed. 
The  patient  passes  insensibly  into  the  tliird  stage  which  is  characterized  by 
inability  to  arouse  the  patient;  cyanosis;  respirations  verj^  slow  and  shallow; 
muscular  relaxation;  the  skin  becomes  relaxed,  cold  and  clammy;  the  pupils 
dilate  just  before  death  occurs. 

Treatment. — Wash  out  the  stomach  thoroughly  and  frequently;  solution 
of  potassium  permanganate  or  tannic  acid  as  chemical  antidotes;  strong, 
hot  cofliee  by  enema;  strychnin  hypodermically  with  atropin;  keep  the 
patient  awake  by  mild  flagellation,  shaking,  shouting,  or  by  the  use  of  the 
electric  brush  swept  quickly  over  his  chest,  using  the  faradic  current;  artifi- 
cial respiration,  external  heat  and  stimulants  in  the  later  stage. 

Oxalic  Acid. — Mistaken  for  Epsom  salt;  taken  with  suicidal  intent. 
Occurs  in  prismatic,  colorless,  odorless  crystals,  vnth  a  very  sour  taste. 
Volatile  without  charring  at  a  red  heat. 

Symptoms. — ^After  large  amounts  have  been  swallowed  there  is  pain  in 
the  mouth,  stomach,  and  abdomen;  persistent  vomiting  of  altered  blood; 
violent  purging  of  a  bloody  material ;  cramps  in  the  legs ;  the  skin  is  cold, 
clammy  and  cyanotic;  collapse  follows;  more  rarely  convulsions  occur. 

Treatment. — Calcium  carbonate  in  the  form  of  chalk,  lime-water, 
whiting,  marble  dust,  plaster  from  the  walls,  or  egg-shells  powdered  and 


1184  POISONS 

suspended  in  a  little  water.     Calcined  magnesia  may  be  given.     Follow 
these  by  an  enema  or  castor  oil  to  sweep  out  the  bowel. 

Phenol  (Carbolic  Acid)  and  Creosote.- — Phenol  is  a  white  crystalline 
solid  when  pure,  very  deliquescent,  and  when  liquefied  in  a  colorless  or 
reddish  colored  liquid,  having  a  characteristic  odor.  Impure  phenol  is  a 
dark  colored  liquid. 

Symptoms. — When  pure  phenol  is  swallowed  death  may  follow  almost 
at  once  from  sudden  respiratory  failure.  If  the  patient  does  not  die  at 
once,  he  suffers  intense  burning  pain  in  the  mouth,  esophagus,  and  stomach; 
the  mucous  membrane  is  stained  and  swollen,  the  eschar  being  white  and 
surrounded  by  a  zone  of  inflammation.  The  face  is  ghostly;  the  skin  cold 
and  clammy;  violent  vomiting  and  purging  may  be  present,  although 
vomiting  may  be  absent.  The  urine  is  diminished  or  suppressed,  that  which 
is  passed  being  dark  colored;  collapse  follows  with  a  small,  imperceptible 
pulse,  low  temperature,  and  extreme  dyspnea.  The  odor  of  phenol  on  the 
breath  and  the  white  eschar  on  the  mouth  are  characteristic  of  this  poison. 

Treatment. — -Any  soluble,  non-poisonous  sulphate,  such  as  magnesium, 
or  sodium  sulphate,  as  the  chemical  antidote.  Wash  out  stomach,'  use 
emetics  or  the  stomach-pump.  Morphin  for  pain,  demulcent  drinks,  such 
as  albumin,  mucilage  of  acacia,  but  no  oils.  External  heat  and  stimulants 
to  overcome  collapse. 

Phosphorus. — Employed  in  the  form  of  a  paste  as  a  rat  and  roach 
poison:  matches  are  sometimes  sucked  for  smcidal  purposes.  The  paste  is 
recognized  by  its  peculiar  garlicky  odor,  and  by  the  luminous  fumes  it  emits 
in  the  dark. 

Symptoms. — These  usually  do  not  appear  until  eight  or  ten  hours  after 
the  poison  has  been  swallowed,  and  are  manifested  by  a  peculiar  taste  in  the 
mouth;  the  odor  of  phosphorous  on  the  breath;  burning  pain  in  the  ali- 
mentary tract;  vomiting,  the  vomit  being  luminous  and  consisting  of  food, 
mucus,  bile,  and  perhaps  blood ;  purging,  the  stools  being  also  phosphorescent 
in  the  dark;  constipation  may  be  present.  At  the  end  of  24  or  48  hours  a 
cessation  of  the  primary  symptoms  occurs  which  may  last  two  or  three  days 
or  longer.  At  the  end  of  this  time,  jaundice  develops  and  the  primary 
symptoms  return  with  renewed  vigor;  the  vomit  is  like  "coffee-grounds," 
due  to  altered  blood;  obstinate  constipation  may  exist;  the  fecal  masses,  if 
passed,  are  white  and  clay  colored;  the  urine  is  scanty,  albuminous  and 
contains  casts,  sarcolactic  acid  and  bile  pigments;  the  nervous  symptoms 
consist  of  headache,  vertigo,  delirium,  con\Tilsions,  and  unconsciousness, 
followed  by  death.  If  the  patient  survives  the  acute  symptoms,  he  may  die 
later  as  the  result  of  fatty  degeneration  of  vital  organs. 

Treatment. — Wash  the  stomach  freely  with  a  i  per  cent,  solution  of 
potassium  permanganate  as  a  chemical  antidote ;  hydrogen  peroxid  may  also 
be  given;  demulcent  drinks.  No  oils  should  be  given,  as  they  increase  the 
solubility  of  the  phosphorus.     Stimulants.     External  heat. 

Potassium  Nitrate  (Nitre;  Saltpetre). 


POISONS  1185 

Symptoms. — After  a  large  dose,  the  patient  experiences  violent  pain; 
in  the  stomach  and  abdomen ;  vomiting  and  purging,  the  ejected  matter  some- 
times containing  blood ;  occasionally  convulsions,  labored  respiration,  cramps 
in  the  legs,  paresthesia,  paralysis  of  the  limbs  and  aphonia  have  been 
observed;  collapse  occurs,  followed  by  coma  and  death. 

Treatment. — ^Emetics,  and  wash  out  the  stomach;  opium  for  the  pain: 
demulcent  drinks;  external  heat,  with  counterirritation  over  the  stomach; 
stimulants. 

Ptom.wn  Poisoning. — -Ptomains  are  alkaloidal  bodies,  the  products  of 
the  decay  of  animal  tissues.  These  are  probablj^  the  cause  of  the  posionous 
action  of  tainted  meat  and  fish,  cream-puffs,  ice  cream,  blanc  mange,  and 
cheese. 

Poisonous  Fish. — -Vomiting,  profuse  purging,  thirst,  great  pain  in  the 
abdomen,  headache,  itching  of  the  skin,  collapse,  and  death  in  some  instances. 

Shell  Fish,  Mussels. — -Erythematous  or  urticarial  eruptions  on  the  skin 
with  itching;  abdominal  pain,  thirst,  vomiting,  diarrhea;  dyspnea;  pupils 
dilated;  collapse;  paralysis  and  death. 

Poisonous  meat  contains  ptomains,  those  produced  when  stale  meat  is 
just  beginning  to  decay  being  more  virulent  than  others  which  replace  the 
first  when  decomposition  is  well  under  way. 

Symptoms. — Headache,  anorexia,  rigors,  thirst,  vomiting,  purging, 
pains  in  the  back  or  limbs,  skin  eruptions,  deliritun,  collapse.  The  tempera- 
ture is  usually  subnormal. 

Ices,  Ice-cream. — The  cheap  varieties  are  colored  with  anilin  dj-es,  which 
may  not  be  free  from  arsenic.  Again,  the  highly  poisonous  alkaloid, 
tyrotoxicon,  may  have  formed  in  the  milk  used,  and  to  this  principle  most 
cases  of  poisoning  of  this  kind  are  traced. 

Symptoms. — -Nausea,  vomiting,  cramps  in  the  abdomen,  collapse ;  diarrhea 
may  be  present. 

Treatment. — Emetic  or  stomach-pump  if  vomiting  has  not  occurred, 
stimulants,  external  heat,  and  artificial  respiration  if  required. 

Silver  Nitrate  (Ltmar  Caustic). — Used  in  the  form  of  the  fused  nitrate 
as  a  caustic.  Otherwise  in  colorless,  rhombic  crystals,  freely,  soluble,  with 
astringent  metallic  taste.  Yields  a  white  precipitate  with  chlorids  and 
stains  organic  matter  black. 

Symptoms. — Violent  pain  in  the  stomach  and  abdomen,  soon  followed  by 
vomiting  and  purging;  the  vomited  matter  is  white  at  first,  turning  dark 
later;  the  Hps  are  at  first  white,  but  soon  turn  brown,  then  black;  the  skin  is 
cold  and  clammy;  cramps  in  the  legs  may  occur;  cardiac  depression  and 
collapse.  Nervous  symptoms,  consisting  of  epileptiform  convulsions,  and 
delirium  are  sometimes  severe. 

Treatment. — Common  salt  and  water,  followed  by  an  emetic  or  stomach- 
pump;  opium  for  the  pain;  oils  and  demulcent  drinks;  external  heat;  stim- 
ulants. 

Strychnin. — -An  alkaloid  occurring  in  nux  vomica  and  ignatia.  Appears 
in  the  form  of  white,  prismatic,  odorless  crystals  which  have  an  intensely 
bitter  taste.     Used  as  a  vermin  killer. 


118G  POISONS 

Symptoms. — -These  may  come  on  suddenly  or  gradually.  If  suddenly, 
the  patient  may  be  thrown  into  tetanic  convulsions  without  warning.  If 
they  develop  gradually,  the  patient  experiences  stiffness  at  the  back  of  the 
neck,  and  muscular  twitchings,  with  a  feeling  of  anxiety  and  impending 
suffocation,  followed  by  violent  tetanic  convulsions  in  which  the  body 
assumes  the  position  of  opisthotonos,  occasionally  emprosthotonos  or 
pleurosthotonos,  the  eyeballs  are  prominent,  the  pupils  dilated,  and  the 
corners  of  the  mouth  drawn  into  risus  sardonicus.  Respiration  is  much 
impeded  or  entirely  arrested,  producing  marked  cyanosis.  The  patient  is 
conscious  and  experiences  the  most  acute  physical  pain  with  mental  anguish 
at  the  prospect  of  death  which  he  believes  to  be  imminent. 

Intervals  of  relaxation  occur  in  which  the  patient  lies  exhausted,  the 
respirations  are  more  rapid  and  full,  and  the  cyanosis  clears  up.  Any 
external  impulse  is  sufficient  to  cause  another  convulsion,  and  these  may  suc- 
ceed each, other  so  rapidly  that  the  patient  dies  of  cramp  asphyxia  or  from 
exhaustion. 

In  tetanus  there  is  usually  the  history  of  a  wound;  symptoms  develop 
much  more  gradually;  the  muscles  of  the  jaw  are  early  involved  and  trismus 
is  much  more  marked  than  spasm  of  the  respiratory  muscles,  and  the  con- 
vulsions are  tonic. 

Treatment. — Emetics  or  wash  out  the  stomach,  if  seen  early.  Amyl 
nitrite  to  relax  the  spasm,  followed  by  chloroform.  During  anesthesia, 
the  stomach  may  be  washed  out  and  a  solution  of  tannic  acid  given  to  act 
as  a  chemical  antidote,  while  hydrated  chloral  with  bromids  in  full  doses 
may  be  given  by  enema  to  act  as  physiological  antagonists.  Artificial 
respiration  if  necessary. 

SuLPHURETED  Hydrogen  has  the  characteristic  odor  of  rotten  eggs. 
It  forms  the  bulk  of  the  gas  emanating  from  sewers  and  cess-pools,  some 
ammonium  sulphid  and  nitrogen  occurring  with  it. 

Symptoms. — If  inhaled  in  small  quantity,  irritation  of  the  eyes,  nose, 
and  throat  occurs,  with  headache,  vertigo,  muscular  relaxation,  nausea,  and 
diarrhea. 

If  inhaled  in  large  quantities,  unconsciousness  rapidly  follows,  with 
cyanosis,  dilated  pupils,  collapse,  and  fatal  coma,  sometimes  interrupted  by 
violent  convulsions. 

In  a  state  approaching  purity,  sewer  gas  kills  almost  instantly;  in  moder- 
ate amount  it  frequently  causes  death  in  24  hours,  all  efforts  to  restore 
consciousness  proving  useless. 

Treatment. — Fresh  air;  artificial  respiration  for  many  hours;  ammonia 
by  inhalation;  stimulation. 

Zinc. — -The  chlorid,  in  solution,  is  used  as  a  disinfectant  (Burnett's 
Disinfecting  Fluid).  A  very  heavy,  corrosive,  colorless  liquid,  of  astrigent 
taste.     It  paftakes  of  the  nature  of  a  corrosive  poison. 

Symptoms. — Burning  sensation  in  throat  and  stomach,  perhaps  signs  of 
local  corro.sion.  Nausea,  vomiting,  purging,  dyspnea,  collapse,  coma, 
death. 

Treatment. — -Carbonate  of  potassium  or  sodium  in  water;  milk;  eggs; 
tannic  acid;  opium  as  a  sedative;  demulcent  drinks;  external  heat,  and 
stimulants. 


APPENDIX. 


TABLES  FOR  REDUCING  THE   METRIC   SYSTEM  INTO  THE   ENGLISH. 

{Troy  Weight.) 


Grains  to  Grams. 


Grains  to  Grams. 


Grains  to  Grams. 


ISa 

= 

o 

00033 

lis 

= 

o 

00034 

T^TJ 

= 

o 

00035 

vss 

= 

o 

000357 

XTU 

= 

o 

00036 

TTTT 

= 

o 

000377 

1Y() 

= 

o 

000388 

r^s 

= 

o 

0004 

Its 

= 

o 

000413 

1%S 

= 

o 

00042  5 

TTU 

= 

o 

00044 

Try 

= 

o 

00045s 

rSTT 

= 

o 

00048 

= 

o 

00049 

ijff 

= 

o 

0005 

ITS 

= 

o 

000528 

ins 

= 

o 

00055 

T  •J 

= 

o 

000574 

TTtr 

= 

o 

0006 

0" 

_ 

= 

0 

00062 

= 

0 
0 

00066 
00694 

= 

0 
0 
0 

0073 
0077 

0082 

h 

= 

0 

0085 

I 

(T 

^ 

0 
0 

0094 
001 

s 

if 

= 

0 

OOII 

iz 

= 

0 

0012 

i 

B" 

= 

0 

00132 

\ 

5- 

= 

0 

00146 

T 
3 

5- 

~ 

0 
0 

00165 
00188 

i 

(T 

= 

0 

0022 

i 

f 

= 

0 

00264 

T 

= 

0 
0 

0033 
0044 

h 

= 

C 

°°55 

rV 

= 

0 

0066 

i 

= 

0 

0082 

\ 

=r 

0 

0094 

y 

= 

0 

on 

i 

= 

0 

0132 

\ 

= 

0 

0165 

J 

= 

.0 

022 

1 

= 

0 

033 

1 

= 

0 

066 

2 

= 

0 

132 

3 

= 

0 

198 

4 

= 

0 

264 

5 

= 

0 

33 

6 

= 

0 

396 

7 

= 

0 

462   . 

8 

= 

0 

5  =  8 

9 

= 

0 

594 

0 

= 

0 

66 

Grams    to  Grains. 


I 

= 

!•; 

43 

2 

= 

30 

86 

3 

= 

46 

29 

4 

= 

61 

72 

5 

= 

77 

!■; 

6 

= 

92 

5« 

7 

= 

loS 

01 

8 

= 

123 

44 

9 

= 

i3« 

«7 

0 

= 

154 

3 

I  pound  avoirdupois  =  453.5925  gm. 
I  ounce  avoirdupois  =  28.3495  gm. 
I  grain  avoirdupois      =       0.0648  gm. 


Grains  to  Milligrams. 


I  dram  or 


=  64 

=  120 

=  194 

=  2  59 

=  324 

=  388 

=  453 

=  S18 

=  583 


3.89  gm. 


ounce  or  480   =       31.1     gm. 


FLUID  MEASURES. 


I  teaspoonful  distilled  water 
I  dessertspoonful  distilled  water 
I  tablespoonful  distilled  water 
I  wineglassful  distilled  water 
I  fluidounce  distilled  water 
16  fluidounces  distilled  water 


1  fluidram 

2  fluidrams 
4  fluidrams 

2  fluidounces 

3.7     c.c. 

7.4     c.c. 
=      14.8     c.c. 
=       59-14  c.c. 

I  pint 

=      29-57  c.c. 
=   473-"  c.c. 

{circa  30  c.c) 
{circa  483  c.c.) 

^A  fluidounce  of  water  which  measures  30  c.c.  does  not  weigh  31 
really  weighs  but  455.7  grains  Troy,  and  not  480  grains. 


1187 


1188 


APPENDIX. 


TABLES  FOR   REDUCING   THE'  METRIC   SYSTEM   INTO   THE    ENGLISH 
FLUID  MEASURES— (CoMimwed). 


Minims 

TO  Cubic 

Centimeters. 

I 

= 

0.06 

2 

= 

0.12 

3 

= 

0.18 

4 

= 

0.24 

5 

= 

0.31 

lO 

= 

0 .62 

15 

= 

0.92 

i6i 

= 

I 

20 

= 

1.23 

30 

= 

1.85 

40 

= 

2  .46 

Cubic  Centime- 
ters TO  Minims. 


I 

=      16. 

2 

=      32- 

3 

=      48. 

4 

=      64. 

S 

=      81 

6 

=      97- 

7 

=    113- 

8 

=    129. 

9 

=    145- 

Fluidrams   to     j  Cubic  Centimeters 
Cubic  Centimeters.       To  Fluidrams. 


3-7 

7-4 

1 1 . 1 


14.8 

18. 5 
22  .2 

259 

29 . 6 

33-3 
37 


I 

= 

0.27 

2 

3 

= 

0.54 
0.81 

4 

= 

1.08 

5 
6 

= 

1-35 
1.62 

I 

= 

1 .89 
2 .  16 

9 

= 

2.43 

0 

= 

2-7 

Fluidounces  to 
Cubic  Centimeters. 


I 

= 

29 

57 

3 

4 

= 

59 

88 

118 

14 
71 
28 

5 

= 

147 

75 

6 

= 

177 

42 

7 
8 

9 

= 

206 
236 
266 

99 
56 
13 

10 

12 

= 

29s 
3  54 

7 
84 

16 

= 

473 

12 

Liters  to 

Fluidounces. 

1  = 

2  = 

33S 
67.6 

3     = 

lOI  .4 

4  = 

5  = 

6  = 

135-2 
169 
202  .8 

7     = 

236.6 

8    = 

270.4 

9    = 

3°4-2 

10    = 

.338 

Liters  to  Pints 

I 

= 

2.x                 1 

2 

= 

4 

2 

3 

= 

6 

3 

4 

= 

8 

4 

5 

= 

10 

5 

6 

= 

12 

6 

7 

= 

14 

7 

8 

= 

16 

8 

9 

= 

18 

9 

10 

21 

Pints  to  Liters. 


473 
946 
419 


365 
838 

3" 
784 
257 
73 


LINEAR  MEASURES. 


Centimeters  to 

Inches  to  Centi- 

Inches to  Milli- 

Millimeters  to 

Inches. 

meters. 

t 

meters. 

Inches. 

I    =   °-3937 

I     =      2.54 

I 

=    25.4 

I     =   0.03937 

2=0 

7974 

2    =      5.08 

2 

=    50-8 

2=0 

07874 

3     =    I 

1817 

3    =      7.62 

3 

=   76.2 

3     =    ° 

iiSii 

4     =    I 

5784 

4    =    10.16 

4 

=    loi  .  6 

4=0 

15784 

5    =    I 

9685 

5    =    12-7 

5 

=    127 

5    =   0 

1968s 

6    =    2 

3622 

6    =    15-2 

6 

=    152-4 

6=0 

23622 

7     =    2 

7559 

7    =    17-78 

7 

=    177-8 

7=0 

27SS9 

8    =   3 

1496 

8    =    20.32 

8 

=    193-2 

8=0 

31496 

9=3 

5433 

9    =    22.86 

9 

=    288.6 

9=0 

3  5433 

10    =   3 

937° 

10    =    25.4 

10 

=    254 

10=0 

3937 

Feet  to  Meters. 


>-3°48 

>.  6096 

).9i44 

[ . 2192 

1-524 

[.8288 

!-i336 

'•4348 

!-7432 

j.048 


Meters  to  Feet. 


=  3-2S 

=  6.56 

=  9-84 

=  13-12 

=  16.4 

=  19.68 

=  22.96 

=  26.24 

=  29.52 


A  micromillimeter  =  o.ooi  millimeter.     Symbol  /i. 


APPENDIX. 


1189 


TO  CONVERT  DEGREES   OF   FAHRENHEIT'S   THERIvIOMETER   TO   CEN- 
TIGRADE, AND  VICE  VERSA. 


Centigrade  to  Fahrenheit. 


To  use  this  table,  convert  the  given 
number  of  degrees  Centigrade  into  de- 
grees Fahrenheit,  and  add  32°. 


Fahrenheit  to  Centigrade. 


665 
22 
775 
3-33 

3-885         - 
4.44 
95 
.    55 

To  use  this,  table  subtract  32°  from  the 
given  number  of  degrees  Fahrenheit  and 
convert  the  remainder  into  degrees  Cen- 
itigrade. 


INDEX 


Abasia-astasia,  1122 

Abscess,  mediastinal,  554;  metastatic,  525; 
of  the  brain,  1072;  of  the  heart,  609; 
of  the  liver,  462-464;  of  the  lung,  262, 
525;  of  the  spleen,  684;  paranephritic, 
751;  perinephric,  751;  postpharyngeal, 
341 ;  tonsillar,  333 

Acarinas,  238 

Acarus  scabiei,  238 

Acetone,  test  for,  806 

Achondroplasia,  830 

Achylia  gastrica,  366,  642 

Acidosis,  802,  812 

Aconite  poisoning,  1173 

Acromegaly,  687,  688-690 

Actinomyces,  178 

Actinomycosis,  178;  of  appendix,  407;  of 
brain,  179;  of  lungs,  179 

Acute  albuminuria,  710;  affections  of  spinal 
cord,  895;  alcoholism,  1138;  angioneu- 
rotic edema,  1125;  anterior  poliomyelitis 
of  children,  319;  arsenical  poisoning, 
H53.  ii74i  articular  rheumatism,  246; 
ascending  spinal  paralysis,  903;  Bright 's 
disease,  710;  bronchial  catarrh,  506; 
bronchitis,  506;  bulbar  palsy,  932; 
catarrhal  gastritis,  349;  laryngitis,  499; 
chorea,  1080;  circumscribed  edema,  1 125 ; 
cystitis,  770;  nephritis,  710;  degenera- 
tion of  internal  organs  of  newborn,  664; 
desquamative  nephritis,  710;  diarrhea, 
391;  diffuse  nephritis,  710;  dyspepsia, 
349;  dyspeptic  diarrhea,  398;  dj'speptic 
enteritis,  398;  encephalitis  der  Kinder, 
1050;  endocarditis,  565-571;  entero- 
colitis, 400;  gastritis,  349;  gastric 
catarrh,  349;  gout,  791,  795;  hemor- 
rhagic inflammation  of  the  dorsal  root 
ganglia,  1056;  hydrocephalus,  280;  hyper- 
emia of  liver,  452;  ileocolitis,  391,  400; 
impaction,  of  gall  stones,  440;  infectious 
cholecystitis,  447 ;  intestinal  catarrh,  391 ; 
leptomeningitis,  889,  1027;  mania,  703; 
miliarj'  tuberculosis,  277;  myocarditis, 
609;  nasal  catarrh,  494;  nephritis,  710; 
pancreatitis,  478;  parenchymatous  hepa- 
titis, 466;  tonsillitis,  333;  pericarditis, 
557;  peritonitis,  485-489;  phthisis,  277; 
pleurisy,  535-543;  poliomyelitis,  319- 
321 ;  renal  dropsy,  710;  rheumatism,  246; 
rhinitis,  494 ;  softening  of  the  brain,  1 044 ; 
spinal  leptomeningitis,  889;  tracheo- 
bronchitis, 506;  tubal  nephritis,  710; 
tuberculosis,  277-285;  of  the  lungs,  283- 
285;  yellow  atrophy  of  the  liver,  466-468 

Adams-Stokes  syndrome,  614 

Addison's  disease,  681-683;  diagnosis  of, 
682;  morbid  anatomy,  681;  prognosis 
of,  683;  symptoms  of,  681;  coloration 
of  skin,  682;  treatment  of,  683 

Ad6nie  and  lymphad^nie,  650 

Adenoid  tissue  of  pharynx,  hypertrophy 
of,  335 


Adherent  pericardium,  561 

Adiposis  dolorosa,  6go,  871 

Adipositas  universalis,  820 

Adiposity,  688 

Ag^nfese  c^r^brale,  1050 

Ageusia,  957 

Agraphia,  motor,  958,  960 

Ague,  47 

Ainham,  1 131 

Ainhum,  1 131 

Alalia,  960 

Albuminoid  disease,  742 

liver,  455 
Albuminous  nephritis,  710 
Albuminuria,     693-695;     extrarenal,    693; 

physiological  or  functional,  695;  renal, 

694;  immediate  cause  of,  694 
Albuminuric  retinitis,  734,  737 
Albumosuria,  695 
Alcohol  poisoning,  1 1 38,  1 1 73 
Alcoholism,   1138;  Acute,    1138;   Chronic, 

1139;    kidney   changes   in,    1140;   liver, 

1 1 40;   lungs,   nen.-ous   system   in,  11 40; 

vascular   changes   in,    1140;   treatment, 

1 142 
Alkapton,  697 

Alterations  in  breathing  and  pulse,  860 
Alveolar  ectasia,  528 
Amaurosis,  972 

Amaurotic  family  idiocy,  1124 
Amblyopia,  972 
American  disease,  1118 
Amimia,  961 

Ammonia  poisoning,  1174 
Amnesic  aphasia,  958 
Amoeba,  coli,  88,  191;  dysenteric,  88,  191 
Amphoric  breathing,  291 
Amphoric  resonance,  290 
Amusia,  957 
Amyloid  disease,  of  kidney,  742;  of  liver, 

455 

Amyotonia  congenita,  1 136 

Amyotropic  lateral  sclerosis,  937 

Anacidity,  366 

Analgesic  paresis  with  panaritium,  924 

Analgic  panaritium,  924 

Anaphylaxis,  120,  517 

Anarthria,  954 

Anchylostoma  americanum,  230 

Anchylostoma  duodenale,  227 

Anemia,  general,  634;  idiopathic,  640; 
lymphatic,  650;  of  the  brain,  1033; 
primary  'or  essential,  636;  Progressive 
Pernicious,  640;  bone  marrow,  in,  643; 
diagnosis  of,  643 ;  etiology  of,  640 ; 
morbid  anatomy  of,  643;  prognosis  of, 
644;  symptoms  of,  641 ;  blood  changes, 
642;  treatment  of,  644;  Secondary  or 
Symptomatic,  634-636;  diagnosis  of, 
636;  due  to  drain  of  chronic  disease, 
634;  due  to  hemorrhage,  634;  from 
inanition,  635;  Symptoms  of,  635; 
treatment  of,  636;  Splenic,  655-658; 
Toxic,  635 

Anemias,  the,  634 


1191 


II92 


INDEX 


Anesthesia,  857 

Aneurysm,  differential  diagnosis  of,  630; 
from  aortic  incompetency,  630;  from 
mediastinal  tumors,  630;  from  pulsating 
empyema,  630;  intracranial,  1049;  of 
the  abdominal  aorta,  629;  of  the 
branches,  of  the  celiac  axis,  629;  of 
the  aorta,  623-629;  of  the  ascending 
aorta,  628;  of  the  descending  aorta,  628; 
of  the  heart'  609-630;  of  the  hepatic 
artery,  629;  of  the  innominate,  629; 
of  the  pulmonary  artery,  630;  of  the 
renal  artery,  629;  of  the  splenic  artery, 
629;  of  the  subclavian,  630;  of  the 
superior  mesenteric  artery,  629;  of  the 
thoracic  aorta,  623-629;  physical  signs 
of,  625-629;  diastolic  shock  626;  symp- 
toms of,  623-629;  Cardarelli's  sign,  626; 
pain,  623;  pressure,  623;  tracheal  tug 
in,  626;  voice,  624;  of  the  transverse 
part  of  aorta,  628;  of  the  valves,  567; 
prognosis  of,  631;  treatment  of,  632, 
633;  varieties  of,  622 

Angina,  chronic,  339;  foUicularis,  123; 
Ludovici,  333;  maligna,  112;  membra- 
nacea,  112;  pectoris,  616-618;  diag- 
nosisof,  617;  simple,  338;  treatment,  618; 
Vincent's  bacillus,  causes,  diagnosis, 
spirilla  of,  symptoms,  treatment  of,   124 

Angioneurotic  edema,  acute,  1125 

Angiostomidse,  212 

Anguilluha  intestinalis  et  stercoralis,  212 

Animal  parasites,  190 

Anisocoria,  984 

Anopheles,  51,  52 

Anorexia  nervosa,  365 

Anosmia,  957 

Anterior  poliomyelitis,  chronic,  939 

Anthrax,  174 

Antimony  poisoning,  1174 

Aortic,  incompetency,  580;  insufBciencj', 
580;  murmur  in,  582;  physical  signs 
of,  582-583;  capillary  pulse,  582;  Corri- 
gan  pulse,  580,  582 ;  Duroziez's  double 
murmur,  583;  Traube's  double  sound, 
583;  sphygmogram,  582;  symptoms  of, 
581-584;  Stenosis  and  Roughening,  584, 
occurrence  and  mechanism,  584;  phys- 
ical signs,  584;  sphygmogram,  585, 
symptoms  of,  584-585;  and  insufficiency, 
586,  and  roughening,  585 

Aphasia,  motor  or  ataxic,  960;  or  loss  of 
faculty  of  speech,  958;  Marie's  \'iews 
on,  963 

Aphemia,  960 

Aphtha,  325 

Aphthae  epizooticas;  180 

Apoplexy,  1035;  cerebral  hemorrhage, 
1035;  arterial  distribution,  1035;  diag- 
nosis of,  1041;  etiology  of,  1035;  morbid 
anatomy  of,  1036;  prognosis  of,  1042; 
symptoms  of,  1037-1041 ;  treatment  of, 
1042;  embolism  and  thrombosis  of  the 
cerebral  arteries,  1044;  of  cerebral 
sinuses,  1048;  diagnosis  of,  1046;  etiology 
of,  1044;  morbid  changes  in,  1044; 
prognosis  of,  1047;  symptoms  of,  1045, 
1048;  treatment  of,  1047,  1049 

Appendicitis,  405-415;  bacilli,  405;  catar- 
rhal, 406;  chronic,  411;  complications, 
410;  definition  of,  405;  diagnosis  of, 
411;  differential  diagnosis  of,  20,  265, 
361,  372,  401,  411-413,  421,  etiology  of, 


Appendicitis; 

405;  exciting  causes,  405;  fever  in,  409; 
gangrenous,  409;  interstitial,  407;  Leu- 
cocytosis,  409,  41 1 ;  McBumey's  point, 
408;  morbid  anatomy  of,  406-408; 
obliterans  in,  406;  pain  in,  408,  410, 
411,  415;  parietal,  407;  pathology,  406; 
perforation  in,  406,  410;  peritonitis  in, 
406,  407,  410;  predisposing  causes,  405; 
prognosis  of,  414;  recurring,  411;  relaps- 
ing, 411;  rigidity  of  muscle,  408,  411; 
sequela;,  410;  symptoms  of,  408-410; 
tenderness,  408,  411;  treatment  of, 
414,  415;  medicinal,  415;  operative,  414; 
tumor,  408,  409,  411;  ulcerative,  406 

Apraxia,  956 

Aprosexia,  335 

Arachnoidea,  237 

Argyll  Robertson  pupU,  860,  913 

Arrhythmia,  612-615 

Arithmomania,  1086 

Arm-jerks,  938 

Arophagia,  367 

Arsenical  poisoning,  1 153,  1 174 

Arterial  pyemia,  568 

Arteriocapillary  fibrosis,  618 

Arteriosclerosis,  618-622,  734,  738;  ab- 
dominal, 621;  blood-pressure  in,  621; 
heart  in,  620,  621 

Arthralgia  saturnina,  1 158 

Arthritis,  atrophic,  783;  deformans,  782; 
gonorrheal,  244;  multiple,  783;  partial 
or  monarthritic,  782,  856;  rheumatic, 
783;  rheumatoid,  782 

Arthropoda,  237 

Ascaris,  canis  et  martis,  226;  lumbricoides, 
232;  texana,  234;  trichiura,  222;  ver- 
micularis,  235;  visceralis  et  renalis,  226 

Ascites,  482-485;  character  of  fluid,  484; 
chylosus,  484;  differential  diagnosis  of, 
484;  from  cyst  of  the  omentum,  485; 
from  hydronephrosis,  485;  from  over- 
distended  bladder,  484;  from  ovarian 
cyst,  484 

Aspiration  pneumonia,  268 

Associated  movements,  935 

Astereognosis,  857 

Asthma,  bronchial,  516;  cardiac,  520,  555, 
573;  hay,  496;  humidum,  557;  Koop's, 
691;  thymic,  691;  uremic,  757 

Atactilia,  957 

Ataxia,  cerebellar  hereditarj',  919;  hered- 
itary', 918;  locomotor,  907;  Ataxic 
spastic  paraplegia,  920 

Atelectasis  of  the  lung,  247 

Ateliosis,  691 

Atheroma  of  the  blood-vessels,  618 

Athetosis,  841 

Athyrea,  675 

Atrophia  musculorum  lipomatosa,  1133 

Atrophic  bulbar  paralysis,  932 

Atrophy,  acute  yellow,  of  the  Uver,  466- 
468;  facio-scapulo-humeral  type  of, 
1 135;  juvenile  hereditarj',  Erb's  form 
of,  1 1 34;  muscular,  1 133;  primarj' 
myopathic,  forms  of,  1133;  progressive 
neuro-muscular,  1 135;  progressive,  pe- 
roneal type  of,  1 135 

Atropin  poisoning,  1175 

Auditory  hyperesthesia,  1000;  or  eighth 
nerve,  lesions  of,  997 

Automatic  chorea,  1090 

Autumnal  catarrh,  496;  fever,  i 


INDEX 


"93 


B 


BabmsKi  reflex,  150,  845 

Baccelli's  sign,  264,  585 

Bacillus  anthrax,  174;  Bordet,  137,  139; 
comma,  76;  dysenterial,  85;  Klebs- 
Loeffler,  112;  lepra,  312;  mallei,  176; 
Oppler-Boas,  379;  parotidis,  140;  pestis, 
93;  tetanus,  169;  typhosis,  i 

Bacteremia,  161 

Bacteruria,  696 

BaUismus,  1066 

Bamberger's  sign,  561 

Banti's  disease,  655 

Barbadoes  distemper,  67 

Barlow's  disease,  661 

Barrel-shaped  lung,  531 

Basedow's  disease,  670 

Basilar  meningitis,  280 

Bednar's  aphthae,  328 

Beef  tape-worm,  206 

Belladonna  poisoning,  1175 

Bell's  mania,  1203;  palsy,  989 

Bends,  the,  11 80 

Beri-beri,  Ii58 

Biemer's  change  of  note,  546 

Big  jaw,  178 

Bilateral  infantile  spastic  hemiplegia,  1050 

Bile-duct,  carcinoma,  449;  cicatricial  con- 
traction, 450;  common,  inflammation  of, 
437;  parasites,  450;  stenosis,  450 

Bile-passages    and    gall-bladder,    diseases 

of,  434 
Bilharzia  haematobia,  199 
Biliary,  calculus,  439 ;  cancer,  440 ;  cirrhosis, 

460;  colic,  440 
Bilious,  fever,  47;  headache,  102;  remittent 

fever,  67 
Birth  palsies,  1053 
Bisulphid  of  carbon  poisoning,  11 63 
Black,  death,  92;  plague,  92;  vomit,  68, 

69.  71 

Blackwater  fever,  61 

Bladder,  catarrh  of,  768;  diseases  of,  768- 
778;  hemorrhoidal  veins  of,  777;  morbid 
growths  of,  778;  muscular  spasm  of,  775; 
treatment  of,  776;  of  incontinence,  776; 
of  retention,  777;  neuroses  of,  774; 
paralysis  of,  774;  stone  in,  774;  tubercu- 
losis of,  310;  worm,  474 

Blepharospasm,  996 

Blood,  and  blood-making  organs,  diseases 
of  the,  634;  megalocytes,  642;  cell 
forms  not  found  in  normal,  635;  nu- 
cleated red  corpuscles,  636,  642 ;  mega- 
blasts,  636;  microblasts,  636;  normo- 
blasts, 636 

Blood-striking,  174 

Blood-vessel,  diseases  of,  618 

Bloody  flux,  85;  murrain,  174 

Blue  rocket  poisoning,  1 173 

Body  louse,  239 

Bone  tumor,  178 

Bothriocephalus  latissimus,  201 

Bothriocephalus  latus,  201 

Bowel,  carcinoma  of,  429-433;  diagnosis 
of,  430-432 ;  from  chronic  inflammatory 
thickening,  432 ;  from  circumscribed 
peritoneal  exudate,  43 1 ;  from  floating 
kidney,  43 1;  of  part  of  bowel  involved, 
430-432 ;  prognosis  of,  432 ;  symptoms  of, 
430;  treatment  of,  432;  emboHc  ulcer  of, 
422;   hemorrhagic   infarct   of,    404;   in- 


Bowel: 

tussusception  of,  416;  invagination  of, 
416;  obstruction  of,  see  Intestinal  Ob- 
struction; strangulation  of,  415;  twists 
and  knots  in,  417;  ulceration  of,  395 

Brachial,  neuralgia,  874;  plexus,  1017; 
lesions  of,  1017 

Bradycardia,  612 

Brain,  abscess  of,  1072;  affections  of  the 
blood-vessels  of,  1032,  1035;  anemia 
of,  1033;  diseases  of,  944;  the  mem- 
branes of,  1025;  edema  of,  1034; 
sclerosis  of,  1057 ;  suppurative  inflamma- 
tion of,  1072;  tumors  of  the,  1065; 
diagnosis  of,  1071;  etiology  of,  1066; 
prognosis  of,  1071 ;  symptoms  of,  1066; 
of  basal  ganglia  or  internal  capsule, 
1 070;  of  base  of  the,  1070;  of  central  or 
motor  region,  1068;  of  cerebellum,  1069; 
of  corpora  quadrigemina,  1070 ;  of  corpus 
callosum,  1070;  of  crus,  1070;  of  occipital 
lobe,  1069;  of  parietal  area,  1068;  of 
pons  and  medulla  oblongata,  1069;  of 
prefrontal  area,  106S;  of  temporosphe- 
noidal  area  on  right  side,  1069;  treat- 
ment, 1 07 1 

Breakbone  fever,  74 

Breathing,  alterations  in,  in  ner\'0us  dis- 
ease, 860 

Bright's  disease,  acute,  710;  chronic,  721 

Brill's  disease,  36 

Broadbent's  sign,  562 

Bromin  poisoning,  1 175 

Bromism,  1175 

Bronchial  asthma,  516;  dilatation,  514; 
gland,  tuberculosis  of,  305;  tubes,  dis- 
eases of,  506 

Bronchiectasis,  511;  diagnosis  of,  516; 
from  abscess  of  the  lung,  516;  from  cir- 
cumscribed empyema,  516;  from  phthis- 
ical cavity,  516;  etiology  of,  514; 
morbid  anatomy  of,  514;  physical  signs 
of,  515;  symptoms  of,  515;  treatment 
of,  516 

Bronchitis,  506-514;  Acute,  506-509; 
diagnosis  of,  508;  etiology  of,  507;  mor- 
bid anatomy  of,  507;  physical  signs  of, 
507 ;  prognosis  of,  508 ;  symptoms  of,  507 ; 
treatment  of,  508;  CapiUarj',  ^eeBronho- 
pneumonia;  Chronic,  509-514;  diagnosis 
of ,  5 1 2 ;  etiology  of,  509 ;  morbid  anatomy 
of,  510;  physical  signs  of,  512;  prognosis 
of,  512;  symptoms  and  course  of,  510; 
treatment  of,  512;  foreign  resorts  in  the, 
5i4;fibrinous,  526,  527;  diagnosis  of,  527; 
etiology  of,  526;  morbid  anatomy  of, 
526;  physical  signs  of,  527;  symptoms 
of,  527;  treatment  of,  527;  plastic,  526, 
527;  putrid,  511 

Bronchocele,  668 

Bronchopneumonia,  268;  tubercular,  268, 

283 

Bronchopneumonic  phthisis,  283 

Bronchorrhea,  510 

Brown-S^quard's  paralysis,  886 

Bruit  de  diable,  639 

Bubo,  parotid,  332 

Bubonic  plague,  92;  bacillus  of,  93;  bubo 
in,  92,  93,  94;  diagnosis  of,  94;  etiology 
of,  93;  morbid  anatomy  of,  93;  progno- 
sis of,  95;  prophylaxis,  95;  symptoms  of, 
94;  treatment  of,  95;  serum  therapy,  95; 
varieties  of,  93;  bubonic  form,  93,  94; 


1 194 


INDEX 


Bubonic  plague: 

malignant  adenilis,  93;  pestis  minor,  93; 
pneumonic  form,  94;  protective  inocu- 
lation, 95;  sidcrans  or  fulminant,  94; 
septicemic  form,  94;  transmission  of, 
93;  treatment,  95 

Buccal  psoriasis,  331 

Buhl's    disease,  664 

Bulbar  palsy,  acute,  935;  asthenic,  936; 
progressive,  932 ;  without  anatomical 
change,  936 

C 

Cachexia,  malarial,  47,  62;  thyroidea  vel 
strumipriva  vel  thyreopriva,  675 ;  strumi- 
priva,  677 

Cachexie  pachydermique,  675 

Caisson  disease,  1 171 

Calmette's  reaction,  296 

Cammidge  reaction,  481 

Camp  fever,  36 

Cancer,  gastric,  376;  in  hepatic  fissure,  481  ; 
of  the  gall-bladder,  449  ;  of  the  esophagus, 
344;  of  the  pancreas,  480;  of  the  peri- 
cardium, 565 ;  of  the  peritoneum,  492 ; 
of  the  pleura,  547;  of  the  stomach,  376- 
382;  of  the  transverse  colon,  429 

Cancrum  oris,  100,  329 

Canker,  325 

Caput  medusa,  453,  458 

Carbolic  acid  poisoning,  1183 

Carbonic  acid  gas  poisoning,  1175;  oxid 
poisoning,  1176 

Carbuncle  fever,  1 74 

Carcinoma  of  the  appendix,  407,  414;  of 
the  biliary  passages,  449;  of  the  bowel, 
429-433;  of  the  cecum,  432;  of  the  duo- 
denum, 431;  of  the  liver,  468;  massive 
form,  469;  nodular  form,  468;  radiating 
form,  469;  with  cirrhosis,  469;  of  the 
lung,  533;  of  the  rectum,  432;  of  the 
stomach,  376-382;  ventriculi,  376 

Cardarelli's  sign,  626 

Cardiac  Asthma,  520,  555,  573,  603; 
Disease,  555 ;  general  symptomatology 
ofi  555;  treatment  of,  591;  muscle, 
degeneration  of,  605 

Cardiohepatic  angle,  560 

Cardiospasm,  367 

Cardiothyroid  exophthalmos,  670 

Cataleptic  rigidity,  842 

Catarrh,  acute  bronchial,  506;  acute  in- 
testinal, 391;  chronic  bronchial,  509; 
nasal,  495;  of  the  bladder,  768 

Catarrhal  fever,  142;  pneumonia,  268 

Catarrhus  lestiviis,  496 

Cauda  equina,  lesions  of,  931 

Caustic  potash  or  soda,  1 176 

Cavernous  breathing,  291 

Cavities  in  lung,  286 

Cecum,  carcinoma  of,  432 

Cellulitis  of  the  neck,  333 

Central  ganglia,  966 

Centrum  ovale,  965 

Cephalodynia,  780 

Cerebellar  hereditary  ataxia,  919 

Cerebellum,  disease  of,  967;  changes  of, 
due  to  tlirombosis  and  embolism,  1044; 
form  of  lesion  of,  968 

Cerebral  disease,  944;  localizations  of, 
944;  hemorrhage,  1035;  hyperemia,  1032; 
palsies  of  children,  1050;  softening,  1044 

Cerebritis,  1072 


Cerebrospinal  fever,  146-156  antimeningi- 
tic  serum,  155;  Babinski's  sign,  150;  brain 
in,  147;  IJrudzenski's  sign,  151;  compli- 
cations and  sequelas,  151;  cranial  nerves 
in,  148;  diagnosis  of,  152;  from  tuber- 
cular meningitis,  153;  from  typhus 
fever,  152;  diplococcus  of,  147;  eruptions 
in,  149,  150;  etiology  of,  146;  fever  in, 
148,  149;  forms  of,  148,  151;  abortive, 
148,  151 ;  chronic,  148,  151 ;  intermittent, 
148,  151;  malignant,  148,  151;  mild, 
148,  151;  ordinary,  148;  sporadic,  154; 
organisms  of,  155;  herpes  in,  149;  in- 
cubation period,  148;  Kernig's  sign  of, 
150;  leukocytosis,  150;  Macewen's  sign, 
151 ;  morbid  anatomy  of,  147;  predis- 
posing causes  of,  147;  prognosis  of,  153; 
Quincke's  lumbar  puncture  in,  153; 
relapses,.  154;  serum  therapy,  155; 
sequelae  of,  151;  spinal  cord  in,  147; 
spinal  fluid  in,  148,  152,  153;  spinal 
membranes,  148;  transmission  of,  147; 
treatment  of,  155 

Cervical  plexus,  1016 

Cervico-brachial,  Neuralgia,  874 

Cervico-occipital,  Neuralgia,  874 

Charbon,  174 

Charcot's  crystals,  510,  519;  disease,  937 

Cheese  poisoning,  1 176 

Cheirospasmus,  11 03 

Cheyne-Stokes  breathing,  603,  703,  860, 
1068 

Chiasm  and  tract,  lesion  of,  975 

Chicken-pox,  135;  complications  in,  136; 
diagnosis  of,  136;  infantile  paralysis, 
136;  varicella  gangrasnosa,  136;  eruption 
in,  136;  incubation  in,  136;  prognosis  of, 
136;  treatment  of,  136 

Children,  reflex  convulsions  of,  1099 

Chill,  the  congestive,  67 

Chills  and  fever,  47 

Chloral  poisoning,  11 86 

Chloranemia,  636 

Chloremia,  636 

Chlorism,  1 146 

Chloroform  poisoning,  1176 

Chloroma,  649 

Chlorosis,  636 

Choked  disk,  973,  1067 

Choking  quinsy,  174 

Cholangitis,  chronic  catarrhal,  434;  sup- 
purative, 443 

Cholecystitis,  acute  infectious,  447;  diag- 
nosis of,  448 ;  etiology  of,  447 ;  jaundice  in, 
447;  morbid  anatomy  of,  447;  symptoms 
of,  447;  treatment  of,  448 

Cholelithiasis,  439 

Cholera,  76;  algid,  76;  Asiatic,  76; 
bacillus  of,  76;  examination  for,  80; 
of  Koch,  76;  collapse  in,  78;  diagnosis 
of,  79;  diarrhea,  78;  epidemics  of,  76; 
eruption  in,  79;  etiology  of,  76;  examina- 
tion of  the  dejecta  of,  80;  infantum,  400; 
intestine  in,  77;  kidneys  in,  77,  79; 
liver  in,  77;  medium  of  infection,  76; 
morbid  anatomy  of,  76;  prognosis  of, 
80;  spleen  in,  77;  stomach  in,  77;  stools 
in,  79;  symptoms  of,  78;  prophylaxis, 
81;  protective  inoculation,  82;  vomiting 
in,  78;  infectiosa,  76;  maligna,  76;  sicca, 
79;  typhoid,  79 

Chorea,  acute,  1078;  diagnosis  of,  1083; 
endocarditis  in,  1082;  etiology  of,  1078; 


INDEX 


II9S 


Chorea: 

morbid  anatomy  of,  1080;  nature  of, 
1080;  prognosis  of,  1083;  symptoms  of, 
1083;  treatment  of,  1083;  automatic, 
1088;  Chronic  hereditary,  1087;  pro- 
gressive, 1087;  electric,  1085  ;  Hunting- 
ton's, 1 087; hysterical,  lo88;major,  1088; 
mild,  1078;  minor,  1078;  pandemic, 
1088;  postchoreal  paralysis  and  post- 
paralytic, 1089;  procursiva,  io62;scelo- 
tyrbe  sive  festimans,  1062;  Sydenham's, 
1078 
Choreic  movements,  842 
Choreiform  affections,  1084 
Chronic  adhesive  pericarditis,  561 
Chronic  angina,  339;  anterior  poUomye- 
litis,  939;  bronchial  catarrh,  509;  bron- 
chitis, 509;  catarrhal  dyspepsia,  350; 
gastritis,  350;  nephritis,  731;  cystitis, 
771;  degeneration  of  the  motor  nerve 
nuclei,  939;  diarrhea,  395;  diffuse 
meningo-encephalitis,  1059;  nephritis, 
721;  endocarditis,  571;  enlargement  of 
the  tonsils,  335;  enterocolitis,  395; 
follicular  pharyngitis,  342 ;  gastric  ca- 
tarrh, 350;  gout,  793;  hereditary  chorea, 
1089;  hydrocephalous,  1075;  impaction 
of  gallstones,  442;  interstitial  hepatitis, 
457;  interstitial  pneumonia,  521 ;  intersti- 
tial nephritis,  731-742;  leptomeningitis, 
1 031;  malaria,  42,  62,  67;  myocarditis, 
607;  nasal  catarrh,  495;  nasopharyngeal 
obstruction,  335 ;  pancreatitis,  480 ; 
parenchymatous  nephritis,  721;  penito- 
nitis,  489;  pleurisy,  543;  pulmonary 
tuberculosis,  285-305;  tuberculosis  of 
the  lungs,  285-305;  rheumatic  arthritis, 
852;  rhinitis,  495;  tubal  nephritis,  72 1; 
ulcerative  phthisis,  286;  valvular  dis- 
ease, 571 

Chronically  contracted  kidney,  731,  742 

Chvostek's  sign,  679 

Chyluria,  nonparasitic,  767 

Cimex  lectularius,  241 

Cingulum,  1056 

Circumflex  nerve,  lesions  of,  1018 

Circumscribed  serous  spinal  meningitis, 
927 

Cirrhosis  of  the  liver,  457-462;  atrophic, 
457;  biliary,  460;  diagnosis  of,  460, 
468,  472;  from  amyloid  liver,  461; 
mvdtilocular  hydatid  disease,  461 ;  tuber- 
cular peritonitis,  459;  etiology,  457,  460; 
Glissonian,  465;  Hanot's,  460;  hyper- 
trophic, 460;  jaundice,  459,  460;  Laen- 
necs',  457;  morbid  anatomy  of,  457; 
of  atrophic,  457;  of  biliary,  460;  portal, 
457;  prognosis  of,  461;  symptoms  of, 
atrophic,  458;  of  biliary,  460;  treat- 
ment of,  461 

Cirrhosis  of  the  lung,  262,  521 

Cirrhotic  kidney,  731 

Cladocoelium  hepaticum,  195 

Clergyman's  sore  throat,  339 

Coated  tongue,  322;  black,  322;  bright 
red,  322;  dry  brown,  322;  strawberry, 
322 

Cocain  poisoning,  1 177 

Cocainism,  1 147 

Coccygodynia,  875 

Coin  clinking  sound,  546 

Colica  pictonum,  1 147 

Colitis,  mucous,  395;  ulcerative,  395 


CoUes'  law  in  syphilis,  183 

Colon,  dilatation  of,  428,  429 

Color  of  tongue,  natural,  322 

Combined  lateral  and  posterior  sclerosis, 

920 
Compression  myelitis,  924 
Congenital  absence  of  kidney,  761;  hypo- 
tonia,  1136;  myohypotonia,   1136 
Congestion    of    the    brain,    1032;    of  the 

kidney,  707 
Conium  poisoning,  I177 
Constipation,  420,  425-429;  treatment  of. 

429;  in  infants,  427 
Constitutional  diseases,  779 
Constriction  of  the  bowel,  415 
Consumption  of  the  lungs,  285 
Contagious  carbuncle,  174 
Continuous  irregularity  of  the  heart,  613 
Contracted  kidney,  731 
Contracture  des  nourrices,  678 
Conus  meduUaris,  lesions  of,  931 
Convulsions,    epileptiform,    841;  reflex  in 

children,  1099 
Convulsive  tic,  995 
Copodyscinesia,  11 03 
Copper  poisoning,  1 177 
Coprolalia,  1086 
Cord,   spinal,   diseases  of  membranes   of, 

886-895 
Coronary  arteries,  sclerosis  of,  607 
Corpora  quadrigemina,  967 
Corpulence,  820 
Corrigan  pulse,  580 
Cortex,    functional    assigrmients    of,    944; 

lesion    of    the    sensory    tract    of,    954; 

irritative,    954;    motor    areas    of,    945; 

sensory  areas  of,  950 
Cortical    areas     covering     speech,     954; 

whose  function  is  unknown  or  uncertain, 

964 
Coryza,  494 
Costiveness,  425 
Coup  de  soleil,  1167 
Courvoisier's  law,  443,  450 
Cow-pox,  131 
Crab  louse,  239,  241 
Cracked-pot  sound,  290,  538 
Cranial  nerves,  diseases  of,  970 
Cretinism,  675;  congenital,^676;  endemic, 

677 

Cretinoid  idiocy,  676;  state  supervening 
in  adult  life  in  women,  675 

Crises,  tabetic,  913 

Croup,  false,  500;  membranous  (see 
Diphtheria);  spasmodic,  500;  treatment 
of,  501 

Croupous  enteritis,  404;  nephritis,  710; 
pneumonia,  253-268 

Crura  cerebri,  967 

Cruveilhier's  atrophy,  939 

Curschmann's  spirals,  519 

Cutis  tensa  chronica,  1129 

Cyanosis,  hemoglobanemic,  658 

Cyanotic  induration  of  kidney,  708 

Cycloplegia,  983 

Cylinders,  704 

Cynanche  contagiosa,  112;  gangrenosa, 
333;  tonsillaris,  333 

Cystinuria,  697 

Cystitis,  768-774;  bacteria  in,  768;  cal- 
culous, 770,  774;  morbid  anatomy  of, 
768;  symptoms  of,  769-770;  treatment 
of,  770-774;  of  acute,  770;  of  chronic,  771 


II96 


INDEX 


Cystospasm,  775-777 
Cysts,  echinococcus,  474;hyclatidosus,  474; 
veterinorum,  475;  of  the  pancreas,  481 

D 

Dandy  fever,  74 

Deafness,  nervous,  998 

Degeneration  of  the  heart,  amyloid,  606; 
calcareous,  607;  fatty,  or  metamorphosis, 
605;  circumscribed,  605;  parenchymat- 
ous or  albuminoid  (cloudy  selling),  605 

Deglutition  pneumonia,  268 

Delayed  conduction  of  sensation,  856 

Delirium,  acute,  860;  cordis,  614;  tremens, 
1141,  1143,  1173 

Delusions,  859 

Dementia  paralytica,  1059 

Demodex  foUiculorum,  239 

Dengue,  74;  black  vomit,  75;  diagnosis 
of,  75;  from  yellow  fever,  72;  etiology 
of,  74;  prognosis  of,  75;  rash  in,  75; 
symptoms  of,  74;  treatment  of,  75 

Dentition,  derangements  due  to,  322,  323 

Depurative  disease,  742 

Derangement  of  speech  of  irritative 
origin,  962 

Derbyshire  neck,  668 

Dercum's  disease,  690,  871 

Dermatosclerosis,  1129 

Devonshire  colic,  1 147 

Diabetes  insipidus,  816-820;  diagnosis  of, 
818;  physical  and  chemical  character 
of  the  urine,  818 

Diabetes  Mellitus,  797-816;  acidosis, 
802,  812;  alterations  in  the  blood,  801; 
coma  in,  812;  comphcations,  803-804, 
816;  diagnosis,  805;  diet,  807,  814; 
etiology,  797;  geographical  and  racial 
distribution,  797;  glycosuria,  798-800; 
morbid  anatomy  of,  800;  neuritis  in, 
803;  prognosis  of,  806;  symptoms  of, 
800-804;  treatment  of,  807-816;  urine 
in,  803 

Diagram  showing  order  of  teeth  eruption, 
323 

Diarrhea,  chronic,  395;  of  children,  398- 
404 

Diastolic  shock,  626 

Diazo  reaction,  13 

Dibothriocephalus  latus,  201 

Dibothrium  latum,  201 

Dicrotism  of  pulse  in  typhoid  fever,  9 

Diffuse,  general  tuberculosis,  277;  My- 
elitis, S97 

Digestive  system,  diseases  of,  322 

Digitalis  poisoning,  1178;  relative  value 
of  different  preparations  of,  595 

Digitalone,  595 

Dilatation,  bronchial,  51I;  of  the  colon, 
428,  429;  of  the  heart,  556,  601-604 

Diphtheria,  112;  antitoxin,  119,  120; 
bacillus  of,  112;  bacteriology  of,  112, 
113;  complications  and  sequelae,  115; 
treatment  of,  122;  ataxic  symptoms, 
116;  bronchopneumonia,  116;  capillary 
bronchitis  in,  116;  heart,  115,  116; 
nephritis,  116;  paralysis,  116,  122; 
tendon  reflexes,  116;  toxic  neuritis,  116; 
contagiousness  of,  113;  diagnosis  of, 
116;  from  scarlet  fever,  117;  epidemic, 
113;  etiology  of,  112;  faucium,  112; 
forms    of,     114,     115;    laryngeal,     115; 


Diphtheria: 

nasal,  114;  constitutional  infection  in, 
115;  pharyngeal,  114;  in  animals,  113; 
Klebs-Loeffler  bacillus,  112;  morbid 
anatomy  of,  113;  prognosis  of,  117; 
prophylaxis  of,  122;  symptoms  of,  114, 
115;  laryngeal  cough,  115;  of  nasal,  115; 
period  of  incubation,  114;  seats  of  in- 
vasion, 114;  treatment  of,  118-122; 
administration  of  antitoxin  for  immuni- 
zation, 120;  serum  sickness,  120;  serum 
therapy,  1 19 

Diphtheritic  endocarditis,  570 

Diplegia,  S39;  facialis,  934;  spastic,  1053 

Diplococcus  intracellularis,  meningitidis, 
147;  pneumonia,  253 

Diptera,  241 

Diseases  of  salivary  glands,  331 ;  ptyalism, 
331;  parotitis,  332  ;Mikulicz's  disease,  332 

Disseminated  nodular  sclerosis,  1057 

Distomum,  capense,  199;  caviae,  195; 
haematobium,  199;  heptipaticum,  195; 
ocuhhumani,  197;  ophthalmobium,  197 

Dittrich's  plugs,  511 

Diver's  disease,  1 171 

Diverticulitis,  429 

Dochmius  Anchylostomum,  duodenalis,  227 

Double  vision  in  disease  of  motor  nerves 
of  the  eye,  986     • 

Dracunculus  loa,  221;  medinensis,  219; 
oculi,  221;  Persarum,  219 

Dropsy  in  heart  disease,  556,  598 

Dnisen-fiber,  317 

Dry  suppuration,  1131 

Dubini's  disease,  1085 

Duchenne's-Aran's  disease,  939 

Duchenne's  disease,  907,  932 

Ductless  glands,  diseases  of,  668-692 

Dunbar's  serum,  498 

Duodenal  carcinoma,  431;  ulcer,  368-376 

Duodeno-cholangitis,  437 

Dura  Mater,  inflammation  of,  1025 

Duroziez's  murmur,  583 

Dysarthria,  954 

Dysentery,  85;  Amebic,  85,  88;  compli- 
cations, 89;  diagnosis  of,  89;  etiology  of, 
88;  morbid  anatomy,  88;  liver  abscess 
in,  89,  464;  prognosis  of,  89;  symptoms 
of,  88;  treatment  of,  go;  ulceration  of 
intestines  in,  88;  Bacillary,  85;  bacteri- 
ology of,  87;  complications  and  sequelae, 
87 ;  diagnosis  of,  87 ;  etiology  of,  85 ;  liver 
abscess  in,  87 ;  morbid  anatomy  of,  85 
perforation  in,  87;  prognosis  of,  87; 
symptoms  of,  86;  treatment  of,  90; 
serum,  91 ;  Chronic,  92 ;  morbid  anatomy 
of,  92;  treatment  of,  92;  follicular,  400; 
tropical,  88;  vaccines,  91 

Dyspepsia,  acute,  349 ;  chronic  catarrhal,  350 

Dyspnea,  555,  573,  624 

Dystrophy,  progressive  muscular,  1133; 
facio-scapulo-humeral,  1 135 ;  peroneal, 
1 135;  scapulo-humeral,  1134 


Echinococcus  disease,  474-478;  cyst,  471, 
474,  476,  755,  760,  1067;  daughter, 
475;  endogenus,  475;  exogenus,  476;  of 
the  pleura,  548;  taenia,  474 

EchoIaUa,  1086 

Echokinesis,  1086 

Eclampsia,  infantile,  1099 ;  uremic,  788 


INDEX 


1197 


Eczema,  802 ;  of  the  tongue,  330 

Edema,  angioneurotic,  1251;  of  the  brain, 
1034;  of  the  glottis,  506 

Egophony,  538 

Eighth  nerve,  lesions  of,  997 

Electrical  excitation  of  motion,  848 

Elephantiasis  grsecorum,  312 

Eleventh  nerve,  lesions  of,  1 01 1 

Elodes  icterodes,  67 

Embolic  pneumonia,  523-526;  non-septic, 
524;  septic,  525 

Embolism  of  cerebral  vessels,  1044; 
in  valvular  disease,  568 

Embryocardia,  668 

Emphysema  of  the  lung,  512,  528-533; 
atrophic,  528;  compensatory,  528;  inter- 
lobular or  interstitial,  528;  pseudohy- 
pertrophic, 529;  senile,  528;  vesicular, 
528,  529 

Empyema,  263;  pulsating,  630 

Encephalasthenia,  1120 

Encephalitis,  suppurative,  1072;  without 
abscess,  1074 

Endarteritis  chronica  deformans,  618; 
obliterans,  618 

Endocarditis,  acute  form,  565-571 ;  cere- 
bral, 569;  definition,  565;  diagnosis  of, 
569;  etiology  of,  566;  morbid  anatomy 
of,  566;  prognosis  of,  570;  septic  type, 
568;  symptoms  of,  567-569;  treatment 
of,  570;  typhoid  type,  568;  chronic, 
571-600;  diphtheric,  570;  infectious, 
570;  mycotic,  570;  Malignant  form, 
570;  diagnosis  of,  570;  severe,  570; 
Ulcerative,  570 

Endocardium;  diseases  of,  565-600 

English  sweat,  316 

Entamoeba,  191;  coli,  191;  histolytica,  191; 
hominis,  191 

Enteritis,  amebic,  85,  88 ;  acute  dyspeptic, 
of  children,  398;  diagnosis  of,  399;  etiol- 
ogy of,  398;  prognosis  of,  399;  prophy- 
laxis, 399;  symptoms  of,  399;  treatment 
of,  400 ;  chronic  catarrhal,  395 ;  diagnosis 
of,  396;  etiology,  395;  morbid  anatomy 
of>  395;  prognosis  of,  396;  symptoms  of, 
395;  treatment  of,  396-398;  croupous, 
404;  diphtheritic,  404;  follicular,  400; 
phlegmonous,  404;  pseudomembranous, 
404;  simple  acute  catarrhal,  391;  diag- 
nosis of,  393;  etiology  of,  391;  morbid 
anatomy  of,  392;  symptoms  of,  392; 
treatment  of,  394 

Enterocolitis,  acute,  391,  400;  chronic, 
395;  diagnosis  of,  401,  413;  etiology  of, 
400;  morbid  anatomy  of,  401;  prognosis 
of,  401;  symptoms  of,  401;  treatment 
of,  401 

Enteroptosis,  389 

Enuresis,  776 

Epidemic  cerebrospinal  meningitis,  146; 
cholera,  76;  erysipelas,  157;  hemoglob- 
inuria of  infants,  766;  parotitis,  140; 
pneumonia,  253;  roseola,  loi 

Epilepsy,  1090;  cardiac,  1091;  clonic 
spasm,  1092;  coma,  1093;  diagnosis  of, 
1094;  etiology,  1090;  focal,  1093;  grand 
mal,  1 09 1;  hysterical,  1113;  Jacksonian, 
1093;  morbid  anatomy  of,  1091 ;  partial, 
1094;  petit  mal,  1093;  prognosis  of, 
1096;  psychic,  1094;  symptoms  of,  1091 ; 
tonic  spasm,  1092;  treatment  of,  1096- 
1099 


Epithelial  desquamation,  330 

Equilibrium,  disturbance  of,  associated 
with  defect  of  hearing,  looi 

Erb's  disease,  936 

Erb's  form  of  juvenile  hereditary  dys- 
trophy,  1 134 

Erb's  symptom,  679 

Ergot  poisoning,  1 1 78 

Ergotism,  1158,  1 178 

Erichsen's  disease,  1121 

Erroneous  projection,  985 

Eruptive-disease  table,  136 

Erysipelas,  156;  bacteriology  of,  156,  157; 
complications  of,  159;  contagiousness 
of,  157;  diagnosis  of,  159;  epidemic  of, 
157;  etiology  of,  156;  facial,  158;  gan- 
grene of,  159;  morbid  anatomy  of,  158; 
prognosis  of,  160;  relapses  and  recur- 
rences of,  157;  serum  treatment,  160; 
sequels  of,  159;  symptoms  of,  158; 
incubation,  158;  treatment  of,  160 

Erythremia,  657 

Esophagismus,  345 

Esophagitis,  342;  acute,  342;  chronic,  342 

Esophagus,  341;  cancer  of,  344;  dilata- 
tion of,  346;  diffuse  or  total,  346; 
diseases  of,  341-349;  diverticula,  347; 
pressure,  347;  traction,  346;  explora- 
tion of,  341;  peptic  ulcer  of,  343,  344; 
spasm  of,  345 ;  stricture  of,  345 

Estivo-autumnal  fever,  47,  58 

Essential  contractions,  1053 

Eustice  Smith's  sign,  552 

Eustrongylus  gigas,  226 

Ewart's  sign,  561 

Exophthalmic  goitre,  670-675 

External  popliteal  nerve,  lesions  of,   1022 

Extra  systole,  613 

Eyeball,  lesions  of  the  motor  nerves  of,  981 

Eyes,  phenomena  of  paralysis  of  motor 
nerves  of,  985 


Facial  atrophy,  1128;  hemiatrophy,  1128; 

nerve,  lesions  of,  989;  paralj'sis  of,  989; 

diagnosis    of,    992 ;    etiology    of,    990 ; 

infranuclear  of   peripheral    facial,    990; 

monoplegia,  989;  nuclear,  990;  prognosis, 

994;   supranuclear,   989;   symptoms   of, 

991;  treatment,   995;  spasm,   995;  ble- 

blepharospasm,  996 
Falling  fits,  1090 

Fallopian  tubes,  tuberculosis  of,  311 
False  croup,  500;  measles,  loi 
Family  periodical  paralysis,  1123 
Famine  fever,  40 

Farcy,  176;  acute,  177;  chronic,  177 
Fasciola  hepatica,  195;  humana,  195 
Fatty    degeneration    of    the    heart,    605; 

infiltration   of   the   heart,    606;    of   the 

liver,    454;   diagnosis   of,   455;   etiology 

of,     454;     morbid     anatomy     of,     454; 

prognosis     of,     455;     symptoms,     455; 

treatment    of,    455;    metamorphosis  of 

heart,  656;  of  liver,  455,  466 
Pebris  fiava,  67 
Febris  miHaris,  316 
Febris  recurrens,  40 
Fehling's  test  solution  for  sugar,  805 
Fetid  stomatitis,  327 
Fetor  oris,  324 


INDEX 


Fever,  estivo-autumnal,  47,  50,  58;  and 
ague,  47;  breakbone,  74;  camp,  36; 
catarrhal,  142;  cerebrospinal,  146; 
dandy,  74;  enteric,  i;  famine,  40; 
glandular,  317;  hay,  496;  intermittent, 
55;  jail,  36;  malarial,  47;  Malta,  45; 
miliary,  316;  nervous,  i;  paratyphoid, 
34;  pernicious  malarial,  59;  petechial, 
36;  relapsing,  40;  remittent,  58;  Rocky 
Mountain  spotted,  34;  scarlet,  103; 
seven  day,  40;  ship,  36;  typhoid,  l; 
typhus,  36;     yellow,  67 

Fibrillary  contractions,  842 

Fibrinous  pneumonia,  253 

Fibroid  heart,  607;  degeneration  of 
myocardium,  60;  phthisis,  297 

Fibrositis,  779 

Fibrous  myocarditis,  607 

Fifth  nerve,  lesions  of,  988;  paralysis  of 
motor  portion,  988;  of  sensory  portion, 
988 

Filaria  aethiopica,  219;  bancrofti,  214; 
diurna,  214,  218;  dracunculus,  219; 
lachrymalis,  221;  loa,  221;  medinensis, 
219;  nocturna,  214;  oculi,  221;  of  the 
dog,  216;  perstans,  214,  218;  subcon- 
junctivalis,  221;  sanguinis  hominis,  214, 
218;  sanguinis  hominis  nocturna,  214 

Filariasis,  pathology  of,  216;  symptoms 
of,  216,  217;  treatment  of,  218 

Fish  poisoning,  1157 

Fisher's  alkaline  treatment,  719 

Flagellata,  192-194 

Flat  worm,  195 

Flea,  241 

Flies,  242 

Flint  murmur,  578,  583 

Floating  kidney,  762;  diagnosis  of,  413 

Flukes,  blood,  199;  liver,  195;  lungs,  198 

Focal  symptoms,  861,  1068,  1 182 

Folic  pourquoi,  1086 

Follicular  dysentery,  400;  enteritis,  400; 
stomatitis,  325;  tonsillitis,  123 

Food  poisoning,  1 155 

Foot  and  mouth  disease,  180 

Fourth  ner\'e,  lesions  of  the,  984 

Fragilitas  ossium,  787 

Friction  rub,  537,  540 

Friedreich's  disease,  918 

Functional  diseases  of  nervous  system, 
1079 

Fusaria  vermicularis,  235 


Gall-bladder,  cancer  of,  449;  atrophy  of, 
444 ;  dilatation  of,  440,  442 ;  inflammation 

of.  447 

Gallop  rhythm,  604 

Galloping  consumption,  280 

Gall-stone,  439-446;  acute  impacted,  440; 
diagnosis  of,  413,  441 ;  from  appendicitis, 
413,  442 ;  prognosis  of,  442 ;  symptoms  of, 
440;  chronic  impacted,  442-445;  symp- 
toms of,  442-444;  due  to  obstruction  of 
the  common  duct,  443 ;  due  to  chronic  ob- 
struction of  the  cystic  duct,  442 ;  due  to 
retention  in  the  bladder,  442;  Cour- 
voisier's  law,  443;  diagnosis  of,  445; 
jaundice  in,  441,  443;  treatment  of, 
445-446;  preventive,  446;  cholangitis 
in,  443;  dilatation  of  gall-bladder  in, 
440,  442,  443 


Gangrene,  802;  of  the  lung,  237;  of  the 
spleen,   174 

Gangrenous  stomatitis,  329 

Gastralgia,  363 

Gastrectasia,  383;  acute,  386 

Gastric  cancer,  376;  crisis,  913;  neuras- 
thenia, 360;  neurosis,  360;  ulcer,  368-376 

Gastritis,  acute  catarrhal,  349 ;  diagnosis  of, 
350;  etiology  of,  349;  gastric  contents  in, 
350;  morbid  anatomy  of,  349;  symptoms 
of,  349;  treatment  of,  350;  chronic 
catarrhal,  350-358;  diagnosis  of,  352; 
etiology  of,  351 ;  gastric  contents  in,  352; 
morbid  anatomy  of,  351;  prognosis  of, 
352;  symptoms  of,  351;  treatment  of, 
353-358;  dietetic  of,  353-356;  diph- 
theritic, 359;  mycotic,  359;  phlegmonous 
or  suppurative,  358;  syphilitic,  359; 
traumatic  and  toxic,  358;  tuberculous, 

359 

Gastro-enteric  fever,  i 

Gastroptosis,  389 

Gastrosuccorrhea,  366 

General  paresis,  1059 

Geographical  tongue,  330 

German  measles,  loi 

Giant  urticaria,  1 125 

Gigantism,  687,  688-690 

Gilles  de  la  Tourette's  disease,  1086 

Gin  liver,  457 

Girdle  pains,  913 

Glanders  and  farcy,  176 

Glands,  bronchial,  tuberculosis  of,  305 

Glandular  fever,  317 

Gl^nard's  disease,  389 

Glissonian  cirrhosis,  465 

Glossitis,  330;  desiccans,  330;  paren- 
chymatous, 330 

Glossolabiopharyngeal  paralysis,  932 

Glossopharyngeal  nerve,  lesions  of,  1003 

Glossy  skin,  1 129 

Glottis,  edema  of,  506 

Glycosuria,  798;  alimentary,  798;  cromaf- 
fin  system,  799;  ner\'Ous,  799;  pancrea- 
tic, 799;  pituitary,  799;  renal,  800 

Goiter,  exophthalmic,  670-675;  diagnosis 
of,  673;  etiology  of,  670;  prognosis  of, 
673;  symptoms'of,  671-673;  Stellwag's 
sign,  671;  Moebius'  sign,  671;  von 
Graefe's  sign,  671 ;  treatment  of,  673-675; 
simple,  668-670;  etiology,  668;  morbid 
anatomy  of,  668;  symptoms  of,  669; 
treatment  of,  669 

Gonococcus  arthritis,  244;  complications 
of,  245;  morbid  anatomy  of,  244;  symp- 
toms of,  245;  treatment  of,  246;  varieties 
of,  245;  infection,  244 

Gordius  medinensis,  219 

Gout,  788-797;  atypical,  792;  chronic, 
793;  etiology  of,  788;  irregular,  792; 
metastatic,  792,  796;  morbid  anatomy 
of,  790;  pathogenesis,  789;  pharyngitis, 
792;  retrocedent,  792,  796;  symptoms 
of,  791;  treatment  of,  794-797;  typical 
acute,  791;  urine,  791 

Gouty  kidney,  731 

Grain  poisoning,  1158-1165 
Grand  mal,  1091 

Granular  kidney,  731;  liver,  457;  pharyn- 
gitis, 339 

Graphospasmus,  1103 
Graves'  disease,  670 
Green  sickness,  636 


INDEX 


"99 


Grip,  142 
Grocco's  sign,  539 
Guinea-worm,  219 
Gynecophorus  hsematobius,  199 

H 

Habit  chorea,  1084 

spasm,  1084 
Hallucinations,  .859 
Harrison's  groove,  827 
Harvest  bug,  239 
Hay  asthma,  496 
Hay-fever,  496-499 

Dunbar's  serum  in,  498 

etiology  of,  496 

symptoms  of,  497 

treatment  of,  498,  499 
Headache,  bilious,  iioo 

paroxysmal,  11 00 

sick,  IIOO 
Head-banging,  1086 
Head-louse,  239,  240 

Hearing,  modifications  of,  in  nervous  dis- 
ease, 860 
Heart,  Abscess  of,  609;  aneurysm  of,  609, 

630;  atrophy  of,  607;  brown,  atrophy  of , 

607;  block,  614;  Chronic  valvular  defects 

of,  571-600;  Congenital  defects  of,  589; 

Dilatation  of,  601-604;  diagnosis  of,  604; 

etiology  of,  602;  physical  signs  of,  603; 

symptoms  of,   602,   604;   treatment   of, 

591-600;   Nauheim  baths,  593;  general 

symptomatology,   555-557;  diseases  of, 

555-618;    fatty    degeneration    of,    605; 
.  fibroid  degeneration  of,   607;   irritable, 

602;  nervous  palpitation,  615;  diagnosis 

of,  616;  treatment  of,  616;  neuroses  of, 

615;  rupture  of,  610 
Heart-action,   610;   diminished   frequency 

of,    612;    increased    frequency   of,    611; 

irregular,  610,  612 
Heat  exhaustion,  1166 

fever,  11 67 
Heberden's  nodosities,  783 
Hematorrhachis,  890 
Hematothorax,  545 
Hematuria,  idiopathic,  764 
Hemeralopia,  972 
Hemiachromatopsia,  976 
Hemianopsia,  975 

heteronymous,  976 

homonymous,  976 
Hemicrania,  11 00 
Hemiplegia,    bilateral     infantile     spastic, 

1053;   in   infants,    1050;   spastica   cere- 

bralis,  1050;  spastica  infantaUs,  1050 
Hemocytozoa  of  malaria,  47 
Hemoglobinanemic  cyanosis,  658 
Hemoglobinuria,  61,  65,  765 

epidemic,  766 

paroxysmal,  766 

toxic,  765 
Hemopericardium,  565 
Hemophilia,  665-667 
Hemoptysis,  256,  288,  573,  625 
Hemorrhagic  infarct  of  the  bowel,  404 

lung,  524 
Hemorrhage,  into  brain,  into  membranes 

of  cord,  890;  into  substance  of  cord,  895 
Hemorrhagic  disease  of  the  newborn,  664 
Hemorrhoids,  458 

Hepatic   artery   and  vein,   calculus,   439;. 
diseases  of,  454;  intermittent  fever,  464 


Hepatitis,  acute  parenchymatous,  466 

Hepatitis,  suppurative,  462-464,  477; 
diagnosis  of,  464;  etiology  of,  462;  mor- 
bid anatomy,  463;  prognosis  of,  464; 
symptoms  of,  463;  treatment  of,  464 

Hereditary  ataxic  paraplegia,  918;  ataxia, 
918 

Hernia  within  the  abdomen,  415 

Hiccough,  1087 

Hippocratic  fingers,  781 

Hobnail  liver,  457 

Hodgkin's  disease,  650-654 

Holy  roller,  1088 

Hook-worm,  American,  230 
European,  227 

Hoppe-Goldflam  symptom  complex,  936 

Huntington's  chorea,  1087 

Hutchinson's  teeth,  188 

Hybrid  measles,  loi 
scarlet  fever,  loi 

Hydatid  cyst,  of  liver,  474 

Hydatid  disease  of  peritoneum,  493 

Hydatid  disease  of  the  pleura,  548 

Hydrarthrosis,  intermittent,  11 26 

Hydrocephalus,  1075;  acquired,  1077; 
chronic,  1075;  congenital,  1075;  external, 
1075;  internal,  1075 

Hydrochloric  acid  poisoning,  1179 

Hydrocyanic  acid  poisoning,  1 1 79 

Hydronephrosis,  759 

Hydropericardium,  564 

Hydroperitoneum,  482-485 

Hydrophobia,  164.;  diagnosis  of,  167; 
etiology  of,  164;  incubation,  164;  morbid 
anatomy  of,  165;  Negri  bodies  in,  165; 
Pasteur  treatment,  168;  prognosis  of, 
167;  prophylaxis,  167,  168;  symptoms  of, 
165;  treatment  of,  168,  169;  varieties  of, 
166 

Hydropneumothorax,  545-547 

Hydrorrachis,  932 

Hydrothorax,  545 

Hymenolepis  muria,  204 

Hymenolepis  nana,  204 

Hyperchlorhydria,  360-363;  definition  of, 
360;  diagnosis  of,  361;  etiology  of,  360; 
gastric  contents  in,  361 ;  prognosis  of, 
361;  symptoms  of,  360;  treatment  of, 
361-363;  diet,  362;  hygienic,  361;  med- 
ical, 361 

Hyperemia  of  brain,  1032 ;  of  the  liver,  450; 
active,  452;  treatment  452;  passive,  450; 
etiology,  450;  morbid  anatomy,  of  451 ; 
symptoms  of,  451  treatment  of,  452 

Hyperpepsia,  360-363 

Hyperplastic  perihepatitis,  491 

Hypersecretion,  366 

Hypertension,  621,  736 

Hyperthyroidism,  670 

Hypertrophic  cirrhosis  of  the  liver,  460 

Hypertrophy  of  heart,  556,  600,  601,  621; 
etiology  of,  600;  pathology,  556;  symp- 
toms of,  601 

Hypertrophic  pulmonary  arthropathy,  781 

Hypnosis  and  suggestion,  1 114 

Hypoglossal  nerve,  lesions  of,  1015 

Hypoparathyreosis,  678 

Hypophosiscerebri,  686 

Hypopituitarism,  687 

Hypotonia  muscular  in  tabes  dorsalis,  912; 
of  muscles  of  childhood,  1136 

Hysteria,  1107-1117;  diagnosis  of,  H15 ; 
etiology  of,    11 07;   prognosis   of,    11 15; 


INDEX 


Hysteria: 

symptoms    of,     1108-1115;     traumatic, 
1 121 ;  treatment  of,  11 15-1117 

Hysterical  epilepsy,  11 13;  fever,  1 112 

Hysterical,  stigmata,  mo 

Hysterogenous  zones,  1 1 15 


Iced  liver,  491 

Ichthyosis  lingualis,  331 

Ichthysmus,  11 65 

Icterus,  434;  gravis,  466;  neonatorum,  437 

Ignis  sacer,  1056 

Ileo-colitis,  acute,  400-402 

Ileus    paralyticus    vel   nervosus,    418 

Illusions,  859 

Impacted  gall-stone,  442 

Increase  of'volume  of  the  lung,  528 

Incubation    periods,    infectious    diseases, 

157-321 

Indurative  degeneration,  607;  mediastino- 
pericarditis,  491 

Infantile  convulsions,  1099;  palsy,  1050; 
paralysis,  319;  scurvy,  661;  spastic 
paraplegia,  1054 

Infantilism,  690 

Infectious  diseases  of  doubtful  nature, 
315-321 

Inflammatory  rheumatism,  246 

Influenza,  142;  complications  of,  143; 
diagnosis  of,  145,  153;  etiology  of,  142; 
fever  in,  143,  144;  herpes  in,  143,  144; 
incubation  of,  142;  morbid  anatomy  of, 
142;  pneumonia  in,  143,  1 46 ;  prognosis  of , 
145;  symptoms  of,  142;  treatment  of, 
145;  varieties  of,  142 

Insufficiency,  aortic,  580;  mitral,  572;  pul- 
monary, 588;  tricuspid,  586 

Insular  sclerosis,  1057 

Interlobular  emphysema,  528 

Intermittent  fever,  47,  55;  hydrarthrosis, 
1127 

Internal  capsule,  966;  lesions  of,  965; 
strangulation,  415 

Interstitial  nephritis,  chronic,  731 

Interstitial  suppurative  nephritis,   746 

Intestinal  obstruction,  415-425;  acute  and 
chronic,  415;  by  abnormal  contents,  417; 
by  fecal  impaction,  418;  by  foreign 
bodies,  417;  by  internal  strangulation, 
415;  by  intussusception,  416;  by'morbid 
growths,  418;  by  strictures,  4.18;  by 
volvulus,  417;  definition,  415;  diagnosis 
of,  411,  421-423;  etiology  of,  416,  417, 
419;  prognosis  of,  424;  symptoms  of, 
419-421;  treatment  of,  424,  425;  sand, 
433 

Intestines,  diseases  of,  391-433 

Intoxications,  the,  1 138 

Intracranial  aneurysm,  1049;  tumors,  1065 

Intrathoracic  tumors,  551 

Intussusception,  416 

Invagination,  intestinal,  416' 

lodin  poisoning,  1179 

Iodoform  poisoning,  11 79 

Iridoplegia,  983;  accommodative,  983; 
reflex,  or  Argyll-Robertson  pupil,  860, 
913,  983;  skin,  983 

Irregular  pulse,  610,  612 

Irritation  of  auditory  nerve,  1000 

Itch,  238 


Jacksonian  epilepsy,  1095 

Jail  fever,  36 

Jaundice,  434;  hematogenous,  436;  malig- 
nant, 466;  obstructive,  434;  diagnosis  of, 
436;  symptoms,  435;  of  the  new-born, 
437;  simple  catarrhal,  437;  diagnosis  of, 
438;  etiology  of,  437;  morbid  anatomy  of, 
437 ;  prognosis  of,  438 ;  symptoms  of,  438 ; 
treatment  of,  438;  toxic  hemolytic,  436 

Jerkers,   1088 

Jigger,  242 

Jumpers,  1088 

K 

Kahler's  disease,  833 

Kalar  Azar,  318 

Katayama,  201 

Keloid  of  Addison,  1 130 

Kendall's  fever,  67 

Keratosis  mucosae  oris,  331 

Kernig's  sign,  150 

Kidney,  abscess  of,  746;  amyloid,  456, 
742-745 ;  anomalies  of  form  and  position, 
761 ;  congenital  absence  of,  761 ;  floating, 
762;  horseshoe,  761;  lobulated,  761; 
cirrhotic,  731 ;  congestion  of,  707;  active, 
707;  passive  induration,  708-710;  con- 
tracted, 731;  chronically,  731;  cyanotic 
induration  of,  708;  cysts  of,  733,  759- 
761;  congenital,  759;  dermoid,  759; 
echinococcus  or  hydatid,  755,  760; 
hydronephrosis,  759;  retention  or  ob- 
struction, 759;  treatment  of,  761;  de- 
rangement of  circulation,  707-710;  dis- 
eases of,  707-768;  gouty,  731;  granular, 
731;  lardaceous,  742;  large  white,  721; 
movable,  762;  senile  atrophy,  732;  stone 
in,  752;  surgical,  746;  tuberculosis  of, 
309;  tumors  of,  756-759;  diagnosis  of, 
757;  symptoms  of,  757;  treatment  of, 
759;  waxy,  742 

Kinepox,  131 

Kohler's  disease,  695 

Koplik's  sign,  98,  99,  100 

Koranyi-Grocco's  sign,  539 

Korsakow's  psychosis,  861,  869,  870 

Krouomania,  1086 


Labyrinthine  vertigo,   looi 

Lactosuria,  698 

Lacunar  tonsillitis,  123 

Lagophthalmos,  991 

La  Grippe,  142 

Landr\''s  paralysis,  903 

Lardaceous  disease  of  the  kidney,  456,  742 ; 

of  the  liver,  455 
Large  white  kidney,  721 
Laryngeal  muscles,  paralysis  of,  624,  1006 
Laryngitis,  acute  catarrhal,  499;  chronic 

catarrhal,  502;  etiology  of,  502;  morbid 

anatomy    of,    502;    prognosis    of,    502; 

symptoms  of,   502;  treatment  of,  502; 

spasmodic  catarrhal,  500;  syphilitic,  505; 

tubercular,  503-504;  diagnosis  of,  504; 

etiology    of,  503;  morbid  anatomy  of, 

503;   prognosis  of,   504;   symptoms  of, 

503;  treatment  of,  504 
Laryngoplegia,  624 


INDEX 


Larynx,  499;  bilateral  abductor  paral- 
ysis of,  1006;  diseases  of,  499;  spasm  of, 
1008;  tensor  paralysis  of,  1007;  total 
paralysis  of,  1006;  unilateral  abductor 
paralysis  of,  1007 

Lata,  1088 

Lateral  sclerosis,  amyotrophic,  937 

Lathyrism,  1159 

Lead  poisoning,  1147,  11 80;  blue  line  of, 
1 149;  etiology  of,  1147;  morbid  anatomy 
of,  ii48;palsy,  11 50;  prognosis  of,  1151; 
symptoms  of,  1149;  treatment  of,  1 152 

Legal 's  test  for  acetone,  806 

Leishmaniasis,  318 

Lenhartz  treatment  for  gastric  ulcer,  375 

Leprosy,  312-315;  anesthetic  form  of,  312, 
314;  bacillus  of,  312;  diagnosis  of,  314; 
etiology,  312;  morbid  anatomy  of,  313; 
prophylaxis  of,  315;  prognosis  of,  314; 
symptoms  of,  313;  treatment  of,  315 

Leprous  neuritis,  314 

'Leptodera  intestinalis  et  stercoralis,  212 

Leptomeningitis,  acute,  1027;  diagnosis  of, 
1030;  etiology  of,  1027;  morbid  anatomy 
of,  1028;  prognosis  of,  1030;  symptoms 
of,  1029;  treatment  of,  1030;  cerebral, 
1027;  chronic,  1031;  spinal,  889 

Leptus  autumnalis,  239 

Leukemia,  645;  acute,  645;  chronic,  649; 
diagnosis  of,  649;  blood  changes  in,  648; 
etiology  of,  645;  lymphoid  645,  648; 
morbid  anatomy  of,  646;  myeloid,  645, 
648;  prognosis  of,  650;  symptoms  of, 
648 

Leukomain  poisoning,  11 55 

Leukoplakea  buccalis,  331 

Leyden's  crystals,  519 

Lice,  239-241 

Lipomatosis  luxurians  muscularis,  1133 

Little's  disease,  1053 

Liver,  abnormalities  of  position  of,  433; 
abscess  of,  462-464;  multiple,  463; 
solitary,  89,  464;  active  hyperemia  of, 
452;  acute  yellow  atrophy  of,  466-468; 
albuminoid,  455;  altered  shape  of,  433; 
amyloid,  455-456;  atrophic  cirrhosis  of, 
457;  ascites,  458;  diagnosis  of,  459; 
etiology,  457;  jaundice  in,  459;  morbid 
anatomy  of,  457;  symptoms  of,  458; 
biliary  cirrhosis  of,  460-462;  carcinoma 
of,  468;  changes  in  hepatic  artery  and 
vein,  454;  cirrhosis  of,  457-462;  treat- 
ment of,  461;  diseases  of,  433-478; 
blood-vessels  of,  450-454;  dislocation  of, 
433;  echinococcus  disease  of,  474;  fatty, 
454:  infiltration  of,  454;  metamorphosis 
of,  455;  floating,  433;  gin,  457;  Glisson- 
ian  cirrhosis,  465;  granular,  457;  hobnail, 
457;  hydatid  cyst  of,  474;  hyperemia  of, 
450;  hypertrophic  cirrhosis  of,  460-462; 
diagnosis  of,  460;  jaundice  in,  460; 
morbid  anatomy  of,  460;  prognosis,  461 ; 
symptoms  of,  460;  treatment,  461; 
lardaceous,  455;  morbid  growths  of,  468; 
nutmeg,  451;  parasites  of,  474-478; 
passive  hyperemia  of,  450;  pericarditic 
pseudocirrhosis,  491;  portal  cirrhosis, 
457-459;  pylethrombosis  of  portal  veins, 
452;  pylephlebitis  portal,  453;  red 
atrophy  of,  450;  sarcoma  of,  469 ;  syphilis 
of,  186,  472-474;  tuberculosis  of,  311; 
waxy,  455 

Lobar  pneumonia,  253 
76 


Lobestein's  disease,  787 

Lobular  pneumonia,  268 

Local  asphyxia,  1126 

Localization  of  cerebral  disease,  944 

Lockjaw,  169 

Locomotor  Ataxia,  907 

Long  thoracic  nerve,  lesions  of,  1018 

Lower  segment,  837 

Ludwig's  angina,  333 

Lues  venerea,  182 

Lumbago,  780 

Lumbar  plexus,  lesions  of,  1 02 1 

Lung,  abscess  of,  262;  cavities  in,  286,  290; 
cirrhosis  of,  262;  diseases  of,  528-535; 
emphysema  of,  512,  528-533;  fibroid 
induration  of,  262;  gangrene  of,  262; 
hemorrhagic  infarct  of,  524;  metastatic 
abscess  of,  525;  tuberculosis  of,  283; 
tumors  of,  533-535;  carcinoma,  533; 
diagnosis  of,  534;  peribronchial  cancer, 
533;  physical  signs,  534 

Lupinosis,  1 159 

Lymphadenie,  650 

Lymphadenitis,  simple,  305,  554;  tuber- 
culous, 554 

Lymphadenoma,  650 

Lymphadenosis,  650 

Lymphatic  glands,  tuberculosis  of,  305-307 

Lymphatism,  655 

Lyssa,  164 

M 

Maladie  de  la  tic  convulsif,  1087 

Malaria,  chronic,  47,  62,  67;  Plasmodium 
of,  63 

Malarial  cachexia,  47,  62;  Fever,  47-67; 
algid  form,  60;  blood  changes,  54;  in 
chronic,  63;  chills  in,  55,  58,  60,  61; 
clinical  varieties,  55;  comatose  form, 
60;      diagnosis,     57,     59,     60;     estivo- 

■  autumnal,  47,  50,  58;  favoring  causes, 
53;  fever,  48,  55,  60,  61,  62;  geographical 
distribution,  53;  hematuria,  61,  65; 
herpes  in,  57;  incubation  of,  49,  53,  55; 
intermittent  form  of,  47,  55,  64;  irregu- 
lar forms  of,  60;  kidneys  in,  55;  latent 
form  of,  61;  liver  in,  54;  migraine,  61; 
morbid  anatomy  of,  54;  mosquito  in,  50, 
51;  Plasmodium,  48,  49,  50,  63;  per- 
nicious, 59;  prognosis,  58,  59;  prophy- 
laxis against,  63;  quartan,  47,  48,  55,  57 
quotidian,  48;  remittent  form,  47,  58 
64;  seasons  favoring,  53;  spleen,  54,  57 
63;  sweating,  56;  symptoms,  55,  58,  60 
6i,  62;  synonyms,  47;  tertian,  47,  48, 
55.  57;  transmission  of,  53;  treatment 
of,  64-67;  urine  in,  55,  59,  61;  varieties 
of,  47 

Malignant  jaundice,  466;  endocarditis, 
570;  lymphoma,  650;  650;  pustule,  174 

Malleus  humidus,  176 

Malta  fever,  45;  diagnosis  of,  47;  distribu- 
tion of,  45;  etiology  of,  45;  incubation, 
45;  joint  involvement,  47;  morbid  anat- 
omy of,  45;  onset,  45;  relapses  in,  45; 
symptoms  of,  45;  treatment  of,  47 

Mammary  glands,  tuberculosis  of,  311 

Mania-a-potu,  703,  1141;  acute,  703 

Marie,  views  on  aphasia,  963 

Marie's  syndrome,  781 

Marsh  fever,  47 
,  Mastication,  spasm  of  muscles  of,  988 


INDEX 


Max  worm,  232 

McBurney's  point,  408 

Measles,  97;  black,  97,  99;  cancrumorisin, 
100;  complications  and  sequelae  of,  99; 
contagiousness  of,  97;  gangrenous  stom- 
atitis, 100;  diagnosis  of,  100,  136;  morbid 
anatomy  of,  97;  pneumonia  in,  99; 
prognosis  of,  100;  recurrent  attacks  of, 
97;  symptoms  of,  98;  bronchitis,  97,  99; 
incubation,  98;  Koplik's  sign,  98,  99, 
100;  treatment  of,  100 

Meat  poisoning,  1 155,  1 184 

Median  nerve,  lesions  of,  1021 

Mediastinal  abscess,  554;  disease,  548- 
554;  tumors,  550-554;  diagnosis  of,  553; 
morbid  anatomy  of,  550;  symptoms  of, 
551;  treatment  of,  554 

Mediterranean  fever,  45 

Megrim,  1 100 

Melsena  neonatorum,  665 

Melanuria,  697 

Membranes  of  the  brain,  diseases  of,  1025 

Membranous  croup,  112 

Meniere's  disease,  looi 

Meningeal  apoplexy,  890 

Meningitis,  cerebrospinal,  epidemic,  146; 
sporadic,  154;  tuberculous,  153,  1027 

Meningocele,  932 

Meningococcus,  147 

Meningo-encephalitis,  chronic  diffuse,  1059 

Mental  phenomena,  859 

Mercury  poisoning,  1 1 80 

Metabolism,  diseases  of  deranged,  779 

Metallic  tinkle,  291,  546 

Metastatic  abscess  of  lung,  525 

Miasmatic  fever,  47 

Micrococcus  lanceolatus,  253 

Micrococcus  melitensis,  45 

Migraine,  1 100 

Migran,  iioo 

Miguet,  326 

Mikulicz's  disease,  332 

Mild  chorea,  1078 

Miliary  fever,  316 

Milk  poisoning,  1 156 

Milk  sickness,  181;  etiology  of,  181; 
morbid  anatomy,  181 ;  symptoms  of,  181 ; 
treatment  of,  182 

Miltzbrand,  174 

Mimetic  facial  paralysis,  989;  spasm,  995 

Mineral  acid  poisoning,  1181 

Miosis,  982 

Mirj'achit,  1088 

Mitral  insufficiency,  572-575;  etiology  of, 
573;  mechanism  of,  572;  murmur,  575; 
physical  signs,  574;  pulse  in,  573; 
relative,  573;  symptoms  of,  573-575; 
treatment  of,  591-600;  stenosis,  575- 
579;  complications  of,  579;  etiology  of, 
576;  first  sound  in,  577;  mechanism  of, 
575;  murmur  in,  577;  physical  signs  of, 
576-579;  pulse  in,  577;  symptoms  of, 
576-579;  thrill  in,  577;  treatment  of, 
591-600 

Moebius  disease,  671 

Mogigraphia,  1 103 

Monlc'shood  poisoning,  11 73 

Monoplegia  facialis,  989 

Morbilli,  97 

Morbus  calducus  sive  sacer,  1090;  divinus, 
1090;  maculosus,  659;  neonatorum,  664; 
Werlhofi,  663;  virgineus,  636 

Morphea,  1130 


Morphin  habit,  1144;  poisoning,  u8l 

Morphinism,  1 144 

Morphinomania,  1144 

Morvan's  disease,  924 

Motion,  phenomena  of,  838 

Motor  agraphia,  960;  aphasia,  960;  areas  of 
the  cortex,  945;  points,  848 

Mouth,  care  of,  324;  -breathing,  335; 
diseases  of,  322,  333 

Mucous  colitis,  395 

Mucous  patches,  184,  186,  331 

Multiple  arthritis  deformans,  782;  mye- 
loma, 695,  833;  neuritis,  861,  866,  870; 
sclerosis  of  brain  and  cord,  1057 

Mumps,  140;  bacillus  of,  140;  complica- 
tions of,  141;  diagnosis  of,  141;  etiology 
of,  140;  morbid  anatomy  of,  140;  prog- 
nosis of,  141;  symptoms  of,  140;  treat- 
ment of,  141 

Muscle-jerk,  814 

Muscle,  sense,  857 

Muscular  system,  diseases  of,  1132-1137 

Musculospiral   nerve,   lesions  of,    1019 

Mushroom  poisoning,  1181 

Multiple  hyaloserositis,  491;  serositis,  491 

Myalgia,  779-781 

Myasthenia,  general  profound,  936;  gravis, 
936;  pseudoparalytic,  936 

Myatonia  congenita,  1057,  1136 

Mycotic  endocarditis,  570 

Mydriasis,  982 

Myelitis,  diffuse,  acute  and  chronic,  897; 
diagnosis  of,  902;  etiology  of,  897; 
morbid  anatomy  of,  897;  prognosis  of, 
902;  symptoms  of,  898-901;  transverse, 
897;  treatment  of,  902-903 

Myelocele,  932 

Myeloma,  multiple,  695,  833 

Myelopathic  albumosuria,  833 

Myiosis,  242 

Myocarditis,  607-610;  acute  suppurative, 
609;  chronic,  607;  fibrous,  607;  inter- 
stitial, 607 

Myocardium,  diseasis  of,  60D-610 

Myocardium,  diseases  of,  600-610;  fibroid 
degeneration  of,  607 

Mj'oclonia,  1085 

Myodegeneration,  607 

Myohypertonia,  1 136 

Myohypotania,  1 136 

Myositis,  779-781,  1132;  acute,  780,  1132; 
chronic,  781,  1132;  infectious,  1132; 
progressive  ossifying,  1132;  rheumatic, 
"39 

Myotonia  congenita,  1136 

Myxedema,  675-678;  diagnosis  of,  677; 
etiology  of,  675;  operative,  677;  prog- 
nosis of,  677;  pure,  675;  symptoms  of, 
675-677;  treatment  of,  677,  678;  with 
cretinism,  676 

N 

Nauheim  bath,  593 

Naunyn's  sign,  443 

Neapolitan  fever,  45 

Necator  americanus,  230 

Ncoplasmata  cerebri,  1065 

Nephritis,  acute  parenchymatous,  7 1 0-72 1 ; 
blood  pressure  in,  716;  complications  of, 
715;  pneumonia  in,  715;  diagnosis  of, 
716;  etiology  of,  710;  morbid  anatomy  of, 
711-713;   glomerular    changes,    712;   in- 


INDEX 


1203 


Nephritis 

terstitial  changes,  712;  tubal  changes, 
712;  prognosis  of,  717;  symptoms  of, 
713-715;  urine,  714;  treatment  of,  718- 
721;  chronic  interstitial,  731;  complica- 
tions of,  737;  diagnosis  of,  738,  739; 
etiology  of,  73 1 ;  morbid  anatomy  of, 
732-734;  prognosis  of,  739;  symptoms  of, 
734-737;  blood  pressure  in,  736;  dimness 
of  vision,  737;  hypertrophy  of  the  left 
ventricle,  735;  urine,  734;  treatment  of, 
740-742;  chronic  parenchymatous,  721- 
731;  complications  of,  726;  diagnosis  of, 
726;  morbid  anatomy  of,  722;  prognosis 
of,  727;  symptoms  of,  724-726;  duration 
of,  726;  urine,  725;  treatment  of,  727- 
731 ;  diet,  728;  hygienic  measures,  728; 
operative,  730;  hemorrhagic,  710;  septic 
and  pyemic,  746;  suppurative  interstitial, 
746;  diagnosis  of,  749;  etiology  of,  746; 
morbid  anatomy  of,  747;  prognosis  of, 
750;  symptoms  of,  748;  urine,  748;  treat- 
ment of,  750,  751 

Nephrolithiasis,  752-756;  diagnosis  of, 
755;  X-ray  in,  755;  etiology  of,  753; 
morbid  anatomy  of,  753;  prognosis  of, 
756;  symptoms  of,  754;  treatment  of, 
756 

Nephroptosis,  762 

Nerve,  phrenic,  affections  of,  1016;  cir- 
cumflex, 1018;  median,  1021;  muscu- 
lospiral,  1019;  suprascapular,  1019; 
treatment  of  lesions  of ,  I02l;ulnar,  1020; 
tumors  of,  878-79 

Nervous  deafness,  998;  treatment  of,  1000; 
Diseases,  alterations  in  breathing  and 
pulse,  860;  focal  symptoms,  861;  in 
vision  and  hearing,  860;  general  symp- 
tomatology, 838;  histology  of,  835; 
mental  phenomena  in,  859;  sensory  phe- 
nomena, 854—858;  phenomena  of  motion 
in,  838-854;  vasomotor  and  trophic 
phenomena,  858;  dyspepsia,  360;  ex- 
haustion, 1 118;  fever,  i;  hypersecretion 
of  hydrochloric  acid,  360-363;  system, 
diseases  of,  835;  weakness,  11 18 

Neuralgia,  872;  brachial,  874;  cervico- 
brachial,  874;  cervico-occipital,  874; 
diagnosis  of,  876;  dorso-intercostal,  874; 
etiology  of,  872;  of  the  feet,  875;  of  the 
fifth  pair,  873;  of  the  phrenic,  874;  of 
the  spinal  column,  875 ;  prognosis  of,  876; 
symptoms  of,  872-876;  treatment  of, 
876-878;  varieties  of,  873-876;  visceral, 
875 

Neurasthenia,  11 18 

Netu-itis,  localized,  861,  866,  870;  multiple, 
861,  869,  870;  symptoms  of,  862-866; 
treatment  of,  871;  progressive  inter- 
stitial hypertrophic  of  ch2dhood,  919 

Neuroparalytic  ophthalmia,  988 

Neuroses,  1078;  traumatic,  1121 

Newborn,  acute  degeneration  of  internal 
organs  of,  664;  hemorrhagic  diseases  of, 
664,  syphilitic  diseases  of,  664 

Nicotin  poisoning,  1182 

Ninth  nerve,  lesions  of,  1003 

Nitric  acid  poisoning,  1181 

Nitrobenzol  poisoning,  1182 

Nodal  rhythm,  613 

Noguchi's  test  for  syphilis,  188 

Noma,  17,  100,  329 

Nose,  diseases  of,  494-499 


Nutmeg  liver,  451 
Nystagmus,  842,  982 


O 


Obesity,  820-824 

Obstruction  of  bowel,  415 

Occupation  neuroses,  11 03 

Ocular  palsy,  987 

Oculomotor  paralysis,  periodical,  987 

Olfactory  nerve,  970 

Oliver's  sign,  626 

Omalgia,  780 

Onomatomania,  1086 

Ophthalmic  reaction  of  tuberculosis,  296 

Ophthalmoplegia,  986 

Opium  poisoning,  11 86 

Oppenheim's  disease,  1136 

Oppler-Boas  bacillus,  379 

Optic    atrophy,    975;    gray,    975;    nerve, 

affections,  972;  and  tract,  971;  neuritis, 

973;  tract,  976 
Oriental  plague,  109 
Osier's  disease,  657 
Osteitis  deformans,  786 
Osteo-arthritis,  782 
Osteogenesis  imperfecta,  787 
Osteomalacia,  831 
Osteopsathyrosis,  787 
Ovary,  tuberculosis  of,  311 
Oxalic  acid  poisoning,  1183 
Oxaluria,  697 
Oxycephaly,  788 
Oxyuris  vermicularis,  235 
Ozena,  495 


Pachymeningitis,  cerebral,  1025;  external, 
1025;  hemorrhagic,  1026;  internal,  1026; 
pseudomembranous,  1026;  purulent, 
1026;  spinal,  887;  cervical  hypertrophic, 
887;  external,  887;  hemorrhagic,  887; 
internal,  887 

Paget 's  disease,  786 

Pain,  sense  of,  855 

Painless  whitlows,  924 

Palpable  kidney,  762 

Palpitation,  555;  nervous,  615 

Palsies,  birth,  1053;  cerebral,  of  children, 
1050 

Palsy,  bulbar,  932-936;  Scrivener's,  1103 

Paludal  fever,  47 

Pancreas,  calculi  of,  482;  cancer  of,  480; 
diagnosis  of,  481;  morbid  anatomy  of, 
480;  symptoms  of,  481;  cysts  of,  481 
diseases  of,  478-482 

Pancreatitis,  acute,  478-480;  diagnosis  of, 
422,  480;  etiology  of,  479;  gangrenous, 
479;  hemorrhagic,  479;  morbid  anatomy 
of,  479;  prognosis  of,  480;  suppurative, 
479;  symptoms  of,  479;  treatment  of, 
480;  chronic,  480 

Pandemic  chorea,  1088 

Papillitis,  973,  1067,  1069 

Papillo-edema,  973,   1067,   1069 

Paradoxical  contractions,  847 

Paragensia,  1003 

Paragraphia,  961 

Paralysis,  acute  ascending,  spinal,  903— 
905;  agitans,  1 062-1 065;  atrophic  bul- 
bar, 932 ;  combined,  of  the  interarytenoid 
and  thyroarytenoid  muscles,  553;  family 


1204 


INDEX 


Paralysis : 

periodic,  1123;  glossolabiopharyngeal. 
932;  Landry's,  903;  of  the  abductors  of 
the  glottis,  932 ;  of  the  arytenoid  muscles, 
1006;  of  the  cricothyroid  muscle,  1006; 
of  the  diaphragm,  1016;  of  the  eye 
muscles,  985;  of  the  facial  nerve,  989; 
of  the  laryngeal  muscles,  624,  loo5;  of 
the  recurrent  laryngeal,  624 ;  of  the  thyro- 
epiglottidean  and  arytenoepiglottidean 
muscles,  1006;  of  the  thyro-arytenoid 
muscle,  1006;  of  the  tongue,  the  soft 
palate,  and  lips,  932 ;  progressive  general 
of  the  insane,  1059;  postchoreal,  1089; 
pseudobulbar,  935;  spastic  of  children, 
1053 

Paramimia,  961 

Paramyoclonus,  multiple,  1085 

Paranephritis,  751 

Paraphasia,  960 

Paraplegia,  ataxic.  Spastic,  920;  cerebralis 
spastica,  1054;  infantile  spastic,  1054 

Parasites,  animal,  190;  of  the  liver,  474,- 
478 

Parasitic  stomatitis,  327;  tumors  of  the 
brain,  1065 

Parathyroid  gland,  678-680 

Paratyphlitis,  405 

Paratyphoid  fever,  34;  definition  of,  34; 
morbid  anatomy,  34;  symptoms,  34; 
serum  reaction,  34;  treatment,  34 

Paresis,  general,  1059 

Paretic  dementia,  1059 

Parkinson's  disease,  1062 

Parotid  bubo,  332 

Parotitis,  acute,  332;  chronic,  332;  epi- 
demic, 140;  secondary,  141 

Paroxysmal  headache,  1 1 00 

Parrot's  ulceration,  328 

Parry's  disease,  670 

Pasteur's  treatment  of  hydrophobia  by 
attenuated  virus,  168 

Pathogenic  fever,  i 

Pediculus  capitis,  239;  pubis,  239;  vesti- 
menti,  239 

Peduncles,  cerebellar,  disease  of,  968 

Peliosis,  659 

Pellagra,  1161-1165 

Peptic  ulcer,  368 

Pericarditic  pseudocirrhosis  of  the  liver, 
491 

Pericarditis,  557;  acute,  557;  diagnosis  of, 
412,  562,  563;  etiology  of,  557;  morbid 
anatomy  of,  557;  physical  signs,  559-562 ; 
Bamberger's  sign,  561;  Broadbent's 
sign,  562;  Ewart's  sign,  561 ;  Friedreich's 
sign,  562;  chronic  adhesive,  561; 
Pins'  sign,  561;  indurative  mediastino- 
pericarditis,  491;  pleuropericardial  fric- 
tion sound,  563;  Rotch's  sign,  560,  563; 
prognosis  of,  564;  symptoms  of,  558-562; 
treatment  of,  564 

Pericardium,  cancer  of,  565;  diseases  of, 
557-565;  tuberculosis  of,  312 

Periliepatitis,  464,  465;  diagnosis  of,  465; 
etiology  of,  464;  morbid  anatomy  of, 
464;  prognosis  of,  465;  symptoms  of, 
465;  treatment  of,  465 

Periodical  oculomotor  paralysis,  987 

Perinephric  abscess,  751 

Periosteal  cachexia,  661 

Peripheral     nerves,     affections     of,     861- 


Perisplenitis,  684 

Peritoneum,  cancer  of,  492;  diseases  of, 
482-493;  hydatid  disease,  493;  tuber- 
culosis of,  308 

Peritonitis,  acute,  485-489;  circumscribed, 
488;  diagnosis  of,  488;  etiology  of,  485; 
general,  486-488;  morbid  anatomy  of, 
486;  physical  signs,  487;  primary,  485; 
prognosis  of,  489;  secondary,  485; 
symptoms  of,  486-488;  treatment  of, 
489;  chronic,  489-491;  adhesive,  490; 
circumscribed,  489,  490;  diffuse,  490; 
in  typhoid  fever,  24,  29 

Perityphlitis,  405 

Permanentes  kinder-tetanus,  1053 

Pernicious  anemia,  640 

Pernicious  Remittent  fever,  47;  malarial 
fever,  59 

Pertussis,  137 

Pestilential  or  putrid  fever,  36 

Pestis  hominis,  92 

Petechial  fever,  36,  146 

Petit  mal,  1093 

Pharyngitis,  acute  catarrhal,  338;  chronic 
catarrhal,  339;  chronic  follicular,  339; 
granular,  339;  phlegmonous,  340;  ulcer- 
ative, 340 

Pharynx,  circulatory  derangement  of,  338; 
diseases  of,  333-341;  hypertrophy  of 
adenoid  tissue  of,  335-337;  spasm  of, 
1004 

Phenomena  of  motion,  838 

Phlegmonous  ehteritis,  404;  tonsillitis,  333 

Phosphaturia,  696 

Phosphorus  poisoning,  1183 

Phrenic  nerve,  affections  of,  874,  1016 

Phthalein  test,  699-701 

Phtherius  inguinalis,  239 

Phthisis,  acute,  283;  bronchopneumonic, 
283;  chronic  ulcerative,  286;  fibroid,  297; 
florida,  280,  283;  pneumonic  form  of, 
283;  pulmonaUs,  285 

Piles,  458 

Pins'  sign,  561 

Pin  worm,  235 

Pituitary  body,  diseases  of,  686-691 

Pityriasis  cthiopius,  1 131 

Plague,  the,  92 

Plasmodium  malariee,  47,  48,  49,  50;  cres- 
cent shaped  body,  50;  vivax,  49 

Pleura,  diseases  of,  535-548;  hydatid 
disease,  548;  morbid  growths  of,  547-548; 
carcinoma,  547;  chondroma  and  lipoma, 
548;  sarcoma,  548;  tuberculosis  of,  308 

Pleurisy,  535;  acute,  535-543;  diagnosis  of, 
541 ;  etiology  of,  535;  morbid  anatomy  of, 
535 ;  paravertebral  triangle  of  dullness  in, 
539;  physical  signs  of,  537-540;  friction 
rub,  537,  540;  Skoda's  resonance,  257, 
538;  prognosis  of,  542;  pus-formation  in, 
536;  resolution  in,  540;  serous  accumu- 
lation in,  535,  538;  symptoms  of,  536- 
540;  treatment  of,  542,  543;  blood- 
letting, 543;  tapping,  543;  chronic,  543, 
544;  treatment  of,  544;  diaphragmatic, 
540;  encj'sted  or  circumscribed,  540; 
exudative,  544;  hemorrhagic,  540;  inter- 
lobular, 540;  latent,  544;  plastic,  544; 
pulsating,  540;  suppurative,  544;  tuber- 
cular, 308,  540 

Pleurodynia,  780,  875 

Plumbism,  1 1 47 

Pneumococcus,  253 


INDEX 


1 205 


Pneumogastric  nerve,  lesions  of,  1003; 
cardiac  branches  of  the,  1008;  gastric  and 
esophageal  branches  of  the,  1009;  in- 
volving the  nucleus  and  trunk,  1004; 
laryngeal  branches  of  the,  1005;  pharyn- 
geal branches  of  the,  1004;  pulmonary 
branches  of  the,  1009;  treatment  of,  loio 

Pneumonia,  253-268;  aspiration  or  deg- 
lutition, 268;  broncho-,  268;  bacte- 
riology of,  268;  cyanosis  in,  270;  diag- 
nosis of,  271;  diagnosis  from  lobar,  271; 
from  tuberculosis,  271;  etiology  of,  268; 
morbid  anatomy  of,  269;  physical  signs, 
271;  prognosis  ot,2  7 1 ;  suffocative  catarrh, 
268,  270;  symptoms  of,  270;  treatment 
of,  271,  272;  chronic  interstitial,  262,  521; 
Croupous,  253-268;  abdominal  pain  in, 
265;  abscess  of  lung  in,  262;  acute  dilata- 
tion of  the  stomach  in,  264;  Baccelli's 
sign  in,  264;  blood  in,  256,  261,  266; 
blood  pressure  in,  266;  cardiac  failure  in, 
262;  carnification  in,  263;  central,  257, 
259;  cerebral  embolism  in,  264;  chill  in, 
256,  260;  complications  in,  263;  conges- 
tion, stage  of,255, 257;  cough  in,  256,  266, 
267;  crepitans  redux,  259;  crisis  in,  253, 
257;  delayed  resolution,  262;  diagnosis, 
264;  differentiation  from  appendicitis, 
265,  412;  from  pleurisy,  264;  from  ty- 
phoid, 265;  diplococcus  of,  253,  254; 
double,  253 ;  empyema,  263 ;  endocarditis, 
263;  epidemic,  253,  254;  etiology,  254, 
expectoration  in,  256,  260;  prune-juice, 
256;  rusty,  256;  fibroid  induration,  262, 
gangrene  of  lung  in,  262;  gray  hepa- 
tization, 255,  259;  heart  in,  256,  260, 
herpes  in,  261 ;  in  theaged,  260;  jaundice 
in,  260;  larval-,  253 ;  lobar-,  see  Croupous ; 
lung  in,  255;  lysis  in,  257;  massive-,  253; 
meningitis  in,  264;  middle  ear  disease  in, 
264;  morbid  anatomy  of,  255,  256; 
mortality  in,  265;  nature  of,  254;  of  the 
apex,  253;  parotitis  in,  264;  pericarditis 
in,  264;  phlegmasia  alba  dolens,  261; 
physical  signs  of,  257-259 ;  pleura  in,  256, 
263;  pneumococcus  in,  253;  pneumonic 
phthisis,  263 ;  predisposing  causes  of, 
255;  prognosis  of,  265;  red  hepatization, 
stage  of,  255,  257;  resolution  of,  262, 
respiration  in,  256,  260;  streptoccus-, 
261;  serum  therapy,  268;  Skoda's  re- 
sonance, 257;  stages  of,  255,  257,  259, 
symptoms  of,  256-260;  temperature  in, 
260;  typhoid  with,  261 ;  varieties  of,  253, 
yellow  hepatization,  stage  of,  256;  em- 
bolic, 523-526;  non-septic,  524;  septic, 
525        . 

Pneumonic  phthisis,  263 

Pneumonitis,  253 

Pneumopericardium,  565 

Pneumothorax,  545;  diagnosis  of,  547; 
etiology  of,  546;  physical  signs  of,  546, 
Hippocratic  succussion,  547;  metallic 
tinkling,  546;  symptoms  of,  546;  treat- 
ment of,  547 

Podagra,  788-797 

Poisons,  overdoses  of,  1 1 73 

Polioencephalitis  inferior  chronica,  932 

Poliomyelitis,  acute,  319-321;  anterior, 
chronic,  939;  age  319;  cerebro-spinal 
fluid  in,  32 1 ;  diagnosis  of ,  321;  etiology 
of,  319;  morbid  anatomy  of,  320;  prog- 
nosis of,  321 ;  prophylaxis,  321 ;  superior. 


Poliomyelitis: 

987;  symptoms  of,  320;  transmission  of, 

319;  treatment  of,  321;  virus  of,  319 
Pollen  catarrh,  496 
Polycythemia,  657 
Polyneuritis,  861,  866,  870 
Polyorrhomenitis,  491 
Polysarcia  adiposa,  820 
Polyuria,  800,  817 
Popliteal  nerve,  lesion  of,  1022;  external, 

1022;  internal,  1022 
Porencephalia,  1050 

Portal  cirrhosis,  457;  vein,  diseases  of,  452 
Postchoreal    paralysis    and    postparalytic 

chorea,  1089 
Posterior  spinal  sclerosis,  907 
Posthemiplegic  mobile  spasm,  1089 
Postpharyngeal  abscess,  341 
Potassium  nitrate  poisoning,  1 184 
Pox,  the,  182 
Pregnancy  in  typhoid,  24 
Pressure  paralysis  of  the  spinal  cord,  924 
Presystolic  murmur,  577 
Primary  lateral  sclerosis,  905 
Profata's  law  (syphilis),  184 
Professional  spasm,  11 03 
Progeria,  691 

Progressive  bulbar  palsy,  932 ;  facial  hemi- 
atrophy, 1 128;  general  paralysis  of  the 

insane,    1059;   muscular   atrophy,    type 

Duchenne-Aran,   939;   neural   muscular 

atrophy,  1135;  pernicious  anemia,  640; 

spastic  paraplegia,  920;  spinal  muscular 

atrophy,  939 
Prosopalgia,  873 
Prostate,  tuberculosis  of,  311 
Protozoa,  190 

Prune-juice  expectoration,  256 
Psammoma,  1066 
Pseudo-angina,  617 
Pseudohypertrophic  emyhysema,    528; 

muscular  paralysis,  1 133 
Pseudohypertrophy  of  muscles,  1 133 
Pseudoleukemia,  650-654 
Pseudomembranous  enteritis,  404 
Pseudoparalytic  myasthenia,  936 
Pseudorhabditis  stercoralis,  212 
Psychical  epilepsy,  1094 
Ptomain    poisoning,     1155,      1184;     413; 

treatment  of,  1 157 
Ptosis,  982 
Ptyalism,  331 
Puking  fever,  181 
Pulex-irritans,  241 ;  penetrans,  242 
Pulmonary  consumption,  285;  hemorrhage, 

256,  288,  573 ;  insufficiency,  588;  stenosis, 

588 
Pulse,  capillary,  582,  11 19;  Corrigan,  580; 

irregular,  610,  612;  water  hammer,  580, 

1119 
Pulsus  bigeminus,  579;  celer  et  altus,  581 ; 

paradoxus,  562;  parvus  irregularis,  574; 

parvus     et     tardus,     585;     rarus,     585; 

trigeminus,  579 
Purpura,  659;  arthritic,  662;  treatment  of, 

663;  hemorrhagica,   663;  treatment  of, 

663;    Henoch's,    663;    rheumatic,    662; 

scorbutic,    659;    simple    arthritic,    662; 

symptomatic,  659 
Putrid  sore  mouth,  327 
Pyemia,   161;  arterial,   568;  diagnosis  of, 

163;  etiology  of,  161;  prognosis  of,  163; 

symptoms  of,  163;  treatment  of,  163 


I2o6 


INDEX 


Pyelonephritis,  746 
Pylephlebitis,  453 
Pylethrombosis,  452 
Pylorospasm,  368 
Pyopneumothorax,  545 
Pyorrhea  alveolaris,  324 
Pythogenic  fever,  i 


Quigila,  1 131 

Quincke's  disease,  1125;  lumbar  puncture, 

153 
Quinsy,  333 

R 

Rabies,  164 

Rachitis,  824 

Rag-sorter's  disease,  174 

Railway  brain,  1121;  spine,  1121 

Raynaud's  disease,  1126 

Reaction  of  degeneration.  851-854,  865; 
partial,  942 

Rectum,  cancer  of,  432 

Red  atrophy  of  the  liver,  573;  granular 
kidney,  731 

Reflex  convulsions  of  children,  1099 

Reflexes,  843-847;  ankle,  845;  Babinski, 
150,  845;  cutaneous,  844;  deep-seated, 
845;  ophthalmic,  846;  patellar,  844; 
periosteal,  845;  segments  of  cord  pre- 
siding over,  847;  tendon  or  deep,  844; 
their  significance,  846 

Relapsing  fever,  40;  complications,  43; 
crisis,  43;  definition,  40;  diagnosis  of,  43; 
etiology  of,  40;  incubation  in,  41; 
jaundice  in,  41 ;  morbid  anatomy  of,  41 ; 
prognosis  of,  44;  prophylaxis  of,  44; 
relapse  in,  43;  skin  eruptions  and,  43; 
spleen  in,  41 ;  symptoms  of,  41 ;  tempera- 
ture, 41;  treatment  of,  44;  transmission 
of,  41,  44 

Relation  of  locality  to  symptoms  in 
cerebral  disease,  944 

Remittent  fever,  47,  67 

Renal  cirrhosis,  731;  dropsy,  698;  infarct, 
767;  sclerosis,  731;  sufficiency,  699 

Ren  mobilis,  762 

Respiration  and  deglutition,  muscles  of, 
affections  of,  1009 

Respiratory  system,  diseases  of,  494-554 

Retina,  affections  of,  971;  functional  dis- 
turbances of,  972 ;  hemorrhage  into,  971 ; 
hyperesthesia  of,  972;  organic  disease 
of,  971 

Retinitis,  971;  albuminuric,  716,  734,  737, 
971 ;  s\'ijhilitic,  972 

Revaccination,  134 

Rhabdonema  intestinal,  212;  strongyloides, 
212 

Rheumatic  arthritis,  783 

Rheumatic  fever,  246-253;  alkaline  treat- 
ment, 252;  bacteriology  of,  246;  carditis 
in,  249,  250;  complications  of,  249; 
diagnosis  of,  250;  etiology  of,  246; 
joints  in,  247,  248;  meningeal  form  of, 
248;  morbid  anatomy  of,  247;  non- 
articular,  248;  predisposing  causes,  247; 
prodrome,  247;  prognosis  of,  250;  recur- 
rence, 249;  skin  in,  248,  249;  subcuta- 
neous nodules,  249;  subacute,  250; 
symptoms  of,   247;  treatment  of,   250- 


Rheumatic  fever: 

253;    of    hyperpyrexia,    252;    myositis, 
1 132;  purpura,  662 

Rheumatism,  246;  acute,  246;  acute 
articular,  246;  endocarditis  in,  249,  566; 
chronic  articular,  782;  inflammatory, 
246;  muscular,  779,  1132;  stiff  neck  of 
torticollis,  780;  simulating  joint  affec- 
tions, 781 

Rheumatoid  arthritis,  782 

Rhinitis,  acute,  494;  chronic,  495;  atrophic, 
495;  hyperatrophic,  495;  symptoms  of, 
495;  treatment  of,  496;  syphilitic,   187 

Rhizomastigida,  193 

Rhizopoda,  191 

Rhythmical  contractions,  841 ;  or  hysterical 
chorea,  1088 

Rickets,  824-829 

Riga's  disease,  326 

Rock  fever,  45 

Rocky  Mountain  Spotted  fever,  34;  defini- 
tion, 34;  diagnosis,  35;  etiology,  34; 
influence  of  seasons  on,  34;  prognosis,  35; 
pulse,  35;  skin  in,  35;  symptoms,  35; 
tick  in,  34;  treatment,  35;  urine,  35 

Romberg's  symptoms,  91 1 

Rose,  the,  156 

Rose  cold,  496 

Rotch's  sign,  560 

Rotheln,  loi 

Round  worm,  232 

Rubella,  loi;  diagnosis  of,  102,  136; 
eruption,  102;  etiology  ofj  loi;  incuba- 
tion of,  1 01;  prognosis  of,  103;  sore 
throat  in,  loi,  102;  symptoms  of,  101; 
treatment  of,  103 

Rubeola,  97;  notha,  loi 

Rumination,  367 


S  line  of  Ellis,  538 

Sacral  plexus,  lesion  of,  1021 

Salivary  glands,  diseases  of,  331;  inflam 
mation  of,  332 

Sand  flea,  242 

Sarcoma  of  the  liver,  469;  diagnosis  of, 
471 ;  symptoms  of,  469;  of  the  lung,  533 

Sarcoptes  scabiei,  238 

Saturnism,  1147 

Scapulodynia,  780 

Scarlatina,  103;  simplex  (see  also  Scarlet 
Fever),  105,  107;  scarlatina  anginosa, 
105,  107;  maligna,  105;  miliaris,  104 

Scarlet  fever,  103;  adenitis,  108;  arthritis 
in,  108;  blood  in,  105;  complications  and 
sequelae,  107,  108;  diagnosis  of,  108,  109, 
136;  Dohle's  sign' of,  109;  endocarditis 
in,  108;  eruption  in,  104;  etiology  of, 
103;  epidemics  of,  103,  107;  hemorrhagic, 
105,  106,  107;  incubation,  104;  menin- 
gitis in,  108;  morbid  anatomy  of,  104; 
nephritis  in,  107,  III;  otitis  in,  108; 
prognosis  of,  109;  prophylaxis  of,  112; 
serum  treatment,  in;  raspberry  tongue, 
105;  symptoms  of,  104;  strawberry 
tongue,  105,  322;  streptococcus  in,  103, 
107;  Umber's  sign,  108;  urine  in,  105 

Schistosomum  haematobium,  199 

Schonlein's  disease,  662 

Schott  movements,  594 

Sciatica,  866-869 

Sciatic  nerve,  lesions  of,  1022 


INDEX 


1207 


Sclerema,  11 29 

Scleroderma,    1129;   annulare,  1 131 

Sclerose  c^rebrale,  1050;  en  placques,  1057 

Sclerosis,  amyotrophic  lateral,  937;  com- 
bined, 920;  combined  lateral  and  poste- 
rior, 920;  disseminated  nodular,  1057; 
insular,  1057;  of  brain  and  spinal  cord, 
1057;  of  the  coronary  arteries,  607; 
posterior  spinal,  907;  primary  lateral, 
905;  toxic,  920 

Scorbutus,  659 

Scotoma,  980 

Scrivener's  palsy,  11 03 

Scrofula,  305 

Scurvy,  659;  diagnosis  of,  661 ;  etiology  of, 
659;  morbid  anatomy  of,  660;  symptoms 
of,  660;  treatment  of,  661 ;  infantile,  661 

Seat-worm,  235 

Secondary  deviation,  985 

Senile  tremor,  1065 

Sensory  aphasia,  958 

Sensory  nerves,  section  of,   1023 

Sensory  phenomena,  854 

Septicemia,  161;  bacteriology  of,  161,  162; 
chronic,  163;  diagnosis  of,  163;  emboli 
in,  161,  162;  etiology,  161;  pathology  of, 
161,  162;  prognosis  of,  163;  prophylaxis, 
164;  symptoms  of,  162;  treatment  of, 
163 

Serratus  palsy,  1018 

Serum  sickness,  120 

Seven-day  fever,  40 

Seventh  nerve,  lesions  of,  989 

Shaking  palsy,  1062 

Shiga's  bacillus,  86 

Shingles,  1056 

Ship  fever,  36 

Shortness  of  breath,  555 

Sick  headache,  11 00 

Silver  nitrate  poisoning,  1184 

Simple  angina,  338;  or  round  ulcer,  368; 
tic,  1085 

Sinus  irregularity,  613 

Sixth  nerve,  lesions  of,  affecting  the  eye- 
ball, 984 

Skodaic  sign,  257,  538 

Sleeping  sickness,  193,  194 

Slow  consumption,  286;  nervous  fever,  i; 
pulse,  55 

Slows,  181 

Smallpox,  124-131;  complications  of,  128; 
contagium,  125;  diagnosis  of,  128,  136; 
forms  of,  127;  confluent,  127;  discrete, 
127;  hemorrhagic,  127;  protozoon  caus- 
ing, 125;  varioloid,  127;  morbid  anatomy 
of,  125;  prognosis  of,  128;  prophylaxis, 
129;  spleen  in,  125;  symptoms  of,  125- 
128;  incubation,  125;  muscular  pain,  125; 
initial  rashes,  126;  diffuse  scarlatinous, 
126;  measly,  126;  temperature  in,  126; 
treatment  of,  129;  special  modes 
to  prevent  pitting,  129;  vaccination,  129, 

Small  sciatic  nerve,  lesions  of,  1022 

Smoker's  patches,  331 

Soor,  326 

Sore  throat,  338 

Spasm,    constant   or   coordinate,    840;   of 

muscles  of  mastication,  988;  tonic  and 

clonic,  841,  1092 
Spasmodic  tabes  dorsalis,  905 
Spasms  of  the  muscles  of  respiration  and 

deglutition,  1087 


Spastic  diplegia,  1053 ;  paralysis  of  children, 
I053i  paraplegia,  1054;  infantile  hemi- 
plegia, 1050;  rigidity  of  the  new-born, 
1053;  spinal  paralysis,  905-907,  1054 

Speech  areas  in  cortex  of  brain,  954; 
derangements  of,  irritative  origin  of, 
962;  to  test  derangements  of,  962 

Spina  bifida,  932 

Spinal  accessory  nerve,  lesions  of,  loii; 
paralysis  of,  loii;  spasm  of,  1012 

Spinal  Cord,  acute  affections  of,  895-905; 
affections  of  the  membranes  of,  886-891 ; 
the  substance  of,  891 ;  chronic  affections 
of,  905;  compression  of,  924;  symptoms 
of,  925;  treatment  of,  927;  disturbances 
of  circulation  of,  895;  hemorrhage 
into  membranes  of,  890;  extrameningeal, 
890;  intrameningeal,  890;  medullary, 
890;  into  the  substance  of,  895;  localiza- 
tion, 881-886;  multiple  sclerosis  of  brain 
and,  1057;  nerves  and  branches,  diseases 
of,  1016;  paralysis,  903,  905;  secondary 
systemic  degenerations  of,  892 ;  after 
cerebral  lesions,  892;  after  injuries  of 
the  Cauda  equina,  891;  after  transverse 
lesions  of  the  cord,  893;  tumors  of,  927 

Spinal  Leptomeningitis,  889 

Spinal  meningitis,  circumscribed  serous, 
930 

Spinal  Pachymeningitis,  887 

Spirillum  of  Koch,  76 

Spirochaeta  Obermeieri,  40 

SpirochsEta  pallida,  182 

Splanchnoptosis,  389 

Spleen,  abscess  of,  684;  amyloid,  684; 
atrophy  of.  684;  diseases  of,  684-686; 
echinococcus,  685;  hemorrhagic  infarct, 
684;  in  anthrax,  174;  in  cirrhosis  of 
the  liver,  457;  in  leukemia,  646;  in 
malaria,  54,  57,  63;  in  typhoid  fever, 
I,  4,  7;  in  typhus  fever,  37;  neoplasm 
of,  685;  rupture  of,  684;  wandering, 
685 

Splenic  anemia,  655-658;  apoplexy,  174; 
fever,  174 

Splenitis,  684 

Splenomegalic  primitive,  655 

Split  spine,  932 

Sporadic  cerebrospinal  fever,  1 54 ;  cholera, 
76 

Spotted  fever,  146 

St.  Anthony's  fire,  156 

Staphylococcus  pyogenes  aureus,  161 

Status  epilepticus,  1096;  lymphaticus, 
655,  692;  parathyreoprivus,  678 

Steeple  head,  788 

Stell wag's  sign,  671 

Stenocardia,  616 

Stenosis,  aortic,  584;  mitral,  575;  pul- 
monary, 588;  tricuspid,  587 

Steppage  gait,  864 

Stigmata,  hysterical,  mo 

Stokes- Adams  syndrome,  612,  614 

Stomacace,  327 

Stomach,  cancer  of,  376;  diagnosis  of, 
380-382;  differentiation  from  ulcer, 
372,  380;  etiology  of,  376;  gastric  con- 
tents in,  377,  378,  379;  morbid  anatomy 
of,  376;  Oppler-Boas  bacillus,  379- 
primary,  376;  prognosis  of,  382;  secon- 
dary, 377;  symptoms  of,  377;  treatment 
of,  382;  Dilatation  of  the,  264,  386-389, 
422;  Diseases  of  the,  349;  Ulcer  of,  368 


INDEX 


Stomatitis,  acute  catarrhal,  325;  aphthous, 
325;  £etid,  327;  follicular,  325;  gangren- 
ous, 17,  100,  329;  herpetic,  325;  mer- 
curial, 327;  mycotic,  326;  parasitic, 
326;  syphilitic,  331;  ulcerative,  327; 
vesicular,  325;  treatment  of  different 
forms  of,  328;  prophylaxis  against,  328 

Streptococcus  erysipelatis,  156 

Streptococcus  pyogenes,  156,  161 

Stricture  of  esophagus,  345 

Strongyloides  intestinalis,  212-214 

Strongylus  duodenalis,  227;  gigas,  226; 
quadridentatus,  227;  renalis,  226 

Struma  exophthalmica,  670;  simple,  668 

Strychnin  poisoning,  1185 

St.  Vitus'  dance,  1078,  1088 

Succussion  sound,  547 

Sudor  anglicus,  316 

Suffocative  catarrh,  268,  270 

Suggestion  and  hypnosis,  11 14 

Suhka  pakia,  1131 

Sulphurated  hydrogen  poisoning,  1185 

Sulphuric  acid  poisoning,  1181 

Sunstroke,  11 67 

Suprarenal  capsule,  disease  of,  681-684 

Suprascapular  nerve,  lesions  of,  1019 

Surgical  kidney,  746 

Swamp  fever,  47 

Sweating  disease  of  Picardy,  316 

Swelled  head,  17S 

Sydenham's  chorea,  1078 

Symmetrical  gangrene  of  the  extremities, 
1126 

Syphilis,  182-190;  acquired,  182;  arteritis, 
in,  186;  chancre,  184;  CoUes'  law,  1 83; 
contagiousness  of,  182;  diagnosis  of, 
188;  etiology  of,  182;  fibroid  induration 
of,  185;  germ  inheritance  of,  183;  gumma, 
185;  hereditary,  182,  183,  187;  Hutchin- 
son's teeth,  188;  initial  sore,  184;  mar- 
riage and,  183,  184;  morbid  anatomy, 
184;  mucous  patch,  184;  Nagouchi's 
test,  188;  organism  of,  182;  papular 
eruption,  184,  185;  pemphigus  neona- 
torum, 187;  primary,  182,  184,  186, 
189;  Profeta's  law,  184;  prognosis,  188; 
prophylaxis,  1 89;  pustular  eruption,  185; 
rupia,  185;  secondary,  182,  184,  186,  189; 
sperm  inheritance,  183;  symptoms  of, 
186,187;  syphilides,  184,  185;  macular, 
185;  squamous,  185;  tertiary,  183,  184, 
186,  190;  treatment,  189,  190;  constitu- 
tional, 1 89 ;  of  primary  sore,  1 89 ;  of  secon- 
dary stage,  189;  of  tertiary  stage,  190; 
transmission,  183,  187;  venereal  wart, 
184;  Wassermann  test,  183,  188,  189, 
190;  of  brain  and  spinal  cord,  187,  1133; 
of  the  layrnx,  505;  of  the  liver,  l86,  472- 
474;  diagnosis  of,  473;  enlargement  of 
spleen,  473;  jaundice  in,  473;  symptoms 
of,  473;  treatment  of,  474 

Syphilitic  ulcer  of  pharynx,  340 

Syringomyelia,  922 


Tabes,  arthropathies  of,  914;  cerebral 
symptoms,  915;  dorsalis,  907-9 1 8 ;  course 
of,  916;  differential  diagnosis  of,  915; 
etiology  of,  907;  gait,  912;  girdle  pains, 
913;  hypotonia  in,  912;  inco-ordination, 
912;  morbid  anatomy  of,  908;  motor 
phenomena,     911;    prognosis    of,     916; 


Tabes: 

reflex  symptoms,  913;  Romberg's  sign, 

911;     sensory    symptoms,     912;    spas- 

modique,   1054;  symptoms  of,  910-915; 

vasomotor    and     trophic     phenomena, 

914;  treatment  of,  916-918 
Tabetic  crises,  911 
Tables     for     conversion    of    metric     into 

English  system,  1187 
Tachycardia,  6ii,  671;  paroxysmal,  613; 

paroxysmal,    true,    614;    treatment    of, 

612;  strumosa,  670 
Tactile  sensibility  in  nervous  diseases,  855 
Taenia,  ajgyptica,    204;    cucurbitini,    209; 

dentata,    209;   inermis,    206;   lata,    201; 

mediocanellata,    206;   nana,    204;    sagi- 

nata,  206;  solium,  209 
Tape -worm,   beef,    206;  dog,  474;  dwarf, 

204;  fish,  201;  pork,  209;  treatment  of, 

204,  206,  211 
Teichmann's  hemin  crystals,  765 
Temperature,  effects  of  high,  1166;  sense 

of,  856 
Tendon  reflexes,  844 
Tenth  nerve,  lesions  of,  1003 
Testes,  tuberculosis  of,  311 
Tetanilla,  678 

Tetanoid  pseudoparaplegia,  1054 
Tetanus,  169;  bacillus  of,  169;  diagnosis  of, 

171;  etiology  of,  169;  intermittent,  678; 

morbid    anatomy    of,    170;    orthotonos, 

170;  predisposing  causes  of,   170;  prog- 
nosis of,   172;  prophylaxis,   172;  serum 

treatment,     172;     symptoms    of,     170; 

treatment    of,    172;    varieties    of,    169, 

170;  neonatorum,  170;  traumatic,  170 
Tetany,  678-680 
Thecosoma  hasmatobium,  199 
Thermic  fever,  1167 
Thick  neck,  668 
Third  nerve,  lesions  of,  981 
Thomsen's  disease,  1 136 
Thread  worms,  235 
Thrombosis     and     embolism,     of    portal 

vein,  452-454;  of  cerebral  sinuses   and 

veins,  1048;  primary,   104S;  secondary, 

1048 
Thrush,  326 
Thymic  asthma,  691;  death,  691;  stridor, 

691 
Thymus  gland,  diseases  of,  691-692 
Thyrocele,  668 
Thyroid  gland  abscess,  681;  enlargement 

of,  668;  neoplasms  of,  680,  681;  diseases 

of,  668-678 
Tic,  complex  co-ordinated,  io86;convulsif, 

995;    douloureux,    873;    simple,     1084; 

generalized,  1085;  localized,  1084;  with 

explosive  utterances,  1086 
Tinnitus  aurium,  1000 
Tongue,  inflammation  of,  330;  paralysis, 

932  ,  .  . 

Tonic  contraction  of  extremities,  1053 
Tonsillar  abscess,  333 
Tonsillitis,    333;    acute    parenchymatous, 

333;   phlegmonous,    333;    chronic,    335; 

diagnosis    of,    336;    etiology    of,    335; 

morbid  anatomy  of,  335;  prognosis  of, 

337;  symptoms  of,  335;  treatment  of, 

337;  follicular,   123;  diagnosis  of,   123; 

joint     pains     in,     124;     symptoms    of, 

123;  treatment  of,  123 
Tonsils,  diseases  of,  123,  333-339 


INDEX 


1209 


Tooth  rash,  324 

Topical  diagnosis  of  cerebral  lesions,  944 

Torticollis,  or  wry-neck,  1012;  congenital, 
I0I2;  rheumatic,  784;  spasmodic,  1013; 
treatment  of,  1012,  1014 

Tower  head,  788 

Trachea,  diseases  of,  506 

Tracheal  tug  in  aneurysm,  626 

Tracheobronchitis,  acute,  506 

Tracts  within  the  brain,  965 

Transverse  myelitis,  897 

Traube's  double  sound,  583 

Traumatic  hysteria,  1121;  neuroses,  1121 

Trembles,  181 

Tremor,  841 :  hereditary,  1065;  hysterical, 
1065:  intention,  841;  other  forms  of, 
1065:  asthenic,  1065:  senile,  1065; 
simple,  1065;  toxic,  1066 

Treponema  pallidum,  182 

Trichina  cystica,  214;  spiralis,  222 

Trichinella  spirilis,  222 

Trichiniasis,  222-226 

Trichocephalus  dispar,  222;  hominus,  222; 
trichiurus,  222 

Trichiuris  trichiura,  222 

Trichomonas  vaginalis,  192;  intestinalis, 
192 

Tricuspid  incompetency,  586;  physical  signs 
of,  587;  jugular  pulse,  587;  stenosis, 
587;  physical  signs  of,  588 

Trifacial  nerve,  lesions  of,  988;  neuralgia 
of,  873 

Trigeminus,  lesions  of,  988 

Trousseau's  system,  679 

Tr3'panosoma  Gambiense  (Sutton),  193, 
194 

Tube-casts,  704-707;  blood,  705;  cylm- 
droid,  704,  707;  epithelial,  705;  granular, 
706;  hyaline,  705;  mucus,  704,  707; 
oily  or  fatty,  706;  pus,  705;  waxy,  706 

Tubercle,  276 

Tubercular  consumption,  285;  peritonitis, 
308;  ulcer  of  appendix,  407 

Tuberculin  test  for  tuberculosis,  273,  296 

Tuberculin  treatment,  299 

Tuberculosis,  272-312;  bacillus  of,  273; 
to  stain,  292;  etiology  of,  273;  age,  275; 
climate,  275;  defective  food,  274; 
Flick's  studies,  274;  heredity,'  274; 
locality,  274;  race,  274;  shape  of 
chest,  275;  traumatism,  275;  acute, 
clinical  varieties,  2 7 7-2 85 ;  miliary  form, 
277-285;  general  miliary  form,  277, 
279-280;  differentiation  from  typhoid, 
279;  miliary  meningeal  form,  280,  1027; 
diagnosis  of,  282;  etiology  of,  280; 
morbid  anatomy  of,  281;  prognosis  of, 
283;  symptoms  of,  281;  treatment  of, 
283;  miliary  pulmonary  form,  278; 
pneumonic  phthisis,  283;  chronic 
fibroid,  297,  298;  physical  signs,  297; 
prognosis  of,  298;  symptoms  of,  297; 
treatment,  298-301,  303-305;  Chronic 
pulmonary,  285-305;  club  fingers  in, 
294;  diagnosis  of ,  295 ;  expectoration  in, 
288,  291,  301;  fever  in,  292,  293,  294, 
304;  meningitis  in,  295;  morbid  anatomy 
of,  285;  physical  signs,  289,  290,  291; 
pleurisy  in,  287;  prognosis  of,  297; 
symptoms  of,  288-295;  treatment  of, 
298-301,  303-305;  climatic,  299;  hygiene 
and  dietetic,  298,  299;  medicinal,  300; 
ophthalmo-reaction,  296;  special  symp- 


Tuberculosis: 

toms,  303-305;  pneumotherapy,  299; 
prophylactic,  301-303;  serum-,  300; 
specific  (treatment  of),  299;  tuberculin 
test  in,  296;  ulcerative,  286;  Von  Pir- 
quet's  reaction,  296;  X-ray,  296;  of  the 
heart  and  blood-vessels,  312;  of  the 
kidney,  309;  miliary  tubercules  in,  309; 
morbid  anatomy  of,  309;  primary  foci 
in,  309;  symptoms  of,  310;  treatment  of, 
310;  of  the  layrnx,  503;  of  the  liver,  311; 
of  the  lymphatic  glands,  305,  554; 
diagnosis  of,  307;  from  Hodgkrn's 
disease,  307;  from  lymphatic  leukemia, 
307;  from  sarcoma,  307;  etiology  of, 
305;  prognosis  of,  307;  symptoms  of, 
306;  tabes  mesenterica,  306;  treatment 
of,  307;  of  the  mammary  glands,  311; 
of  the  ovaries.  Fallopian  tubes,  and 
uterus,  311;  of  the  pelvis  of  the  kidney, 
ureters,  and  bladder;  310;  of  the  peri- 
cardium, 312,  565;  of  the  peritoneum, 
308;  of  the  pleura,  308,  540;  of  the  serous 
membranes,  307-309;  of  the  testes, 
prostate  gland,  and  seminal  vesicles, 
311;  of  the  thyroid,  680 

Tuberculous  leptomeningitis,  280,  1027; 
lymphadenitis,  305 

Tuberculous  meningitis,  280 

TufneU's  treatment,  632 

Tumors  of  the  brain,  1065;  of  the  spinal 
cord  and  membrane,  927;  diagnosis  of, 
929;  prognosis  of,  930;  symptoms  of, 
928;  treatment  of,  931;  varieties  of, 
927 

Twelfth  nerve,  lesions  of,  1015 

Typhlitis,  405 

Typhoid  carriers,  2 

Typhoid  fever,  i;  abortive  form  of,  16; 
albuminuria  in,  12;  arthritis  in,  19; 
atypical  forms  of,  15;  bacteriology  of, 
1-2;  bed-sores  in,  17,  30;  blood  changes 
in,  13,  14,  15,  21;  bone  lesions  in,  5,  19; 
Brand  bath  treatment  of,  25;  cardiac 
complications  in,  18;  carphologia,  11; 
chills  in,  6,  9,  15,  16;  cholecystitis  in, 
4,  19;  cholelithiasis,  19;  circulatory 
system  in,  5,  18;  complications  in,  16^ 
19;  constipation  in,  15,  29;  contagious- 
ness of,  2;  cough  in,  12;  convulsions,  15; 
cystitis  in,  5,  18;  death,  24;  definition, 
l;  delirium  in,  10,  28;  diabetes  in,  16; 
diagnosis,  20-22,  279,  412;  diazo-reac- 
tion  of  urine  in,  13;  diet  in,  24,  25; 
disinfection  of  excreta  in,  32,  33; 
Ehrlich's  reaction  in,  see  Diazo;  etiology, 
I ;  expectant  symptomatic  treatment 
of,  28;  hemorrhage  in,  10,  29;  hemor- 
rhagic form  of,  16;  herpes  in,  7;  in 
children,  3,  24;  incubation  of,  5; 
indications  for  alcohol  in,  28;  influence 
of  age  on,  3,  24;  influence  of  pregnancy 
on,  24;  influence  of  seasons  on,  3; 
insanity,  18;  jaundice  in,  7;  kidney  in, 
4;  liver  in,  4;  management  of  conva- 
lescence in,  31;  mesenteric  glands  in,  I, 
4;  meteorism  in,  10,  29;  methods  of  re- 
ducing temperature  in,  25,  27;  milk  leg 
in,  see  Phlegmasia  Alba  Dolens  1 7 ;  mode 
of  conveyance  of,  2;  morbid  anatomy 
of,  3-5;  muscular  system  in,  5;  muscular 
tremor,  10 ;  nervous  or  meningeal  form 
of,     16,    21;    neuritis,     18;    noma,     17; 


INDEX 


Typhoid  Fever: 

parotitis  in,  4,  l8;  perforation  in,  5,  17, 
22,  29,  30;  perforation  of  gall  bladder 
in,  4;  perichondritis,  19;  peritonitis 
in,  24,  29;  Peyer's  patches  in,  3,  4; 
Phlegmasia  Alba  Dolens,  (mUk  leg), 
5,  17;  pneumonia  in,  5,  17;  predis- 
posing causes  of,  3 ;  prodromal  symptoms, 

5,  6;  prognosis  of,  23;  prophylaxis  in, 
32;  pulmonary  form,  16;  pulse,  9; 
relapses  in,  19;  renal  form,  12;  respira- 
tory organs  in,  5,  17;  rose-colored  spots 
in,  1,  6;    sequelae  of,  16;  skin  rashes  in, 

6,  7;  splenic  enlargement  in,  i,  4,  7; 
suppurative  processes,  5,  18;  sweating, 
9;  symptoms,  5-15;  temperature  in,  7-9; 
thrombosis  in,  17;  tonsillar  form  of,  16; 
treatment  of,  24-3 1 ;  by  diet  and  rest, 
24;  expectant  symptomatic,  28;  of 
convalescence,  31;  of  special  symptoms, 
28-31 ;  tympanitic  distention  in,  see  Me- 
teorism;  typhoid  spine  in,  19;  ulcer,  3;  of 
appendix,  407;  unusual  form  of  onset, 
15;  urine  in,  12,  13;  vaccination,  31; 
walking  form  of,  6;  Widal  reaction,  21; 
without  enteric  lesions,  5 

Typhus  abdominalis,  i ;  exanthematicus, 
36;  fever,  36;  definition,  36;  etiology,  36; 
contagiousness,  36;  cough  in,  38; 
diagnosis  of,  38;  eruption  of,  36,  37; 
incubation  of,  37;  lungs  in,  38;  morbid 
anatomy,  36;  prognosis  of,  39;  skin 
eruption,  37;  pediculus  corpus  and, 
38;  prophylaxis  in,  39;  stimulation  in, 
40;  symptoms  of,  37;  temperature,  37; 
treatment  of,  39;  urine  in,  38;  icterodes, 
67;  tropicus,  67 

U 

Ulcer,  gastric  and  duodenal,  368;  course 
and  termination  of,  371;  diagnosis  of, 
372;  from  appendicitis,  413;  from  cancer, 
372,  380;  etiology  of,  368;  gastric  con- 
tents in,  371,  372;  hemorrhage,  370, 
374;  morbid  anatomy  of,  369;  prognosis 
of,  373;  symptoms  of,  370-371 ;  treat- 
ment of,  373-376;  Lenhartz,  374,  375; 
operative,  374;  simple  or  round,  368 

Ulceration  of  the  bowel,  395 

Ulcerative  colitis,  395 

Ulcus  ventriculi  pepticum,  368 

Ulnar  nerve,  lesions  of,  1020 

Umber's  sign,  108 

Uncinariasis,  229,  230,  231 

Uncinaria  duodenalis,  227;  americana,  230 

Undulant  fever,  45 

Unilateral  progressive  facial  atrophy,  1128 

Upper  segment,  837 

Uremia,  701-704,  709,  714,  737;  differ- 
ential diagnosis  from  cerebral  hemor- 
rhage, and  alcoholism,  704;  differential 
diagnosis  of,  717;  symptoms  of,  702; 
treatment  of,  720 

Ureters,  tuberculosis  of,  310 

Urinary  organs,  diseases  of,  693-778 

Uterus,  tuberculosis  of,  311 

V 

V^accina,  131 

Vaccine  disease,  131-135;  complications 
of,  133;  disease,  humanized  lymph  in, 
132,  134;  efficiency  of,  131,  135;  etiology 


Vaccine  disease: 

of,  131;  operation  in,  1 32;  phenomena 
of,  132;  rashes,  133,  135;  revaccination, 
134;  treatment,  135;  ulcers  in,  134 

Vaccinia,  131;  hemorrhagica,  133;  nature 
of,  131 

Vaccinochancre,  134 

Vaccinosyphilis,  134 

Vagus  nerve,  lesions  of,  1003 

Valvular  (chronic)  defects,  571-600;  con- 
genital, 572,  589;  morbid  anatomy  of, 
571.  572;  relative  frequency  of,  571, 
589;  disease,  chronic,  prognosis  of,  590; 
treatment  of,  591-600;  digitalis  in, 
595-597;  Nauhcim  and  Schott  method, 
593-595;  of  dropsy,  598;  of  dyspnea, 
598;  of  irregularities  of  heart  action  and 
palpitations,  599;  lesions,  associated  or 
combined,  571 

Valvulitis,  565 

Vaquez's  disease,  657 

Varicella,  135 

Variola,  124;  protozoon  of,  125 

Variolas  cytoryctes,  125 

Variolas  sine  variolis,  128 

Varioloid,  127 

Vasomotor  and  trophic  derangements, 
1 1 25 

Vasomotor  coryza,  496 

Vena  medinensis,  219 

Ventricular  rhythm,  614 

Vermes,  195,  236 

Vesical  catarrh,  768 

Vesicular  emphysema,  528 

Vesicular  or  herpetic  stomatitis,  325 

Visceral  pains,  911 

Visceroptosis,  389 

Vision,  modifications  of,  in  nervous  dis- 
ease, 860 

Vocal  cords,  paralysis  of,  624,  1006 

Volvulus,  417 

Vomiting,  nervous,  365 

von  Graefe's  sign,  671 

Von  Pirquet's  reaction,  296 

W 

Wasserman's  test  for  syphilis,  183,  188, 
189,  190 

Wasting  palsy,  939 

Water  cancer,  see  Noma 

Water  hammer  pulse,  580,  1 1 19 

Water  on  the  brain,  280 

Waxy  kidney,  742;  liver,  455 

Wernicke's  scheme,  955 

Whip  worm,  222 

Whooping-cough,  137-140;  bacillus,  137; 
complications  and  sequelae  of,  138; 
diagnosis  of,  138;  etiology,  137;  morbid 
anatomy  of,  137;  paroxysmal  stage, 
'37.  138;  prognosis  of,  139;  prophylaxis, 
139;  serum  therapy,  140;  shape  of  chest 
in,  137;  symptoms  of,  137;  treatment  of, 

139 
Widal  reaction,  21 
Winckel's  disease,  664 
Wolfsbane  poisoning,  1173 
Wool-sorter's  disease,  174 
Word-blindness,  958 
Word-deafness,  958 
Word-image,  955 
Worms,  195,  236;  bladder,  202;  flat,  210; 

guinea,  219;  hook,  227-230;   max,  232; 


INDEX 


Worms: 

pin,   235;  round, 
201,  212;  thread. 

Writer's     cramp, 
1105-1107 

Wry-neclc,  1012 

Wurm,  176 


Xerostomia,  332 


Yellow  Fever,  black  vomit  in,  68,  66,  71; 
232;  seat,   23s;  tape,  diagnosis,      71-73;      distribution,      68; 

235;  whip,  222  etiology,  68;  facies,  71;  fever,  67,  70,  71; 

1103;      treatment     of,  incubation,  78;  jaundice,  68,  71 ;  kidney 

in,  69,  73;  liver  in,  69;  morbid  anatomy, 
69;  mosquito  in,  68;  prognosis,  73;  pro- 
phylaxis, 73;  pulse,  71;  skin  in,  69; 
stages  of,  70,    71;  stomach,  69;   symp- 

X  torns,  69;  synonyms,   67;  treatment  of, 

73;  urine  in,  71,  73 


Yellow  atrophy  of  the  heart,  605;  of  the 
liver,  acute,  466 


Zinc  poisoning,  1186 
Zona,  1056 
Zoster,  1056 
Zuckergussleber,  491 


T98 
1913 


